Orders
The nurse has this amount of time to notify the physician responsible for the patient's care and place the verbal order for Violent Restraints
What is 1 hour?
Documentation of face-to-face evaluation with physician and restraint order
What is Behavioral Restraints/Seclusion Order form
Person approved to perform the face-to-face evaluation
What is a Physician?
Written modification to patients plan of care when restraints are initiated and/or dc'd: There will be a described intervention, goal of the intervention and responsibility for implementation of each intervention specified. The plan of care should be reviewed and updated in writing within _______ hours.
What is 12?
When a patient is accompanied by a non-hospital employee/law enforcement and has handcuffs in place you do not need an order from the physician.
What is True?
Non-hospital employee/law enforcement must remain with patient at all times!!!
When a verbal order is received for Non-Violent Restraints, a written order must be entered into the patients medical record within how many hours.
What is 24 hours?
Form used for documenting patient monitoring and assessments
What is Medical Treatment/Safety Restraint Flow Sheet?
Non-Violent restraints require assessment of respiratory effort, circulation of each restrained extremity, skin integrity and level of consciousness.
(How often)
What is every 2 hours or more frequently as needed?
Restraints are discontinued at the _________ possible time, regardless of the scheduled order expiration.
What is earliest?
Certified Nursing Assistants are allowed to assess patients in restraints.
What is False?
This type of order for Restraints is not acceptable at any time
What is a standing order or PRN order?
Alternatives attempted with the patient should be documented prior to this action.
This is how often restraints are released to allow position changes, range of motion exercises, fluid nourishment, toileting and assessment to help determine if the patient is ready to be released from restraints.
What is every 2 hours?
Restraints must be implemented in the ______ restrictive manner possible.
What is least?
In an urgent situation, a qualified nurse can place restraints on a patient.
What is True? For Violent restraints, the nurse must update the physician and the patient must by seen face-to-face by physician and an order must be written within 1 hour after applying restraints. For Non-Violent restraints a physician's assessment and written order need to be entered into the patient's medical record within 24 hours
An order for Non-Violent Restraints must be entered how often?
What is every 24 hours?
Education and explanation regarding the need for restraints is given to whom
Who is patient and/or family?
Violent restraints require assessment of respiratory effort, circulation of each restrained extremity, skin integrity and level of consciousness.
(How often)
What is every 2 hours or more frequently as needed?
Staff will be trained and able to demonstrate competency prior to ______ restraints, performing associated monitoring and assessment of or providing care for a patient in restraints.
What is applying?
When a patient is restrained during surgery and is still restrained in PACU, a restraint order is needed
What is False?
If a patient has medically necessary restraints in PACU this is considered part of the surgical procedure and would not need an order. If a patient is transferred to another unit and still requires the use of the restraints, an order would then be needed.
Action that must be taken if restraints are needed after they have been removed.
What is obtaining a new Restraint order?
What are documentation requirements?
When Violent Restraints are medically necessary, the patient is monitored and assessed by qualified personnel.
(How often)
What is a minimum of every 15 minutes?
Restraint alternatives such as placing a patient close to the nurses station, ensuring the call light is within reach, placing the bed in the lowest position and locking it in place are all examples of ________ measures.
What is environmental?
What is True?