Question

A patient has been placed in physical restraints by an order of the healthcare provider. What nursing responsibilities exist? Select all that apply.

Answer 1

Question: A patient is under physical restraints by the order of a healthcare provider. What are the responsibilities of a nurse?

Sol:

The responsibilities of a nurse towards the patient under physical restraint include

1. To check and record the complete restraint order. This contains the reason, rationale, duration, and also the type of restraint to be applied.

2. Communicate with the patient and his family members to assess the status and inform the process and need for physical restraint.

3. Then, obtain the required consent for the restraint procedure as per hospital norms.

4. Apply the least restrictive restraint as per the medical order and institute policy. See that there is no chance for falls and dislodgement or damage to the medical equipment used in the process.

5. Have special attention to patients' dignity, privacy, independence, and emotional status.

6. Monitor the patient every 15 minutes in the first hour until he is stable with restraint.

Then monitor the patient every 1- 2 hours for children, 4-hour for adults, or as per intervals specified in the order.

a) Check for the patient's needs like nutrition, hydration, toileting, and other physical comforts.

b) Examine the restraint for chances of movements and injury.

c) Inspect the vitals like respiration, circulation, and provide motion exercises if needed.

d) Analyze the patient's mental condition to see if he is anxious or stressed out by the procedure and assure him.

e) Assess the skin condition for bruise or irritation and change the position as needed.

f) Provide any drug treatment as prescribed by the healthcare provider.

g) Notice for responses and improvements due to treatment.

7. Document the restraint flow sheet periodically as per the restraint norms.

8. Periodically review the restraint for early discontinuation of the restraint or for renewing the order.

The goal should be to avoid restraint unless necessary and provide effective medical care.