When caring for a patient who has been restrained, how often will the nurse perform an assessment?
a. Every 15 minutes
b. Every 30 minutes
c. Every hour
d. Every 2 hours
A
After application, evaluate the patient's condition every 15 minutes for signs of injury. Frequent assessments prevent injury to the patient and allow removal of the restraint at the earliest possible time. Observation and frequent assessments prevent complications such as suffocation, skin breakdown, and impaired circulation. The Joint Commission recommends that the patient's condition be evaluated every 15 minutes. If the nurse restrains the patient in an emergency situation because of violent or aggressive behavior that presents an immediate danger, a face-to-face physician assessment within 1 hour is needed to determine the patient's continued need for restraints. Restraints should be removed at least every 2 hours. If the patient is violent or noncompliant, remove one restraint at a time and/or have staff assistance while removing restraints. Removal provides an opportunity to change the patient's position, offer nutrients, perform full range of joint motion (ROJM), and toilet and exercise the patient.
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