Which measure should a nurse include in the care plan for a client who has mitt restraints to prevent pulling out tubes?
A.
Removing the mitts when the client is asleep.
B.
Performing range of motion exercises every two hours.
C.
Tying the restraints securely around the wrists and to the bed.
D.
Placing the restraints loosely to allow increased freedom of movement.
The correct answer and Explanation is :
The correct measure a nurse should include in the care plan for a client who has mitt restraints to prevent pulling out tubes is:
B. Performing range of motion exercises every two hours.
Explanation
Performing range of motion (ROM) exercises every two hours is essential for clients in mitt restraints because it helps maintain joint and muscle function. Mitt restraints are often used to prevent patients from pulling out tubes or disrupting their treatment. While effective in their purpose, mitt restraints can lead to complications if not managed properly. Prolonged immobility and restraint can cause muscle stiffness, joint contractures, and decreased circulation. ROM exercises help mitigate these risks by ensuring that muscles and joints are kept active, which promotes better circulation and flexibility.
Here’s a breakdown of why the other options are not ideal:
- A. Removing the mitts when the client is asleep: Removing restraints when the client is asleep can lead to safety risks, such as pulling out essential tubes or causing self-harm. Restraints are generally kept in place to ensure safety and prevent unwanted actions, so removing them can compromise the client’s well-being.
- C. Tying the restraints securely around the wrists and to the bed: Restraints should be applied securely but not excessively tight. Excessive tightness can lead to skin damage, impaired circulation, and increased discomfort. The goal is to use restraints effectively while minimizing physical harm.
- D. Placing the restraints loosely to allow increased freedom of movement: Restraints that are too loose may not effectively prevent the client from pulling out tubes or performing unwanted actions. Properly applied restraints should balance safety with comfort and functionality. Looseness may defeat the purpose of using the restraints in the first place.
In summary, performing ROM exercises every two hours is crucial for preventing the complications associated with prolonged restraint use, while the other options either pose safety risks or fail to address the need for maintaining joint and muscle health.