Which nursing intervention should be performed before applying client restraints

Which nursing intervention should be performed before applying client restraints?

A.
Visual inspection of skin for placement.

B.
Positioning for proper body alignment.

C.
Assess the need for restraints placement.

D.
Review facility policy before usage.

The Correct Answer and Explanation is:

The correct answer is C. Assess the need for restraints placement.

Explanation:

Before applying client restraints, the primary nursing intervention is to assess the need for restraints placement. This step is crucial because restraints should only be used when absolutely necessary and as a last resort after other less restrictive measures have been tried and found ineffective. Here’s a detailed breakdown of why this assessment is so important:

1. Patient Safety and Dignity: Restraints can have significant physical and psychological effects on patients, including potential harm from restricted movement, pressure injuries, and emotional distress. Therefore, it’s essential to thoroughly evaluate if restraints are the only viable option for ensuring the patient’s safety and preventing harm. This assessment helps in making informed decisions that respect the patient’s dignity and rights.
2. Clinical Indications: The use of restraints should be based on specific clinical indications. For instance, restraints might be considered if a patient is at risk of harming themselves or others, or if they are engaging in behaviors that could impede their recovery or medical treatment. However, this decision should be made only after considering and ruling out other interventions, such as increasing supervision, using bed alarms, or modifying the environment to reduce fall risks.
3. Ethical and Legal Considerations: There are ethical and legal standards governing the use of restraints. Many institutions require that restraints be applied only when all other options have been exhausted, and there must be a clear, documented justification for their use. Assessing the need helps ensure compliance with these standards and avoids unnecessary or unjustified restraint application.
4. Policy Review: While reviewing the facility policy (Option D) is important and should be done before using restraints, the immediate action to be taken is to assess whether restraints are genuinely needed. The policy will provide guidance on the proper use and documentation of restraints, but the decision to apply them must be based on a thorough assessment of the patient’s needs.
5. Positioning and Skin Inspection: Visual inspection of the skin (Option A) and positioning (Option B) are important steps once the decision to use restraints has been made. They ensure that restraints are applied safely and do not cause additional harm. However, these steps come after the initial decision to use restraints has been justified.

In summary, assessing the need for restraints is the critical first step. This evaluation ensures that restraints are used appropriately, ethically, and in accordance with the patient’s best interests and safety.