A patient is confused and has been restrained to prevent injury. Which of the following is a priority as the nurse plans care for the shift?
a. Calling the physician for an order for a chemical restraint
b. Applying the most restrictive restraint to prevent injury
c. Removing the restraints on the patient at least every 2 hours
d. Checking on the restrained patient last
C
Assess proper placement of restraint, skin integrity, pulses, temperature, color, and sensation of the restrained body part. Remove restraints at least every 2 hours or more frequently as determined by agency policy. If patient is violent or noncompliant, remove one restraint at a time and/or have other staff present while removing restraints. Chemical restraints are medications, such as anxiolytics and sedatives, used to manage a patient's behavior and are not a standard treatment for a patient's condition. Always attempt restraint alternatives before using a restraint. If a restraint is needed, always use the least restrictive device. Checking restrained patients last is not appropriate. Legislation emphasizes reducing the use of restraints. The Joint Commission and Centers for Medicare and Medicaid Services enforce standards for the safe use of restraint devices.
You might also like to view...
A client is suspected of having acromegaly. What definitive diagnostic testing is the most reliable method of confirming acromegaly?
A) A serum glucose level B) Glucose tolerance test in combination with a GH measurement C) Growth hormone levels D) Bone radiographs
The National Cancer Institute has confirmed a direct cause-and-effect relationship between immune system changes and the development of cancer
Indicate whether the statement is true or false
Which organization required audits of care, which later became part of a quality assurance program?
a. The Joint Commission on Accreditation of Hospitals (JCAH) b. The American Nurses Association (ANA) c. The National League for Nursing d. The American Hospital Association
The interprofessional treatment team for a homebound patient with a history of medication nonadherence suggests that the nurse case manager make daily home visits to administer medications to the patient. In which way should the case manager respond?
1. "My job description does not include medication administration to patients in the home." 2. "My time is better spent supervising others who provide this type of direct care." 3. "My daily schedule is too full to commit this amount of time to administering medications." 4. "My role as case manager is to organize and coordinate care, not to provide direct patient care."