A patient becomes violent on the unit and attacks another patient. The nurse is unable to calm him or convince him to walk to seclusion, and he begins punching and headbutting the wall with force and screaming that he will not go to his room or seclusion. With no physician on the unit at that moment, the nurse calls a Code Grey. Which of the following is the appropriate intervention? 

Initiate 4-point restraints.

Explanation

•After the nurse calls a Code Gray for assistance and moves all patients from the common area for their own safety, the nurse directs the staff to initiate 4-point restraints.

•The nurse may initiate seclusion or restraints without a physician order based upon their own assessment of the patient, but the physician must then be contacted to give a telephone order and come to the unit for a face to face evaluation within one hour.

•Orders must specify the type of restraint and the reason for it. For psychiatric clients, the time limit for an order for seclusion or restraints is 4 hours. For nonpsychiatric clients, restraints may be ordered for 24 hours. After that time, the physician must write a new order.

•The Omnibus Budget Reconciliation Act (OBRA) clearly states that restraints should be applied only as a last resort and that the least restrictive restraints should be used.

•In this case, seclusion is not appropriate because of the level of agitation and the likelihood of the patient hurting himself in seclusion. The nurse has to protect the patient from himself, so 4-point restraints are the next level of restriction. 5-point restraints (which include a waist strap) would not be used unless the patient was thrashing wildly and in danger of hurting himself even in restraints.

•PRN medications are an appropriate intervention either before the patient reached this level of agitation or after restraints are initiated. Once a patient has become violent, the nurse must maintain safety on the unit and PRN medications become a lower priority.

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