Final answer:
The nurse should perform regular monitoring under direct supervision, ensure skin integrity under restraints, and assist with hand and wrist exercises. Additionally, they should monitor vital signs and prepare for treatments like dialysis with sterile procedures.
Step-by-step explanation:
The nurse caring for an adult client in soft wrist restraints should include several critical actions in the plan of care. Monitoring is of utmost importance, which means providing direct supervision to ensure the safety and well-being of the patient. The supervising registered nurse should assess the patient's condition frequently, at least every two hours, to ensure the restraints are not too tight and circulation is not compromised.
The plan of care should also involve protecting the skin integrity by padding under the restraints and checking the skin for any signs of irritation or breakdown. Additionally, the patient's hand and wrist must be positioned and moved appropriately to ensure proper circulation and to prevent any muscular atrophy. Exercises such as assisting in bending the hand up toward the shoulder, tilting the hand to the side away from the body, and bending the fingers to make a fist can help maintain muscle strength and reduce the risk of complications from immobility.
Furthermore, the nurse should review the patient's history and current condition, monitoring their vital signs and responding to their needs before, during, and after the dialysis treatment, if applicable. Preparing solutions and equipment to ensure accurate and sterile procedures is also a fundamental part of the comprehensive care plan for a patient in restraints.