Question

A nurse receives a change-of-shift report for an older adult client who had a total hip replacement. The client is not oriented to time, place, or person and attempts to get out of bed, pulling out an IV line that is supplying fluids and antibiotics. The client's primary health care provider ordered a vest restraint and bilateral soft wrist restraints. Which actions by the nurse would be appropriate? Select all that apply.

Frequently monitor and document the behavior that requires continued use of restraints. Tie the restraints in quick-release knots. Tie the restraints to the side rails of the bed. Ask the client they need to go to the bathroom; provide range-of-motion (ROM) exercises every 2 hours. Position the vest restraints so that the straps are crossed in the back. Document the client's response to the intervention.

Answer 1

The appropriate actions by the nurse include frequently monitoring and documenting the behavior that requires continued use of restraints, tying the restraints in quick-release knots, positioning the vest restraints so that the straps are crossed in the back, and documenting the client's response to the intervention.

Step-by-step explanation:

Firstly, frequent monitoring and documentation of the client's behavior are essential to ensure that the restraints are used only when necessary. This helps in maintaining the client's safety while also adhering to ethical and legal standards. It allows the healthcare team to assess the ongoing need for restraints and make necessary adjustments to the care plan.

Secondly, tying the restraints in quick-release knots is crucial for the client's safety. Quick-release knots enable the restraints to be easily and rapidly removed in case of an emergency or if the client's condition improves, preventing any delay in providing necessary care. This approach aligns with patient-centered care, prioritizing the client's well-being and comfort.

Additionally, positioning the vest restraints so that the straps are crossed in the back helps distribute pressure more evenly, reducing the risk of injury or skin breakdown. This technique ensures that the restraints are applied effectively while minimizing discomfort for the client. It reflects a balanced approach between the need for restraint and promoting the client's physical well-being.

In summary, these actions collectively contribute to maintaining the client's safety and comfort while addressing the behavioral challenges associated with the postoperative period. Regular assessments and documentation, appropriate restraint techniques, and consideration of the client's response are integral aspects of providing high-quality care in this scenario.