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What is the safest nursing action during patient restraint use?
Asked on Dec 26, 2025
Answer
Ensuring patient safety during the use of restraints involves continuous assessment and adherence to protocols to prevent harm. Restraints should only be used when absolutely necessary and in accordance with facility policies and ethical guidelines.
Example Nursing Steps:
- Step 1 – Assess the patient's condition and need for restraints, ensuring all alternative measures have been exhausted.
- Step 2 – Apply restraints according to the manufacturer's instructions and facility policy, ensuring they are not too tight and allow for some movement.
- Step 3 – Monitor the patient closely, checking circulation, skin integrity, and mental status regularly, and document all assessments and interventions.
Additional Comment:
- Always prioritize the patient's dignity and rights, using the least restrictive method necessary.
- Ensure that the patient and family are informed about the reason for restraint use and the expected duration.
- Regularly review the need for continued restraint use and remove them as soon as it is safe to do so.
- Follow the ABCs (Airway, Breathing, Circulation) to ensure the patient's physiological needs are met while restrained.
- Be aware of the potential for skin breakdown and other complications associated with restraint use.
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