Question

A nurse is teaching a group of newly licensed nurses about the use of mechanical restraints. Which of the following information should the nurse include in the teaching?

A. Complete documentation about the client's status every hour while they are in restraints.
-The nurse should document the client's status, including behavior and vital signs, and address the client's physical and safety needs every 15 min.

B. Maintain the client in restraints for a minimum of 4 hr.
-Restraints should be removed as soon as the client is able to follow instructions, control their behavior, and is no longer at risk for injuring themselves or others. The maximum amount of time an adult client should remain in restraints is 4 hr.

C. Apply restraints when other means of managing the client's behavior have failed
- According to the Patient Self-Determination Act, clients have a right to be free from restraints or seclusion unless the safety of the client or others is at risk. De-escalation methods for controlling behavior should be attempted prior to initiating restraints.

D. Request that the provider assesses the client within 8 hr of the application of restraints.
-The use of mechanical restraints requires a provider's prescription. In emergent cases, the prescription can be obtained after restraints have been applied. However, the provider must evaluate the client within 1 hr of the initiation of restraints.

Answer 1

When teaching about mechanical restraints, it's important to include that documentation should occur every 15 minutes, restraints should be removed as soon as possible, restraints are a last resort, and the provider must assess the client within 1 hour of application.

Step-by-step explanation:

When educating newly licensed nurses on the use of mechanical restraints, several critical guidelines must be included in the teaching.

• Documentation: The nurse should comprehensively document the client's behavior and vital signs every 15 minutes, not just every hour. This documentation should detail the client's physical status, safety needs, and any interventions carried out.
• Duration of Restraint: Mechanical restraints should be removed at the earliest opportunity when the client can follow instructions and no longer poses a risk to themselves or others. Restraints should not be maintained for a predetermined minimum time; the focus should be on the client's behavior and risk assessment.
• Use of Restraints: Restraints should be used only as a last resort when noninvasive de-escalation methods fail. It resembles the legal requirements outlined in the Patient Self-Determination Act, emphasizing the right to be free from unnecessary restraint or seclusion.
• Provider Assessment: The prescribing provider must assess the client within 1 hour of applying restraints, not 8 hours as might be misunderstood. In emergency cases, this assessment may follow the initiation of restraints, but it must occur promptly.

These points ensure the safe and ethical use of mechanical restraints, complying with healthcare policies and respecting patient rights.