Question

1, Identify nursing priorities/standards of care for these interventions

Administer Wrist Restraints/Standards of Care:

Nursing Standards of Care:        

Rationale:

Answer 1

Restraint in any involuntary method (chemical or physical) of restricting an individuals freedom of movement, physical activity, or normal access to the body.

Wrist restraints are devices used in hospitals, clinics, medical institutions and detention facilities that are meant to safely secure a patient when they may otherwise hurt themselves or others.

Nursing standards of care :

• when nurse monitor the patient or resident who restrained, must observe and monitor the patients physical condition, the patients emotional states, the patients responses to the restraint.
• Before applying restraints , the nurse must exhaust alternative measures to restraints such as a bed alarm, distraction and a sitter.If the nurse determines that a restraint is necessary, it's use is discussed with the patient and family and a prescription is obtained from the health care provider.
• The nurse should be aware of the complications that can occur when using restraints. Complications include, serious injury ,muscle weakness, infections, skin breakdown , behavioral changes, etc..
• The patient will be observed at least every 2 hours .Direct continuous observation is required.
• In-person assessments must be documented every 10 to 15 minutes , with no time lapse of greater than 15 minutes.

Rationale :

• Wrist restraints are used for safely securing arms to keep a patient from harming themselves or a care giver.
• To allow a doctor or nurse to administer a medical procedure.
• It can be used to keep a person in proper position and prevent movement.
• To keep the patient from pulling at the tubes, drains and lines.