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You can use a flowsheet to document assessments. The flowsheet should include the following: patient behavior that indicates the continued need for restraints. patients mental status, including orientation.
Proper documentation, including the behaviors that necessitated the application of restraints, the procedure used that necessitated the application of restraints, the procedure used in restraining the condition of the body part restrained, and the evaluation of the patient response.
When the registered nurse monitors and evaluates the clients responses to the restraints or safety device, the nurse will assess and evaluate the client and their: Mental Status. Is the person afraid or fearful? Physical Status. Response to the Restraint.
The patient restrained for the management of violent or self-destructive behavior will be under continuous observation with documentation by a NA/Sitter of patient activity every 15 minutes. Nurse will document a nursing assessment to include respiratory status, circulatory status, range of motion, and behavior.
Documentation patient behavior that indicates the continued need for restraints. patients mental status, including orientation. number and type of restraints used and where theyre placed. condition of extremities, including circulation and sensation. extremity range of motion. patients vital signs. skin care provided.
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The patient restrained for the management of violent or self-destructive behavior will be under continuous observation with documentation by a NA/Sitter of patient activity every 15 minutes. Nurse will document a nursing assessment to include respiratory status, circulatory status, range of motion, and behavior.
The points that must be included in such documentation are the reason for the restraint; alternatives to the restraint that were used; the method of restraint; the procedure used in applying the restraint; date and time of application of the restraint; clients response to application of the restraint; condition of the
The timing of nursing interventions for the restrained patient is crucial! 1) Assess the patients status every 15 minutes. 2) Offer fluids, ROM exercises, and toileting every 2 hours. 3) Immediately remove restraints once the patient is no longer a danger to themselves or others.

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