The nurse is assessing a 55-year-old male in bilateral wrist and ankle restraints for violent behavior. The nurse notes that the patient’s toes have a 5 second capillary refill time. Which action by the nurse is most appropriate?

Remove the restraints. A patient in wrist restraints is at risk for impaired circulation to the distal extremities. If signs of impaired circulation are noted, namely prolonged capillary refill time, the restraints must be removed immediately. Massaging underperfused tissue can cause damage. Merely loosening the restraints is not sufficient. Once the restraints are removed and circulation is restored, the incident and all physical findings must be documented.

The nurse is assessing a 55-year-old male in bilateral wrist and ...

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Safety and Infection Control
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Category: Safety and Infection Control
Difficulty: 3

Topics: Cardiovascular Crisis Management Mental Health Disorders Health Promotion Tissue Integrity

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