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The nurse coming on for the evening shift receives report that one of the patients on the psychiatric unit is in 4-point restraints. Which of the following is true regarding assessment of the patient?

Explanation

•The nurse will assess the patient at change of shift and then at least every hour. Vital signs are taken hourly and ROM is done every 2 hours for patients in restraints.

•At the hourly assessment, the nurse will evaluate the patient's response to seclusion or restraints, offer support or reassurance, and attempt to work with the patient to formulate a plan to expedite release. This may include utilizing PRNs, considering coping skills to use, and contracting for safe behavior on the unit.

•Seclusion or restraint only continues if the nurse feels that the patient is not yet able to be safe on the unit and would benefit from more time for medication to become effective or to be free from the stimulation of the unit. Every four hours, a physician must write a new order to continue the selusion or restraint.

•The nurse is also responsible for assigning a mental health worker or another nurse to continuously monitor the patient in seclusion or restraints. The patient is never left unattended due to risk of injury.

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