The nurse is caring for a client in restraints. Which of the following would the nurse ensure was included in the documentation for this client? (Select all that apply.)
a. type of restraint used
b. client's response to the restraints
c. assessment for the need of the restraint
d. position of the bed
e. client's age
f. notification of the family
A, B, C, F
The nurse's responsibility in meeting the client's basic needs increases as the client is restrained and unable to meet his or her own needs. Restraints must be released once every 2 hours. The nurse must assess the color, temperature, sensation motion, and capillary refill in the area distal to the restraint and perform range-of-motion exercises. The client should also be toileted minimally at this time and have fluids in reach at all times unless contraindicated. The call light must also be in reach at all times so that the client may call for assistance as needed. The nurse should document the completion of the preceding interventions and the client's response.
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