Question

A 6-month-old male infant is admitted to the postanesthesia care unit with elbow restraints in place. He has an endotracheal tube and is ventilator-dependent but will be extubated soon following recovery from anesthesia. Which nursing intervention should be included in this child's plan of care?

1) Keep restraints on at all times to prevent unplanned extubation.
2) Remove restraints one at a time and provide range-of-motion exercises.
3) Remove all restraints simultaneously and provide play activities.
4) Document the reason for application of the restraints every 72 hours.

Answer 1

The best nursing intervention for a ventilator-dependent infant after anesthesia is to remove the restraints one at a time, maintain safety, and perform range-of-motion exercises, while documenting the necessity of restraints.

Step-by-step explanation:

Nursing Intervention for a Ventilator-Dependent Infant

The appropriate nursing intervention to include in this child's plan of care after being admitted to the postanesthesia care unit with elbow restraints and an endotracheal tube would be to remove the restraints one at a time and provide range-of-motion exercises. This approach ensures the child's safety by preventing unplanned extubation while also attending to the infant's physical needs. Since the infant is recovering from anesthesia and will soon be extubated following their recovery, gentle stimulation and movement can be beneficial. Additionally, it is important for the nursing documentation to reflect the application and assessment of restraints, ensuring that the reasons for their use are continuously justified and meet regulatory standards.