Final answer:
The nurse is required to document alternative measures attempted before applying restraints, a verbal order for renewal of restraints every 48 hours, and detailed descriptions of the restraint application process.
Step-by-step explanation:
The nurse is required to document the following when caring for a patient with prescribed extremity restraint:
a. Alternative measures attempted before applying restraints: The nurse should document any non-restraint interventions or strategies that were attempted before resorting to the use of restraints. This can include medications, therapeutic activities, or behavioral approaches.
b. A verbal order for renewal of restraints every 48 hours: The nurse should document the verbal order from the healthcare provider to renew the restraints every 48 hours. This documentation ensures that the restraints are regularly assessed for appropriateness and continued need.
c. Detailed descriptions of the restraint application process: The nurse should document a detailed description of the steps taken to apply the restraints, including the type of restraint used, the body part restrained, and any specific instructions or precautions observed.
The nurse is required to document alternative measures attempted before applying restraints. Restraints have strict documentation guidelines to ensure patient safety and ethical treatment. Proper documentation includes not only what was done but also why it was necessary, stressing the importance of showing that less restrictive means were considered and rationale if they were not implemented. It ensures accountability and adherence to hospital policies and legal requirements. This is an essential component of the restraint application process, distinguishing from other processes, such as specimen labeling or needle counts, that are part of different procedures outlined in medical protocols. Therefore, it is critical to have a clear record, especially in situations requiring extremity restraints, to validate the patient's treatment regimen and the healthcare provider's actions.