Show:
Suicide Precations
Violent Restraints
Non-Violent Restraints
Safety 1:1s
100

A patient tells you they are feeling suicidal. What should you do?


  1. STAY WITH THE PATIENT AND CALL FOR HELP
  2. For patients identified as high risk for suicide, constant 1:1 visual observation should be implemented (in which a qualified staff member is assigned to observe only one patient at a time) that would allow the staff member to immediately intervene should the patient attempt self-harm.
100

How long is a violent restraint order good for? 


    1. 4 hours (18 and older), 2 hours (9-17 years old), 1 hour (<9 years old)


100
How long is a non-violent restraint order good for? 

1 full calendar day


100

True or False: Any order is required for a safety 1:1

False - a safety 1:1 is nursing driven and can be implemented and discontinued without a provider order 
200

Name 3 things that need to be removed from the room

Cords not actively in use on the patient

patient belongings (clothing, shoes, belts, jewelry) etc. 

extra linens 

200

Who can sit for a violent restraint patient? 

Trained nursing support staff (not PCOs) or RNs

PCOs cannot sit in a 1:1 for violent restraints

200

What are signs and symptoms of harm from a restraint? 

  1. Skin alterations (redness, bruising, skin tears/abrasion)
  2. Hand discoloration (red, pale, dusky)
  3. Patient states their hand is numb/tingling/hurts
200

What are indications for a safety 1:1? 

fall risk 

delirium/dementia 

impaired judgement 

pulling at lines/tubes 

300

Name 3 things that do not need to be removed from the room? 

Why can these items stay? 

trash cans/plastic trash bags 

shower/room curtains 

call light

in use equipment 

the 1:1 stays with the patient to continuously observe and mitigate any remaining risks 

300

What is the required documentation and frequency for RN's with violent restraints? 


q2 restraint check 

hygiene 

skin/circulation 

ROM 

Fluids, food, elimination 

300

How do you check a restraint is not too tight? 

Two fingers between the restraint and the limb 

300

What is a contraindication to the usage of Remote Video monitoring? 

Suicide orders 

transfer from a psych facility within 24 hours  

does not respond to verbal redirection 

less than 18 years old

bi-pap with bilateral wrist restraints 

400

What orders do you need for a patient on a 1:1 for suicide? 

Suicide precautions

1:1 for suicide 

dietary orders modified (paper/plastic set up) 

400

What is required documentation and frequency for CNA's for patients on violent restraints? 

q15 mins 

behaviors 

signs of injury 

limb observation 

400
What are alternatives to attempt prior to applying a restraint? 
Closer to the nurses station

redirection/reorientation 

diversional activities 

camouflage devices 

increase frequency of rounding 

400

Describe the weaning process for a safety 1:1

1st hour inside the door 

2nd hour outside the door 

3rd hour frequently checks back on the patient 

if patient does not require intervention throughout this process then the 1:1 can be removed 

500

How often is an environmental check documented?  

when suicide precautions are initiated 

every time there is a changing of the sitter (i.e. breaks and change of shift) 


500
When violent restraining a patient, what is required from the provider? 

Face to face within 1 hour 

violent restraint orders 

restraint orders that match appropriate indication (violent) 

type of restraint on the patient 

500

True or False: Neoprene restraints can only be used for violent restraints

FALSE the type of restraint does not drive the indication (any type of restraint can be used for violent or non-violent; always use the least restrictive restraint possible)

500
What can you attempt to implement prior to placing a patient on a 1:1? 

Closer to the nurses station 

bed alarm/fall precautions 

frequent rounding 

toileting schedule 

diversion strategies