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Zorluk: Çok zorSafe Use of Restraints and Safety Devices

A critical care nurse is managing a 72-year-old client with septic shock who is mechanically ventilated and receiving continuous vasopressor infusions. As sedation is lightened, the client exhibits acute delirium, becomes highly agitated, and repeatedly grasps at their endotracheal tube. The healthcare provider prescribes bilateral soft wrist restraints to prevent self-extubation. Which of the following nursing plans demonstrates the most accurate synthesis of safety guidelines, delegation, and restraint protocols?

  1. Secure the restraints to the movable portion of the bed frame using quick-release ties, assign the unlicensed assistive personnel (UAP) to provide routine skin care, and perform an RN evaluation of peripheral perfusion at least every two hours.Cevap
  2. B
    Delegate the continuous monitoring of the client's airway patency and the hourly assessment of peripheral circulation to an experienced UAP, allowing the RN to prioritize titrating the vasopressor infusions.
  3. C
    Apply the restraints and request a PRN (as-needed) physical restraint prescription from the provider, ensuring the restraints can be quickly reapplied during future episodes of delirium without trialing alternatives.
  4. D
    Prioritize weaning the client's vasopressor infusions to stabilize circulation before applying the restraints, allowing the client to move their arms freely during the hemodynamic titration process.

Cevap

The nurse must secure the restraints to the movable portion of the bed frame using quick-release ties, delegate routine non-clinical tasks to the UAP, and perform the neurovascular assessments at least every two hours.
The correct plan represents the standard of care for non-violent (medical-surgical) restraints used to support medical healing. The nurse correctly secures the restraints to the movable portion of the bed frame using quick-release knots to prevent injury if the bed position changes. Furthermore, the nurse appropriately delegates routine, non-assessorial tasks like skin care to the UAP, while retaining the responsibility for clinical assessments (such as peripheral perfusion and the ongoing need for restraints), which must be conducted at least every two hours.

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1
Analyze the clinical indication and prioritize interventions.
The client is at immediate risk of self-extubation (Airway).
Airway protection takes absolute priority over hemodynamic titration in this critical moment, necessitating immediate safe application of the ordered restraints.
2
Determine safe restraint application techniques.
Restraints must be secured with quick-release knots to the movable portion of the bed frame.
Securing restraints to the movable frame prevents injury when bed positioning changes, and quick-release knots ensure rapid removal during emergencies.
3
Evaluate delegation boundaries.
Routine skin care is delegated to the UAP; clinical assessments are retained by the RN.
UAPs cannot perform clinical judgments such as airway patency monitoring or neurovascular assessments.
4
Verify legal compliance for restraint orders.
Ensure the order is time-limited and not PRN.
CMS regulations strictly prohibit PRN (as-needed) orders for both physical and chemical restraints.

Anahtar Kavram

Management of Medical-Surgical Restraints and Prioritization
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Konular

Safe Use of Restraints and Safety Devices

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