What Are Restraints?
The number of engaged bedrails to be considered physical restraint
What is FOUR?
Using an above-the-neck vest that’s not secured properly may increase the risk of this.
What is strangulation?
Utilize this person to sit with a confused patient.
What is a companion?
It's the number you dial to call security when assistance is needed in a violent patient situation.
What is *119?
It's when the nurse assesses a patient in restraints.
What is at initiation and every 15 minutes in restraints?
The reason why we put a patient in violent restraints.
What is an imminent threat to self or others?
Restraining a patient in this position increases their chances of aspiration.
What is supine?
Involving them might help reassure the patient, and give the nurse a better understanding of the patient's coping mechanisms.
What are friends and family?
It is the length of time a violent restraint order is good for.
What is 4 Hours?
This initial order may not be renewed or extended by anyone before a ________ is performed on the patient.
What is a physician examination?
A device that restricts freedom of movement or access to one’s body.
What is a physical restraint?
When you deprive an individual of his/her freedom, as a healthcare provider you assume this (legal term).
What is fiduciary responsibility?
These are 3 alternatives to using restraints.
What is using a companion, using distraction or de-escalation strategies, offering reassurance, and using bed or chair alarms?
It is the length of time a physician has before he must see a restrained patient face-to-face, if an order was made over the phone.
What is 1 Hour?
Where in the chart you will notate that the patient and/or family understands the reason why restraints are being used.
What is Patient Education?
A medication given to a patient to calm agitation that is not part of their normal treatment regimen.
What is a chemical restraint?
Restraining a patient in this position increases their chances of suffocation.
What is prone?
These are two restraint alternatives for a patient that frequently falls out of bed.
What are low beds, floor mats, scoop mattress, body pillow or item to define edge of bed, review individualized toileting program, assess reasons for getting up, anticipate needs, night lights?
These are 3 items a nurse must assess while a patient is in restraints.
What are: VS, circulation, ROM, hydration, elimination, level of distress and agitation, mental status, cognitive functioning, skin integrity, and release of restrained limbs?
Frequency that nurses must assess and chart Restraint-Free Interventions are being initiated on all of their patients.
What is every shift?
Holding a patient in a room involuntarily and preventing them from leaving.
What is seclusion?
These are 3 negative outcomes of restraint use
What are Pressure Ulcers, Agitation, Permanent loss of mobility, Depression, Loss of independence, Increased incontinence, Increased seriousness of fall related injuries, Strangulation, Circulation impairment, Social isolation, Contractures and Death?
To avoid restraints, attempt to identify ________ that stimulate violent behavior.
What is triggering events and issues?
These are reasons to remove a patient's violent restraint.
What is: the patient no longer verbalizes threat to self or others, Sleeping patients, Verbally negotiates and physically demonstrates self-control and safe behavior, Order expires?
Three things that should be documented in the patient's chart regarding restraint use.
Reason for restraint.
Alternative interventions attempted or judged to be ineffective prior to application of restraints.
Restraint(s)utilized.
Notification of the patient’s family when appropriate.
Patient and/or family education as appropriate related to the restraint episode.
Patient’s physical and psychological response to the use of restraint.
Modifications to the Plan of Care.
Assessment findings, interventions, and observations.
Significant changes in the patient’s condition. Any assistance provided to the patient to meet the release criteria.
Debriefing.