The nurse is caring for a patient in restraints. Which essential information will the nurse document in the patient's medical record to provide safe care? (Select all that apply.)
a. One family member has gone to lunch.
b. Patient is placed in bilateral wrist restraints at 0815.
c. Bilateral radial pulses present, 2+, hands warm to touch
d. Straps with quick-release buckle attached to bed side rails
e. Attempts to distract the patient with television are unsuccessful.
f. Released from restraints, active range-of-motion exercises completed
ANS: B, C, E, F
Proper documentation, including the behaviors that necessitated the application of restraints, the procedure used in restraining, the condition of the body part restrained (e.g., circulation to hand), and the evaluation of the patient response, is essential. Record nursing interventions, including restraint alternatives tried, in nurses' notes. Record purpose for restraint, type and location of restraint used, time applied and discontinued, times restraint was released, and routine observations (e.g., skin color, pulses, sensation, vital signs, and behavior) in nurses' notes and flow sheets. Straps are not attached to side rails. Comments about the activities of one family member are not necessarily required in nursing documentation of restraints.
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