Question

A patient in restraints is no longer displaying assaultive or aggressive behaviors after an hour. What should the nurse do next?

a. Call the provider and ask for guidance.
b. Remove the restraints to allow the patient to use the restroom, then place them in seclusion until the target of aggression has left the unit.
c. Remove the restraints per institution procedure.
d. Continue the restraints until the patient is asleep.

Answer 1

The nurse should carefully assess the patient and remove the restraints per institution procedure, respecting the patient's rights and ensuring safety. Restraints should be the last resort and used for the shortest time necessary.

Step-by-step explanation:

When a patient who has been placed in restraints is no longer displaying assaultive or aggressive behaviours, the appropriate next step for the nurse would be to follow the institution's procedures for restraint removal. Restraints should be used for the shortest duration necessary and only when alternative methods have failed or are deemed inappropriate. The nurse should perform a careful assessment of the patient to ensure that the reasons for initial restraint are no longer present and that the patient is no longer a danger to themselves or others.

According to most healthcare regulations and best practice guidelines, once the patient has calmed down and is no longer aggressive, restraints should be removed as soon as it is safe to do so. This aligns with option c: Remove the restraints per institution procedure. The priority is to respect the patient's rights and minimize the use of restraints, engaging in less restrictive measures to ensure the safety and well-being of the patient and others. After removing the restraints, the nurse should continue to monitor the patient's behaviourally and provide additional care and support as needed.