Restraints

While restrained, the patients ____, ____, and ____ must be maintained.

All of the above

Non-violent restraints need to have the order renewed:

Every calendar day

A patient in restraints must have an active plan of care reflecting the use of restraints. When the restraint is no longer needed you DO NOT need to update the plan of care.

False

Role of assistive personnel with use of restraints: PCTs, CNAs, and security are allowed to initiate restraints in the management of patients.

False

Seclusion is the involuntary confinement of a person alone in a room and that person is physically prevented from leaving or who has the perception that physical intervention will be used if he/she attempts to leave the room. True or False

True

Four railings placed up in a bed are not documented as a restraint when used for safety of a patient in bed.

True

Injury reporting related to restraint usage: Any patient or staff injury related to restraint use is to be reported as soon as possible via the Event Reporting in MIDAS.

True

Patients have the right to be free from restraints of any form that are not medically necessary or are used as means of coercion, discipline, convenience, or retaliation by staff.

True

Use of Security when managing patients in the violent restraint: Security must be contacted before releasing or removing the violent restraint on any patient.

True

"Lockable" restraints are kept __________.

With security

When restraining a patient for either physical safety or violent or self-destructive behavior, when is the initial restraint order obtained?

a) Immediately

When releasing or removing lockable restraints always use a ____ person approach.

b) 2

What is the nurse's responsibility for the "renewal" order for the violent/self-destructive patient in restraints?

b) Contact the ordering physician and "discuss" the patient's behavior and document

Mr. Allen 45 y.o. is admitted at 0900 because he is threatening to kill himself and others. To keep him and others safe, bilateral wrist restraints are applied. At what time does the trained nurse need to complete a face-to-face assessment?

b) Within 1 hour of the restraint application

Mr. Allen 45 y/o is placed in lockable restraints at 0900 because he is kicking and threatening staff. At what time does the trained nurse need to complete a face-to-face assessment?

b) Within 1 hour of the restraint application

Dr. Martin is notified that Mr. Allen is threatening to kill himself and others. Which of the following are true regarding assessment for continued need for restraints?

c) An assessment for violent restraints must be done Every 1 hour

Dr. Martin is notified that Mr. Allen is threatening staff and kicked at staff. Violent restraint orders are attained and applied. How frequently must the restraint order be "renewed"?

c) Every 4 hours

Mr. Edwards is POD#1 from a right ORIF. It is 0800 and he becomes agitated and very confused. He pulled out his IV and NG tube. You try 2 other alternatives (moving patient closer to the nurses' station and camouflage lines) but they don't work. You call the attending physician and report your findings and get an order for restraints. You informed the patient why he is being restrained and what he can do to have the restraints removed. What should be monitored and documented a minimum of every two hours while Mr. Edwards is in restraints?

d) All of the above

When is it appropriate to release restraints to provide care to patients?

e) All of the above

How often should a nurse document on violent restraints?

q 15 minutes