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Zorluk: KolaySafe Use of Restraints and Safety Devices

A client with acute delirium is placed in bilateral soft wrist restraints to prevent the removal of a central venous catheter after less restrictive measures were unsuccessful. Which of the following nursing actions are appropriate when caring for this client? Select all that apply.

  1. Assess the peripheral pulses, skin temperature, and capillary refill of the hands.Cevap
  2. B
    Secure the restraint straps to the bed's side rails using a square knot.
  3. Release the restraints at least every 2 hours to provide skin care and range-of-motion exercises.Cevap
  4. D
    Request a PRN (as needed) prescription for the restraints from the primary healthcare provider.
  5. E
    Delegate the evaluation of the client's ongoing need for restraints to the unlicensed assistive personnel (UAP).
  6. Attach the restraint straps to the movable portion of the bed frame using a quick-release tie.Cevap

Cevap

The appropriate nursing actions are to assess the peripheral pulses and skin temperature, release the restraints at least every 2 hours for range-of-motion exercises, and attach the restraint straps to the movable portion of the bed frame using a quick-release tie.
Appropriate restraint management requires the nurse to ensure patient safety and prevent complications. Assessing peripheral circulation prevents ischemic injury. Releasing the restraints every 2 hours allows for skin care and prevents joint contractures. Attaching the straps to the movable portion of the bed frame with a quick-release tie ensures the restraints move with the client when the bed's head or foot is adjusted, and allows the restraints to be immediately removed in a medical emergency.

Adım Adım Çözüm

1
Identify the safety principles required for a client in physical restraints.
The nurse must prioritize circulation, skin integrity, legal guidelines, and emergency safety.
Restraints pose significant risks of injury, ischemia, and entrapment if applied or monitored incorrectly.
2
Evaluate each proposed nursing action against standard restraint guidelines.
Neurovascular checks, regular removal for range-of-motion, and tying to a movable bed frame with quick-release knots are correct and necessary safety practices.
These actions prevent circulatory compromise, maintain joint mobility, and allow for rapid restraint removal in an emergency.
3
Identify the unsafe or illegal practices among the options.
Tying restraints to side rails, using square knots, obtaining PRN prescriptions, and delegating assessment to a UAP are incorrect.
These actions violate safety standards, legal regulations regarding PRN orders, and the registered nurse's scope of practice.

Anahtar Kavram

Safe application, legal requirements, and monitoring of physical restraints
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Konular

Safe Use of Restraints and Safety Devices

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