A nurse is caring for a hospitalized 78-year-old patient with delirium who has repeatedly attempted to remove a chest tube placed for a hemothorax. The provider has ordered soft wrist restraints. Which actions reflect appropriate use of physical restraints? Select all that apply.
Select All That Apply
Choose your responses, then check the answer.
Explanation
Document the behavior requiring restraint, alternatives attempted, restraint details, monitoring, and education (Choice 1). Assess circulation, skin, range of motion, and toileting at least every 2 hours and release the restraint for care and repositioning (Choice 2). Try and document least-restrictive alternatives before applying restraints (Choice 3). Attach the restraint with a quick-release knot to the movable bed frame, not the side rail (Choice 5). A restraint must allow two fingerbreadths and must not immobilize the wrist without slack (Choice 4). Orders cannot be renewed automatically without focused reassessment merely because confusion persists (Choice 6).
Frame restraints around three CMS/TJC mandates: (1) Last-resort principle — try and document alternatives first. (2) Time-limited orders — non-behavioral medical orders are renewed by the provider at most every 24 hours after re-evaluation; behavioral restraint orders are time-limited (4 hours adults, 2 hours adolescents 9-17, 1 hour children <9) and require an in-person evaluation within 1 hour by a provider/LIP; PRN restraint orders are PROHIBITED. (3) Active monitoring — q2h release/assess circulation, skin, ROM, hydration, and toileting (q15min for behavioral or violent restraints with continuous observation per facility). Other essentials: two-fingerbreadth fit, quick-release knot to movable bed frame, never to side rails, never use sheets/gauze as makeshift restraints, attempt patient/family education, and discontinue at the earliest safe moment. Side-rails-up x4 is also considered restraint when used to prevent voluntary egress.
Medical-surgical unit. Patient: 78-year-old male postoperative day 3 with hospital-induced delirium, chest tube placed for traumatic hemothorax, has pulled at the tube three times in the past 4 hours despite redirection. Sitter unavailable. Family departed. Provider has just ordered bilateral soft wrist restraints.
Least-Restrictive Intervention — Ethical and legal principle requiring nurses to attempt the lowest-impact strategy that maintains safety before progressing to more restrictive measures; documented alternatives are required by CMS and TJC before applying restraints
Two-Fingerbreadth Fit — Standard for proper restraint cuff fit: the nurse should be able to slip two fingers between the cuff and the patient skin to ensure adequate circulation; tighter than this indicates risk of compression injury and neurovascular compromise
Time-Limited Restraint Order — CMS and TJC requirement that physical restraint orders specify a maximum time and require provider re-evaluation; non-behavioral orders renewable at most every 24 hours; behavioral orders limited to 4 hours adult, 2 hours adolescent, 1 hour child; PRN orders are prohibited