which observation by the charge nurse would indicate that the nurse who cared for this client performed an unsafe action in the use of the restraint?

Dr. Smith has written an order for a vest restraint to be applied on a client from 10:00 pm to 7:00 am because the client becomes disoriented during the night and is at risk for falls

At 11:00 pm, the charge nurse makes rounds on all of the clients in the unit. When assessing the client with vest restraint, which observation by the charge nurse would indicate that the nurse who cared for this client performed an unsafe action in the use of the restraint?

• A. A safety knot was used to secure the restraint
• B. The client’s record indicates that the restraint will be released every 2 hours
• C. The restraint was applied tightly
• D. The call light was placed within reach of the client.

Answer C.

• Restraints should never be applied tightly because that could impair circulation.
• The restraint should be applied securely (not tightly) to prevent the client from slipping through the restraint and endangering himself or herself.
• A safety knot should be used because it can easily be released in an emergency.
• Restraints, especially limb restraints, must be released every 2 hours (or per agency policy) to inspect the skin for abnormalities.
• The call light must always be within the client’s reach in case the client needs assistance.

The correct answer is C. The restraint was applied tightly.

Here's a breakdown of why:

• Safety knot: A safety knot is a specific type of knot used to secure restraints safely, preventing the client from becoming entangled or injured.
• Releasing the restraint: Releasing the restraint every 2 hours is a standard practice to ensure the client's circulation and comfort.
• Call light placement: Placing the call light within reach of the client is important for their safety and communication needs.

Tight application of a restraint is a serious safety hazard and can lead to:

• Circulation problems: Tight restraints can restrict blood flow, leading to tissue damage or necrosis.
• Skin breakdown: Prolonged pressure from a tight restraint can cause skin breakdown and ulcers.
• Increased anxiety: Tight restraints can increase the client's anxiety and distress, potentially worsening their condition.

Therefore, the charge nurse's observation of a tightly applied restraint indicates an unsafe action that needs to be addressed immediately. The nurse who applied the restraint should be informed of the issue and instructed to loosen the restraint to ensure the client's safety and comfort.

Restraint Application in Healthcare:

Understanding Restraints:

• Purpose: Restraints are used as a last resort to prevent patients from harming themselves or others. They should only be applied when other interventions have failed and the risk of harm is significant.
• Types of Restraints: There are various types of restraints, including physical restraints (e.g., limb restraints, vest restraints) and chemical restraints (e.g., medications).

Safe Restraint Application:

• Assessment: Before applying a restraint, healthcare providers must conduct a thorough assessment to determine the need for restraint and the most appropriate type.
• Least Restrictive Means: The least restrictive means of restraint should always be used. This means considering alternatives to physical restraints, such as environmental modifications or behavioral interventions.
• Proper Application: Restraints should be applied correctly, using appropriate techniques and knots to ensure patient safety and comfort.
• Frequent Monitoring: Patients who are restrained must be monitored closely to assess their physical and emotional well-being. Restraints should be released periodically to allow for range of motion, circulation, and comfort.
• Documentation: The application and release of restraints must be documented in the patient's medical record, including the reason for restraint, the type of restraint used, and the monitoring schedule.

Risks Associated with Restraints:

• Physical Harm: Improperly applied restraints can lead to physical harm, such as skin breakdown, pressure ulcers, and circulatory problems.
• Psychological Distress: Restraints can cause psychological distress, including anxiety, agitation, and a sense of loss of control.
• Increased Risk of Falls: Restraints can paradoxically increase the risk of falls, as patients may struggle against them or become disoriented.

Alternatives to Restraints:

• Environmental Modifications: Modifying the environment can help to reduce the risk of falls and agitation. This may include removing hazards, providing adequate lighting, and ensuring the patient's room is clutter-free.
• Behavioral Interventions: Behavioral interventions, such as redirection, calming techniques, and therapeutic activities, can help to manage agitated behavior without resorting to restraints.
• Medication Review: Reassessing the patient's medication regimen can help to identify and address any underlying medical conditions or medication side effects that may be contributing to agitation.

Conclusion:

Restraints should be used as a last resort and only when absolutely necessary to protect the patient from harm. By following safe restraint practices and exploring alternative interventions, healthcare providers can minimize the risks associated with restraints and promote patient safety and well-being.