A nurse is contributing to a plan of care for a client who has a new prescription for a wrist restraint. Which of the following actions should the nurse include in the plan?
A.
Check that the restraint is tied to a fixed frame of the bed.
B.
Pad bony prominences on the wrist.
C.
Remove the restraint every 4 hr to allow movement.
D.
Tie the restraint with a knot that will tighten when pulled.
The Correct Answer and Explanation is:
The correct answer is B. Pad bony prominences on the wrist.
Explanation:
When implementing wrist restraints, it’s essential to prioritize the safety and comfort of the client while ensuring the effectiveness of the restraint. Here’s a detailed breakdown of the appropriate actions to include in the plan of care:
1. Padding Bony Prominences: Padding bony prominences, such as the wrists, is crucial when using restraints. This practice helps prevent skin breakdown and pressure ulcers. Bony prominences are areas where the bone is close to the skin surface, and without padding, restraints can cause irritation or injury due to continuous pressure. Proper padding ensures that the restraint does not directly press against these areas, reducing the risk of injury and enhancing comfort.
2. Tying the Restraint to a Fixed Frame: While it is essential to secure restraints properly, they should be tied to a part of the bed that moves with the client, such as a fixed frame. This ensures that the restraint remains secure but allows for safe movement. Restraints tied to a movable part can increase the risk of injury or improper application.
3. Removing the Restraint Regularly: The guideline for removing restraints is typically every 2 hours, not 4 hours. The client should be assessed regularly for any signs of discomfort or complications, and the restraint should be removed to provide the client with the opportunity to move, stretch, and avoid complications from prolonged use. This interval helps prevent physical and psychological harm.
4. Knot Tightening When Pulled: Restraints should be secured with a knot that does not tighten when pulled, as this can cause additional harm and discomfort. Instead, knots should be easy to release in case of an emergency while still holding the restraint securely.
Overall, padding bony prominences is an integral part of ensuring the safety and comfort of the client while using wrist restraints. It helps prevent complications such as skin breakdown, which is a significant consideration in restraint use.