Restraint
Your patient has been in the restraint chair for 25 minutes. They are stating they need to use the bathroom. What is your next step?
Call for staff and security assistance
When is the maximum order renewal time for violent restraints or seclusion for patients 18 years and older?
4 hours
What does Jarvis mean in Mental Health?
State statute that gives courts the power to order the administration of medication for a committed person who is unwilling to take prescribed psychiatric medications.
Looking at the diet and nutrition order on your table, your patient ate 100% of dinner and your order above states your patient should have 375ml of tube feeds (day 3). Would you page the service to ask about holding the tube feeds?
Yes
Who can help you fill out a BSP?
NLT, multidisciplinary care team
You have taken a patient out of the restraint chair to use the bathroom, and you have determined that they need to go back into the restraint chair. Do you need a new order?
When do you page the provider to complete a face-to-face assessment for violent restraint or seclusion?
When initiating a new order and if order if a restraint or seclusion continues beyond 24 hours
What is a Price Sheppard order?
A Court order that authorizes health care professionals to order and administer ECT without the consent of the patient who has been determined to be mentally ill.
Looking at the MAR on your table, you determined the patient would benefit from Haldol, from what you see here in the MAR can you just give the Haldol?
No, it is a linked order and you must give the Ativan and Benadryl also.
If admit a patient to the unit who identifies as a tobacco user, what protocol do you need to initiate?
Tobacco Use Assessment and Nicotine Replacement RN Protocol (which includes a nicotine consult)
Your patient is in the restraint chair. Where are you positioned in the room?
With the patient, no barriers (windows, walls, doors)
Does your verbal order time need to match the time the restraint started?
Yes
What is the 72-Hour Hold law in MN?
A person held under a 72-hour emergency hold must be released by the facility within 72 hours unless a court order to hold the person is obtained.
How often would you change your intermittent antibiotic IV infusion tubing?
Every 24 hours
Why would we complete a BSP?
To provide consistency and a plan when caring for a patient, family, or visitor who has demonstrated a pattern of challenging high-risk behaviors or has threatened or caused harm to others.
After you have completed your restraint documentation, what is your next step to ensure your documentation is accurate?
When placing an order for restraint for seclusion, what type of order do you place?
Verbal
What is a provisional discharge?
A provisional discharge is discharge to a location or services if patient demonstrates safety and be willing agree to:
Take medications as prescribed
Meet with their case manager
Remain safe & sober
Follow treatment recommendations & Keep all appointments
Your patient is on intermittent 0.9 NS IV infusion depending on their po fluid intake. How often do you change the tubing?
When charting that a patient does not have an advance directive or a psych advance directive, does the RN also chart whether or not the patient wants more information?
Yes…. When the measure is not met, more often than not it is because the RN charted that the patient would like more information but did not provide a comment as to what was done (what education was provided, who was notified, etc.)
Your patient is 24 weeks gestation. While you should avoid restraints if able, you have determined this patient needs to be restrained. What position should they be placed in during restraints?
LEFT lateral decubitus position with right side supported with pillows or blankets. Do not use restraints that compress the abdomen (i.e., restraint chair, vest, body or belt restraint).
You have called security to the unit for a violent patient. Security assists in escorting the patient to seclusion after you have given that direction. Who is responsible for the documentation of the physical hold?
Nursing
A patient is placed on a 72-hour Hold on a Thursday evening at 1900, Monday is Memorial Day. When does the 72-hour Hold start and end?
Starts 1900 on Thursday, ends on 1900 on Wednesday
Looking at the diet and nutrition order on your table, what amount of total tube feeding should your patient receive on day two?
750 mL
If you are injured during a violent restraint, what incident reports need to be completed? hint: there are 3
Employee incident, patient safety incident, and violent patient report