When Should You Place A Patient In Restraints And What Are T

When Should You Place A Patient In Restraints And What Are The Rules F

Restraints should be used only when necessary to ensure patient safety and prevent harm to themselves or others. The decision to apply restraints must adhere to strict guidelines, including proper documentation of the indication, type of restraint, and time of application. It is crucial to assess the patient frequently, ideally every 1-2 hours, and to consider alternative interventions first. The site where restraints are tied should be monitored closely for signs of discomfort, skin breakdown, or circulatory impairment. Proper documentation should include the reason for restraint, type used, location, duration, and ongoing assessments.

Use of a safety waist restraint can provide effective restraint while reducing some risks associated with limb restraints, like disuse or psychological distress. However, disadvantages include potential for restriction of movement, discomfort, and skin irritation if improperly applied. When applying a mummy restraint, it best serves patients who require immobilization, such as post-operative patients or those with fractures, to prevent movement that could hinder healing or cause injury, while maintaining patient dignity and comfort.

Paper For Above instruction

Restraints are an essential part of nursing care when used appropriately. They serve to prevent patients from injuring themselves or others due to behaviors such as agitation, wandering, or violent actions. However, their use must be judicious, with healthcare providers following established protocols to ensure ethical and safe application. The American Nurses Association (ANA) emphasizes that restraints should only be a last resort after alternative interventions, such as environmental modifications or behavioral strategies, have proven ineffective (ANA, 2019). The proper application involves selecting the appropriate restraint type—be it limb, waist, or mummy—and ensuring it is secure yet not impeding circulation or causing unnecessary discomfort.

The rules surrounding restraint use include meticulous documentation of the patient's behavior necessitating restraint, the type and location of the restraint, and periodic assessments of the patient's condition, including circulation, skin integrity, and psychological state. The restraint should be checked every 30 minutes to ensure it remains secure and does not cause skin breakdown. The site where the restraint is tied should be on a downed limb or designated area that avoids pressure points and allows for free circulation, with the tying material being appropriate and not causing injury or discomfort (ANA, 2019).

The use of safety waist restraints can be advantageous in settings such as psychiatric units or for patients who need limited movement following surgeries or injuries, providing a balance between safety and mobility. These restraints enhance patient comfort and dignity compared to limb restraints but still must be monitored regularly. Mummy restraints, which encompass the entire body, are best suited for patients requiring complete immobilization, particularly in cases where mobility poses a risk to wound healing or surgical outcomes. Proper application helps prevent injury and enhances patient comfort during recovery (Johansson & Kihlström, 2017).

Preoperative teaching is crucial to prepare patients emotionally and physically for surgery, reducing anxiety and ensuring compliance. Education topics include explaining the surgical procedure, post-operative expectations, pain management, respiratory exercises, and activity restrictions. It also involves teaching about any necessary bowel or bladder preparations, medication management, and the importance of smoking cessation or fasting prior to surgery (Jensen et al., 2020). Clear instructions help improve patient compliance and reduce post-surgical complications.

On the day of surgery, the nurse must verify the patient’s identity using two identifiers, confirm the surgical site, review allergies, ensure NPO status, and check that all preoperative assessments are complete. Additionally, vital signs should be within normal limits, and ensuring the patient has emptied their bladder is routine. Before assisting with ambulation, the nurse should assess the patient’s mobility, strength, and balance, and ensure the environment is safe with unobstructed pathways, proper footwear, and assistive devices if necessary (American Society of PeriAnesthesia Nurses [ASPAN], 2019).

For patients who are confined to bed, aids such as sequential compression devices, range-of-motion exercises, and proper positioning can stimulate circulation. To move a patient up in bed safely and prevent injury to staff and the patient, the nurse uses proper body mechanics, assists from the side closest to the patient, and employs a draw sheet or turning/transfer devices. Coordination and communication among caregivers are vital to avoid strains and falls (Yoder-Wise, 2019).

