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Zorluk: OrtaSafe Use of Restraints and Safety Devices

A primary nurse is developing a care plan for an adolescent client with viral encephalitis. The client exhibits severe agitation and has bilateral soft wrist restraints in place to prevent the dislodgment of a peripherally inserted central catheter (PICC). Which actions are appropriate for the nurse to include in the plan of care? Select all that apply.

  1. Fasten the restraint straps to the movable part of the bed frame using quick-release slip knots.Cevap
  2. Release the restraints temporarily every two hours to perform range-of-motion exercises and check skin integrity.Cevap
  3. C
    Obtain a standing, as-needed prescription from the attending provider to reapply the restraints if the agitation worsens.
  4. D
    Direct the assistive personnel to evaluate the peripheral pulses and capillary refill in the client's hands.
  5. E
    Attach the restraint straps directly to the side rails of the bed to facilitate rapid removal in an emergency.
  6. Ensure that two fingers can be easily inserted between the restraint padding and the client's wrist.Cevap

Cevap

The nurse should fasten straps to the movable bed frame with quick-release knots, release restraints every two hours for care and assessment, and ensure two fingers fit under the restraint padding.
Appropriate care for a client in restraints includes ensuring safety and maintaining circulation. Fastening straps to the movable portion of the bed frame using quick-release knots prevents injury when adjusting the bed and allows for emergency removal. Removing the restraints every two hours is mandatory to assess the skin, promote circulation, and provide range of motion. Ensuring two fingers can fit between the restraint and the client's wrist confirms that the device will not impede blood flow or cause nerve compression.

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1
Analyze the client situation and the indication for restraints.
The client has soft wrist restraints for a non-violent, medical-surgical reason (preventing PICC line dislodgment).
Identifying the type of restraint indication (medical-surgical vs. behavioral/violent) determines the required frequency of monitoring and documentation.
2
Evaluate each option against established safety standards and legal guidelines for restraint use.
Safe practices include quick-release knots, tying to movable bed frames, 2-hour releases, and 2-finger tightness. Unsafe practices include PRN orders, tying to side rails, and delegating assessments.
Applying regulatory standards ensures the client's physical safety, protects their legal rights, and maintains proper nursing delegation.
3
Select all interventions that represent safe, evidence-based nursing care.
The options involving quick-release knots on the movable frame, 2-hour care intervals, and appropriate fit verification are selected.
These interventions mitigate the risks associated with physical restraints, such as nerve damage, impaired circulation, and strangulation/injury from bed movement.

Anahtar Kavram

The safe application, monitoring, and legal documentation requirements for physical restraints in a clinical setting.
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Konular

Safe Use of Restraints and Safety Devices

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