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Zorluk: OrtaSafe Use of Restraints and Safety Devices

A nurse on a medical-surgical unit is caring for a client who is confused and repeatedly attempting to remove a newly placed percutaneous endoscopic gastrostomy (PEG) tube. After multiple alternative safety measures have failed, the healthcare provider prescribes bilateral soft wrist restraints. Which action by the nurse ensures the safe use of these restraints?

  1. Releasing one restraint at a time every 2 hours to provide skin care and perform range-of-motion exercises.Cevap
  2. B
    Fastening the restraint straps to the side rails of the bed using a quick-release slip knot.
  3. C
    Obtaining a prescription to use the restraints on an 'as needed' (PRN) basis when the client becomes agitated.
  4. D
    Delegating the hourly assessment of the client's radial pulses and capillary refill to the unlicensed assistive personnel (UAP).

Cevap

Releasing one restraint at a time every 2 hours to provide skin care and perform range-of-motion exercises.
For clients with non-violent (medical-surgical) physical restraints, the standard of care requires the nurse to remove the restraints at least every 2 hours to assess skin integrity, evaluate neurovascular status, perform range-of-motion exercises, and meet basic needs (e.g., toileting, hydration). Releasing only one restraint at a time is a critical safety measure; it ensures the client's hands are not completely free to pull at medical devices (such as the PEG tube) while care is being provided.

Adım Adım Çözüm

1
Analyze the scenario requirements.
The client has non-violent (medical-surgical) physical restraints applied to prevent the removal of a medical device (PEG tube).
Identifying the type of restraint dictates the monitoring and care protocols required.
2
Evaluate the standard of care for physical restraints.
Non-violent restraints require the nurse to assess skin integrity, circulation, and basic needs (toileting, hydration) at least every 2 hours.
Regular assessment prevents complications such as nerve damage, skin breakdown, and circulatory impairment.
3
Determine the safest method for providing restraint care.
Releasing one restraint at a time ensures the client cannot use a free hand to remove the medical device while the other limb is being assessed.
This maintains the therapeutic goal of the restraint while adhering to safety and physiological needs.

Anahtar Kavram

Safe application and monitoring of physical restraints
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Konular

Safe Use of Restraints and Safety Devices

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