Final answer:
The use of all four side rails and restraints for a CVA patient should be individualized, with restraints being a last resort. Healthcare providers should assess each patient's needs and involve an interdisciplinary team in care planning to ensure safety while respecting patient independence.
Step-by-step explanation:
For a patient who has suffered a Cerebrovascular Accident (CVA), commonly known as a stroke, the use of side rails and restraints must be tailored to the individual's needs for safety and mobility. Having all four side rails up at all times may not be necessary and could infringe on patient rights and their sense of independence. Restraints should be a last resort and only used when less restrictive interventions have been tried and are deemed necessary by the healthcare team to ensure the safety of the patient or others.
It is important for healthcare providers to assess each patient's risk for falls or harm and to engage in proactive care planning. This may involve interventions like bed alarms, supervised ambulation, or placing the bed in the lowest position with only the necessary side rails up. Restraints may be considered in cases where the patient's behavior poses an immediate risk to their safety and all other options have been exhausted. Any decisions about the use of restraints should involve interdisciplinary team discussions, which include the surgeon, nurse, and anesthesia professional, as well as adherence to hospital policies and relevant laws.