An elderly client is admitted with a diagnosis of dementia. He attempts several times to pull out his nasogastric tube. An order for cloth wrist restraints is received by the nurse. Which of the following actions by the nurse is MOST appropriate?
REWORDED QUESTION: What is appropriate care for a patient requiring restraints?
STRATEGY: "MOST appropriate" indicates there may be more than one correct response.
NEEDED INFO: Informed consent is needed to use restraints; if client is unable to consent, then consent of proxy must be obtained after full disclosure of risks and benefits; restraint of patient without informed consent or sufficient justification is false imprisonment. Assess and document need for restraints; consider use of alternative measures and document. Physician's order is required specifying duration and circumstances under which restraints should be used; cannot order restraints to be used PRN. Monitor patient closely and periodically reassess continued need for restraints, and document.
CATEGORY: Implementation/Safe and Effective Care
(1) Attach the ties of the restraint to the bed frame
CORRECT: Allows the raising and lowering of the side rail without causing injury to the patient
(2) Perform circulation checks to the extremities, which are restrained once a shift
Circulation checks should be done every 1-2 hours; vascular injury may result from poor circulation from a restraint that's too tight
(3) Remove the restraints when the patient is up in a wheelchair
Restraints should be secured when patient is at risk for harm to himself and is unattended; should be removed every 2 hours and skin assessed and area massaged; patient should not be left unattended when restraint is removed for care
(4) Explain the need for restraints only to the family
Restraints can increase patient's confusion or combativeness; patient and family should receive explanation for the need for the restraint, the type of restraint, and the anticipated duration of use
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