A nurse directs the intervention team who must take an aggressive patient to seclusion. Other patients were removed from the area. Before approaching the patient, the nurse should ensure that the staff takes which of the following actions?
Select all that apply.
a. Remove jewelry, glasses, and harmful items from the patient and staff members.
b. Appoint a person to clear a path and open, close, or lock doors.
c. Quickly approach the patient, and grab the closest extremity.
d. Select the person who will communicate with the patient.
e. Move behind the patient to use the element of surprise.
ANS: A, B, D
Injury to staff members and to the patient should be prevented. Only one person should explain what will happen and direct the patient; this person might be the nurse or staff member who has a good relationship with the patient. A clear pathway is essential; those restraining a limb cannot use keys, move furniture, or open doors. The nurse is usually responsible for administering the medication once the patient is restrained. Each staff member should have an assigned limb rather than just grabbing the closest limb. This system could leave one or two limbs unrestrained. Approaching in full view of the patient reduces suspicion.
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