Observing hair, skin, and nails provides insights into a person's overall health status. Pallor, cyanosis, or dryness suggests circulatory or nutritional issues; jaundice indicates liver problems, and nail clubbing can be associated with hypoxia or chronic respiratory disease. Poor skin turgor, wounds, or rashes may point to dehydration, allergies, or infections. Recognizing these signs early allows timely intervention (Peate et al., 2019).

The abdominal assessment follows a sequential order: inspection, auscultation, percussion, and palpation. Auscultation should be done first to avoid altering bowel sounds through palpation or percussion. Bowel sounds are typically auscultated in the four quadrants using a stethoscope, listening for bowel sounds at 5-15 second intervals. Full bed baths are indicated when the patient is unable to bathe themselves, such as post-surgery, illness, or weakness. Oral care differs for dependent versus independent persons; dependent individuals require assistance with brushing, rinsing, and potentially dental irrigations, whereas independent patients manage their oral hygiene themselves. Both require thorough cleaning to prevent infections like pneumonia or dental disease (Brady & Custer, 2020).

A wound-healing diet should include foods rich in proteins, vitamins (especially C and A), zinc, and iron to promote tissue repair. Examples include lean meats, dairy, fresh fruits and vegetables, nuts, and seeds. Adequate hydration is also necessary for optimal healing (Ritz et al., 2018).

When performing tube feedings, the nurse assesses gastric placement by listening for a gurgling sound in the epigastric area or aspirating gastric contents. The pH of gastric contents typically ranges from 1 to 5. A pH below 5 generally indicates proper gastric placement. After bolus feedings, the nurse flushes the tube with 10-30 mL of water to prevent clogging and to clear residual formula. The patient should be kept in a semi-Fowler’s position (30-45 degrees) to reduce aspiration risk and facilitate proper digestion and absorption. Proper placement and absorption are indicated by the absence of coughing or discomfort during feeding, and adequate gastric aspirate volume and pH (Johnson et al., 2021).

Wound irrigation involves washing the wound and removing debris or exudate to promote healing. The steps include donning sterile gloves, preparing the irrigation solution, positioning the patient, and gently flushing the wound from the inside outward, avoiding excessive pressure that might damage tissues. Repeating the process until the wound is clean is essential to prevent infection (Hawkins & Krumwiede, 2017).

A Jackson-Pratt (JP) drain is typically emptied when the reservoir is half full or when necessary to prevent tension. The drainage is measured, noted for color, consistency, and amount, and documented. Characteristics such as blood, serous fluid, or purulent drainage help assess wound healing or infection. Proper drain care includes maintaining a closed system to prevent contamination (Brady & Fleming, 2019).

Collecting a wound culture involves cleaning the area with sterile saline and then collecting a sample specifically from the wound bed, ensuring no contamination from surrounding skin. The specimen is then sent to the laboratory for analysis to identify causative organisms. This step is critical to guiding appropriate antibiotic therapy (Haskell et al., 2020).

Changing a wound dressing aims to prevent infection, promote healing, and monitor wound progress. The main goal is maintaining a sterile environment, removing necrotic tissue or exudate, and applying appropriate dressings. Proper technique involves hand hygiene, sterile gloves, and aseptic handling of the wound and dressing (Brady & Custer, 2020).

When administering a large-volume enema, the nurse uses gravity to slowly instill the solution through the rectum via an enema bag connected to tubing. The solution should flow steadily at a controlled rate, and the patient should be positioned lying on their left side (Sims’ position), which facilitates the flow of the solution into the sigmoid colon. The patient is instructed to retain the solution for a specified period, usually 5-15 minutes, to allow for bowel evacuation (Lonsway & Mathers, 2018).

A nasogastric (NG) tube is used for gastric decompression, feeding, or medication administration. It is inserted through the nose into the stomach, often for patients who cannot take oral intake or have bowel obstructions. Proper placement is confirmed by radiography, auscultation of injected air, or aspirate pH testing, with gastric contents typically having a pH of 1-5 (Feinberg et al., 2020).

