Fundamentals of Nursing Q 520
Which of the following is the nurse’s legal responsibility when applying restraints?
A. Document the patient’s behavior.
B. Document the type of restraint used.
C. Obtain a written order from the physician except in an emergency, when the patient must be protected from injury to himself or others.
D. All of the above.
Correct Answer: D. All of the above
When applying restraints, the nurse must document the type of behavior that prompted her to use them, document the type of restraints used, and obtain a physician’s written order for the restraints. Nurses are accountable for providing, facilitating, advocating and promoting the best possible patient care and to take action when patient safety and well-being are compromised, including when deciding to apply restraints.
Option A: Restraint use should be continually assessed by the health care team and reduced or discontinued as soon as possible. After the discontinuing restraints, interprofessional teams should debrief with the patient, patient’s family, or substitute decision maker to discuss intervention, previous interventions and alternatives to restraints.
Option B: There are three types of restraints: physical, chemical and environmental. Physical restraints limit a patient’s movement. Chemical restraints are any form of psychoactive medication used not to treat illness, but to intentionally inhibit a particular behaviour or movement. Environmental restraints control a patient’s mobility.
Option C: With any intervention, such as restraint use, nurses need to ensure they actively involve the patient, patient’s family, substitute decision-makers and the broader health care team. Nurses are also accountable for documenting nursing care provided, including assessment, planning, intervention and evaluation. In emergency situations, nurses may apply restraints without consent when a serious threat of harm to the patient or others exists and only after all alternative interventions were unsuccessful.