The nurse is caring for a patient in restraints. Which of the following pieces of information about restraints requires nursing documentation in the medical record? (Select all that apply.)
a. The patient states that her gown is soiled and needs changing.
b. Attempts to distract the patient with television are unsuccessful.
c. The patient has been placed in bilateral wrist restraints at 0815.
d. One family member has gone to lunch.
e. Bilateral radial pulses present, 2+, hands warm to touch
f. Released from restraints, active range-of-motion exercises complete
ANS: B, C, E, F
Attempts at alternatives are documented in the medical record, as are type of restraint and time restrained. Assessments related to oxygenation, orientation, skin integrity, circulation, and position are documented, along with release from restraints and patient response. Comments about hygiene or the activities of one family member are not necessarily required in nursing documentation of restraints.
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