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JCAHO Guidelines for restraints and seclusion

In the event of an emergency, restraints or seclusion may be initiated without a physicians order, ONLY RN can make decision. Within 1 hour after initiation of restraints or seclusion a staff member must notify the MD regarding the patients physical and psychological condition. VERBAL ORDER MUST BE OBTAINED.

Orders if restraints must be reissued by MD by the following

-Every 4 hours for adults (18 and older)
-Every 2 hours for children and adolescents (9-17) and
-Every 1 hour for children younger than 9 years old

In person evaluation by the MD

-Within 4 hours of initiation of restraints or seclusion of an adult over 18 years old.
-Within 2 hours for adolescents and children 17 and younger
- If individual is no longer in restraints or seclusion when the original order expires, the MD must conduct an in person evaluation within 24 hours of intervention

Baker Act Publication

Do not publish (nonexistent, NP).Every pt has code number and only pt can contact family and give secure # if they want family to get info on them.

Informed Consent

Required for procedures (ECT). Pt can sign if deemed competent. If not competent legal guardian can make decision. If pt doesn't have family, Judge can make decision or appoints a guardian to make pts decisions.

Voluntary Baker Act

Can leave at anytime they want. If having suicidal/homicidal thoughts get physician to make the baker act involuntary and can't go anywhere. If they get away call law enforcement to get them back.

Goal of Baker Act

To increase community care of persons with mental illnesses/facilitate return to normal community life. TO KEEP EVERYONE SAFE!

Mentally Ill

impaired emotional process and impairment to utilize conscious controls.

Baker Act Admission

-Voluntary admission needs to shows evidence of mental illness, suitable for treatment, application for admission.
-Involuntary harm to self or other (major reason).Evaluation and emergency care. Are on constant observation. A nurse CANNOT baker act a patient, no verbal orders. Doctor/Nurse Practitioner with specialty in psych has to come in to Baker Act. ER physician can baker act. The ONLY PERSON THAT CAN LIFT A BAKER ACT IS A PSYCHIATRIST! You CANNOT baker act with intoxication and CANNOT suture w/o consent

How long is a baker act good for?

72 hours once medically clear, after deemed medically clear clock starts ticking. Weekend does not count. Once 72 hours are done and does not consent to be a voluntary admission, then court much be consented to make decision.

Voluntary Admission

Minors may be denied admission under discretion of the MD/facility. Hearing is needed to verify voluntariness of the minor's consent. If child is in facility you have to notify parents. Usually parents are the ones that bring in child. If mother brings in child, its INVOLUNTARY he/she cannot leave facility, and dad can't come and get child out.

Discharge of Voluntary Patients

Pt can request for discharge, and can sign themselves out. To go home pt must show sufficient improvement of condition, can go to community facility. If minor parent or guardian must request discharge. If they don't fit into involuntary criteria...Its up to psychiatrist to determine if they feel its safe for pt to go home, if not becomes involuntary and 72hr clock starts ticking.

Ex Parte Order

Court Order for involuntary admission, takes 2-3 people to sign affidavit and file petition, after that law enforcement goes out and brings pt in under baker act. If person has a FELONY, they DO NOT go to a baker act facility, they go directly to jail.

Involuntary Placement

-People who refuse many times, medical treatment, usually chronic patients. (pt does not want dialysis or psych evaluation, so doctor baker acts for psychiatric evaluation to make sure the patient is sound in mind)\
-To make sure pt is competent to make a life decision, they are baker acted.
-Patients who can't care for themselves (mental disorder, i.e dementia) are baker acted because they are incapable of surviving on their own.
-If wants court hearing, its usually within 5 days, no court on weekends or baker act hours

Whats the maximum amount a pt can be baker acted?

6 months


a normal healthy emotion. Its serves as a warning signal and alerts us of potential threat/trauma. It triggers energy. Anger is not a primary emotion, automatic response. It instills feelings of power. Expression of anger is a learned behavior and can be controlled. Its a healthy emotion. It all depends on how we deal with it.

What happens when anger is denied or buried?

Physical problems occur (i.e migranes, ulcers, colitis, CAD) Depression and low self esteem may occur.


behavior intended to threaten or injure the victim's ecurity or self-esteem". Its a way of expressing anger. It's a negative function that is destructive.

S/Sx of Anger

Intense distress, gritting teeth/clenching fists, change in tone of voice, increased energy, frowning, flushed face and pacing (good sign you need to watch out for them, BEST THING FOR THE pt TO BURN OFF ENERGY).

S/Sx of Aggression

Sarcasm(red flag goes up), pacing, self mutilation, invasion of personal space, suspiciousness, verbal/physical threats and throwing objects.



Mgmt of Aggressive Behavior

The key is prevention. YOU NEED TO KNOW WHAT THE PT IS CAPABLE OF!! Don't respond to anger or ignore what you see. Listen to the patient (tell you that he is getting aggressive)

Mgmt of Aggressive Feelings

Listen to and stay with pt. Allow verbal expression of anger, sLimits though. provide quiet aresa, administer medication. Use relaxation techniques (take deep breaths, draw picture, distraction, diversion), Use physical outlets


Mgmt of Losing Control

Assess the situation. Where did it happen? Was anyone else involved? Is there anything that can be used as a weapon? Give pt space, do not touch, express expectations(control behavior) (If you do that again, you're going into seclusion!). You need to tell them why and what's expected, SET LIMITS to give them opportunity to control behavior. If taking pt down, clear the chairs to provide safety for pt.

Other Interventions/Safety

Restraints/seclusion. Tell pt what you are going to do, DO NOT change plan. Make sure everyone/everything is READY (seclusion room, restraints, medication, clear pathway) Care for the pt.( debrief pt, what got you so keyed up? what could we do to make it better for you (ALWAYS ASK)? what did you feel like when we put you into seclusion

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