A nurse on the medical surgical floor is caring for a patient who is confused and combative after abdominal surgery. The patient has pulled out the nasogastric (NG) tube required for gastric rest. The nurse called the doctor to discuss these issues. The doctors ordered 2-point restraints, so the nurse creates a telephone order read back (TORB). The nurse knows that the restraint order will require which of the following?


•Physical restraints can refer to any device that prevents the patient from moving freely or restricts normal access to the patient’s own body. These can include applying wrist or ankle restraints as well as tucking sheets in tightly to restrict movement or putting all the bed rails up to keep a patient in bed.

•Restraints for nonviolent behavior: Typically, these types of physical restraints are interventions to keep a patient from pulling at tubes, drains, and lines. 

•If the RN applies restraints due to urgent patient safety concerns, the RN will then page the physician to describe the need for restraints and obtain the order for the specific the type of restraint and a limited time frame for use (24 hours max).

•The initial order must be signed and verified by the doctor within 24 hours, along with an assessment of the continued need for restraints. 

•Assess skin integrity and neurovascular status every 30 minutes and release the restraint every 2 hours for range of motion exercises.

•The nurse caring for a restrained patient must document appropriately every 2 hours on restraint status assessment of the client's response. The client must also be given opportunities for toileting and eating meals if the patient is not NPO.

•Restraints or seclusion for violent, self-destructive behavior: These interventions are for patients who are violent or aggressive, threatening to hit or striking staff, or banging their head on the wall, who need to be stopped from causing further injury to themselves or others. These orders require an in-person assessment within one hour and a new order obtained every 4 hours for the restraints (or seclusion) to continue.

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