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Psychology/ Mental Health Nursing ATI

Terms in this set (640)

● In general, seclusion and/or restraint should be ordered for the shortest duration necessary, and only if less restrictive measures are not sufficient. They are for the physical protection of the client and/or the protection of other clients and staff. ● A client may voluntarily request temporary seclusion in cases in which the environment is disturbing or seems too stimulating. ● Restraints can be either physical or chemical, such as neuroleptic medication to calm the client. ● Seclusion and/or restraint must never be used for: ◯ Convenience of the staff ◯ Punishment of the client ◯ Clients who are extremely physically or mentally unstable ◯ Clients who cannot tolerate the decreased stimulation of a seclusion room ● When all other less restrictive means have been tried to prevent a client from harming self or others, the following must occur in order for seclusion or restraint to be used: ◯ The treatment must be ordered by the primary care provider in writing. ◯ The order must specify the duration of treatment. ◯ The provider must rewrite the order, specifying the type of restraint, every 24 hr or the frequency of time specified by facility policy. ◯ Nursing responsibilities must be identified in the protocol, including how often the client should be: ■ Assessed (including for safety and physical needs), and the client's behavior documented ■ Offered food and fluid ■ Toileted ■ Monitored for vital signs ◯ Complete documentation includes a description of the following: ■ Precipitating events and behavior of the client prior to seclusion or restraint ■ Alternative actions taken to avoid seclusion or restraint ■ The time treatment began ■ The client's current behavior, what foods or fluids were offered and taken, needs provided for, and vital signs ■ Medication administration ● An emergency situation must be present for the charge nurse to use seclusion or restraints without first obtaining a provider's written order. If this treatment is initiated, the nurse must obtain the written order within a specified period of time (usually 15 to 30 min).