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restraints
Question | Answer |
---|---|
A Mechanical or physical device used to restrict freedom of movement or prevent normal access to part of the body | physical restraint |
provide orientation, encourage family or sitters to stay with client, provide visual and auditory stimuli, including clock, radio, tv, and calendar w/large print,place pt. in a room close to nurse's station. | alternatives to restraints |
high risk for fall or injury, possible interruption of needed therapies, possible removal of life support eqipment, risk of injury to self or others | qualifiers for restraint use |
establish existence of qualifier present, establish reason for problematic behaviors(time of day, enviroment, pain, other activities), is behavior harmful to self or others(does it meet one of the qualifiers) | nursing assessment |
MD order is required(may require direct MD observation), | physical restraint orders |
order will include: date and time, type of behavior observed, type of restraint and location, time limitation-duration, criteria for release | physical restraint orders |
side rails are considered restraints if: | all four rails are in the up position |
also known as psychoactive drugs when overused in hospital settings. Pts. who display aggresive or agitated behavior may have prn orders for these. | chemical restraints |
anti-psychotics; ex is | Haldol |
anti-anxiety; ex is | Ativan |
anti-depressants; ex is | Trazadone |
sedative-hypnotic; ex is | Ambien |
restricted breathing and/or circulation, pressure ulcers, nerve damage, bowel/bladder problems, contractures, fear, anger, decreased self-esteem. | potential complications |