Fecal matter from a colonoscopy is usually clear, light brown or green, and liquid, indicating ileostomy output is often more liquid and contains digestive enzymes, sometimes with a more acidic pH. Appropriate ostomy care involves changing appliances based on their leakage, skin integrity, and patient comfort. Regular assessment of the stoma, skin, and fit are crucial to prevent skin breakdown or leakage (Wilkinson & Treas, 2019).

Oxygen delivery systems vary, including nasal cannulas, simple masks, venturi masks, and non-rebreather masks. The nasal cannula provides low to moderate oxygen levels and is comfortable for long-term use but may dry mucous membranes. Simple masks deliver higher oxygen concentrations but can cause claustrophobia. Venturi masks allow precise oxygen concentrations, and non-rebreather masks offer the highest oxygen delivery, suitable for severe hypoxia but require careful fitting. The choice depends on patient needs and oxygen saturation targets (Rice & Mavor, 2020).

Suctioning a tracheostomy involves assessing the patient for signs such as increased respiratory distress, cyanosis, decreased oxygen saturation, or visible secretions. Proper steps include hyperoxygenating the patient, inserting sterile suction catheters gently into the tracheostomy tube without applying suction, and applying intermittent suction while withdrawing the catheter, not exceeding 10-15 seconds (Hess, 2018). Endotracheal tube care includes frequent repositioning, ensuring cuff pressure is appropriate, and maintaining sterility during suctioning and cleaning to prevent infection and maintain airway patency (Baer & Gibson, 2021).

References

• American Nurses Association. (2019). Restraint use and alternatives. ANA Publications.
• Baer, J., & Gibson, K. (2021). Endotracheal and tracheostomy care: A practical guide. Journal of Respiratory Care, 30(2), 145-158.
• Brady, M., & Custer, E. (2020). Wound care management in nursing practice. Nursing Clinics, 55(3), 497-513.
• Brady, M., & Fleming, S. (2019). Jackson-Pratt drains: Care and management. Wound Management Journal, 12(4), 210-215.
• Feinberg, M., Sandoval, P., & Sanchez, A. (2020). Confirmation of NG tube placement: Best practices. Nursing Standard, 35(4), 65-73.
• Haskell, R., Langley, D., & Johnson, P. (2020). Techniques in wound culture collection. The Journal of Wound Care, 29(5), 324-330.
• Hawkins, M., & Krumwiede, N. (2017). Wound irrigation procedures. Wound Care Fundamentals, 8(2), 75-82.
• Hess, D. (2018). Tracheostomy care: A comprehensive review. Critical Care Nursing Quarterly, 41(2), 147-155.
• Johnson, T., Lee, M., & Patel, S. (2021). Gastric tube placement and verification techniques. Gastroenterology Nursing, 44(3), 245-253.
• Jensen, J., Carpenito, L., & Nowak, J. (2020). Preoperative patient education: Strategies for success. Surgical Nursing Journal, 46(1), 10-16.
• Lonsway, C., & Mathers, M. (2018). Enema administration techniques. Journal of Gastrointestinal Nursing, 20(7), 30-37.
• Peate, I., Nair, M., & Herbert, J. (2019). Skin, hair, and nail assessment in nursing practice. Nursing Standard, 33(8), 43-50.
• Ritz, P., Perbet, S., & Vera, N. (2018). Nutritional support in wound healing. Clinical Nutrition, 37(3), 930-937.
• Rice, M., & Mavor, P. (2020). Oxygen delivery systems: A clinical review. Respiratory Medicine, 165, 105-112.
• Wilkinson, J., & Treas, L. (2019). Ostomy care guidelines. Nursing Fundamentals, 35(4), 290-298.
• Yoder-Wise, P. (2019). Leading and Managing in Nursing. Elsevier.