Question

Confused pt, soft wrist and ankle restraints on. care is effective if which actions are documented? SATA

- restraints secured tightly to skin
- pt placed in room near nurses station
- restraints attached to side rails of bed
- informed consent obtained from spouse
- alert and oriented *3
- placed in prone position

Answer 1

To provide effective care for a patient in restraints, it is important to document that the restraints are secured tightly to the bed frame, the patient is placed in a room near the nurses' station, and the restraints are attached to the side rails of the bed. The prone position is not recommended for a patient in restraints. Informed consent from a spouse would not be applicable in this situation, but it would be relevant to document that the patient is alert and oriented *3.

Step-by-step explanation:

In this scenario, the question is asking about the effective care for a patient who is in restraints. Restraints are used to limit a patient's movement and ensure their safety. When documenting the care of a patient in restraints, the following actions should be documented:

• The restraints are secured tightly to the bed frame or another secure structure, not to the patient's skin, to prevent injury.
• The patient is placed in a room near the nurses' station for close monitoring and quick response if needed.
• The restraints are attached to the side rails of the bed to restrict movement.

It is important to note that the prone position (lying face down) is not recommended for a patient in restraints as it can restrict breathing. Also, obtaining informed consent from a spouse would not be applicable in this case. Reporting that the patient is alert and oriented *3 (to self, place, and time) would be relevant to document.