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Zorluk: OrtaSafe Use of Restraints and Safety Devices

A newly admitted client is severely disoriented and repeatedly attempts to remove a functioning chest tube. The nursing staff is evaluating the need for physical restraints to prevent disruption of this critical intervention. Which action by the nurse aligns with established safety and legal protocols for restraint use?

  1. Implementing and documenting the failure of less restrictive alternatives, such as concealing the tubing, before requesting a prescriptionCevap
  2. B
    Obtaining a PRN (as-needed) prescription for physical restraints to be applied if the client's agitation escalates
  3. C
    Anchoring the restraint straps securely to the bed's side rails to prevent the client from reaching the chest tube
  4. D
    Directing the unlicensed assistive personnel (UAP) to assess the client's radial pulses and determine the need for continued restraint

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Implementing and documenting the failure of less restrictive alternatives, such as concealing the tubing, before requesting a prescription
According to strict regulatory guidelines and standards of care, physical restraints are considered a measure of last resort. The registered nurse must first implement, evaluate, and thoroughly document the failure of less restrictive alternatives (e.g., bed alarms, frequent observation, or concealing medical lines) before requesting a prescription for restraints from the healthcare provider.

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1
Evaluate the clinical indication for restraints.
The client's safety is at immediate risk due to the potential removal of a life-saving chest tube.
Restraints can only be utilized when clinically justified to ensure physical safety and prevent life-threatening disruptions.
2
Determine the necessary legal and procedural prerequisites before application.
Less restrictive measures must be trialed and their ineffectiveness documented.
Regulatory standards mandate that physical restraints are strictly an intervention of last resort.
3
Review the distractors for unsafe practices.
PRN orders, side-rail anchoring, and delegating assessments to UAP are identified as protocol violations.
Eliminating these options confirms that trialing alternatives is the only legally and ethically sound choice.

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Safe Use of Restraints and Safety Devices
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Safe Use of Restraints and Safety Devices

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