The nurse is caring for an elderly client following a total knee replacement. The client is disoriented to time and place, and has pulled out multiple IVs. The health care provider writes an order for soft wrist restraints. Which of the following are appropriate nursing actions for this client? Select all that apply.
check restraints for proper placement and check the skin every 2 hours
document the type of restraint, need for continued use, and trial release results
Numbers 2, 4, and 5 are correct.
Clients in restraints must be offered toileting and nutrition every 2 hours. Restraints should be checked every 2 hours for proper placement, and the skin assessed. Documentation of restraints includes type of restraint, the need for continued use, and the results of a trial release. Many facilities require that a trial release be performed on clients with restraints at least once per shift. Restraints should be tied with a quick-release knot in case of emergency. Restraint orders must be renewed every 24 hours, and they may not be written on a PRN basis. Follow facility guidelines when caring for restrained clients.