Definision : solitary containment in a fully protective environment with close surveillance by
nursing staff for purposes of safety or behavior management. Activities : Obtain a physicians order, if required by institutional policy, to use a physically restrictive intervention Designate one nursing staff member to communicate with the patient and to direct other staff Identify for patient and significant others those behavior which necessitated the intervention Explain procedure, purpose, and time period of the intervention to patient and significant others in understandable and nonpunitive terms Explain to patient and significant others the behaviors necessary for termination of the intervention Contract with patient (as patient is able) to maintain control of behavior Instruct on self-control methods, as appropriate Assist in dressing in clothing that is safe and in removing jewelry and eyeglasses Remove all items from seclusion area that patient might use to harm self or nursing staff Assist with needs related to nutrition, elimination, hydration, and personal hygiene Provide food and fluids in nonbreakable containers Provide appropriate level of supervision/surveillance to monitor patient and to allow for therapeutic actions, as needed Acknowledge your presence to patient periodically Administer PRN medication for anxiety or agitation Provide for patients psychological comfort, as needed Monitor seclussion area for temperature, cleanliness, and safety Arrange for routine cleaning of seclusion area Evaluate, at regular intervals, patients need for continued restrictive intervention Involve patient, when appropriate, in making decisions to move to a more/less restrictive intervention Determine patients need for continued seclusion Document rationale for restrictive intervention, patients response to intervention, patients physical condition, nursing care provided throughout intervention, and rationale for terminating the intervention Process with the patient and staff, on termination of the restrictive intervention, thr circumstances that led to the use of the intervention, as well as any patient concerns about the intervention itself Provide the next appropriate level of restrictive intervention (e.g.,physical restraint or area restriction), as needed. SECURITY ENHANCEMENT Definition : intensifying a patients sense of physical and psychological safety Activities : Provide a nonthreatening environment Demostrate calmness Spend time with patient Offer to remain with patient in a new environment during initial interaction with others Stay with patient in a new environment during initial interactions with others Present change gradually Discuss upcoming changes (e.g., an interward transfer) before event Avoid causing intense emotional situations Give pacifier to infant, as appropriate Hold a young child or infant, ass appropriate Facilitate a parents staying overnight with the hospitalized child Facilitate maintenance of patients usual bedtime rituals Encourage family to provide personal items for patients use or enjoyment Listen to patients/familys fears Encourage exploration of the dark, as appropriate Leave light on at night, as needed. Discuss specific situations or individuals that threaten the patient or family Explain all tests and procedures to patient/family Answer questions about health status in an honest manner Help the patient/family identify what factors increase sense of scurity Assist patient to identify usual coping responses Assist patient to use coping responses that have been successful in the past
SEDATION MANAGEMENT Definition : administration of sedatives, monitoring of the patients response, and provision of necessary physiological support during a diagnostic or therapeutic procedure Activities : Review patients health history and results of diagnostic test to determine if patient meets agency criteria for conscious sedation by a registered nurse Ask patient or family about any previous experiences with conscious sedation Check for drug allergies Determine last food and fluids intake Review other medications patient is taking and verify absence of contraindications for sedation Instruct the patient and/or family about effects of sedation Obtain informed written consent Evaluate the patients level of consciousness and protective reflexes before administering sedation Obtain baseline vital signs, oxygen saturation, EKG, height and weight Ensure emergency resuscitation equipment is readily available, specifically a source to deliver 100% O, Emergency medication, and a defibrillator Initiate an IV line Administer medication as per physicians order or protocol, titrating carefully accourding to patients response Monitor the patients level of consciousness and vital signs, oxygen saturation, and EKG as per agency protocol Monitor the patient for adverse effects of medicatio, including agitation, respiratory depression, hypotension, undue somnolence, hypoxemia, arrhythmias, apnea, or exacerbation of a preexisting condition Ensure availability of and administer antagonists, as appropriate per physicians order or protocol Document actions and patient, as per agency protocol Provide written discharge instructions, as per agency protocol.
SEIZURE MANAGEMENT Definition : care of a patient during a seizure and the postictal state Activities : Guide movements to prevent injury Minitor direction of head and eyes during seizure Lousen clothing Remain with patient during seizure Maintain airway Establish IV access, as appropriate Apply oxygen, a appropriate Monitor neurological status Minitor vital signs Reorient after seizure Record length of seizure Record seizure characteristics : body parts involved, motor activity, and seizure progression Decument information about seizure Administer medication, as appropriate Administer anticonvulsants, as appropriate Monitor antiepileptic drug levels, as appropriate Monitor postictal period duration and characteristics
SEIZURE PRACAUTIONS Definition : prevention or minimization of potential injuries sustained by a patient with a known seizure disorder Activities: Provide low-height bed, as appropriate Escort patient during off-ward activities, as appropriate Monitor drug regimen Monitor compliance in taking antiepileptic medications Have patient/significant other keep record of medications taken and occurence of seizure activity Instruct patient not to drive Instruct patient about medication and side effects Instruct family/significant other about seizure first aid Monitor antiepileptic drug levels, as appropriate Instruct patient to carry mediction alert card Remove potentially harmfull objects from the environment Keep suction at bedside Keep ambu bag at bedside Keep oral or nasopharyngeal airway at bedside Use padded side rails Keep said rails up Instruct patient on potential precipitating factors Instruct patient to call if aura occurs
SELF-AWARENESS ENHANCEMENT Definition : assisting a patient to explore and understand his/her thoughts, feelings, motivations, and behaviors. Activities : Encourage patient to recognize and discuss throught and feelings Assist patient to realize that everyone is unique Assist patient to identify the values that contribute to self-concept Assist patient to identify usual feelings about self Share observation or thoughts about patients behavior or response Facilitate patients identification of usual response patterns to various situations Assist patient to identify life priorities Assist patient to identify the impact of illness on self-concept Verbalize patients denal of reality, as appropriate Confront patients ambivalent (angry or depressed) feelings Make observation about patients current emotiona; state Assist patient to accept dependency on others, as appropriate Assist patient to change view of self as victim by defining own rights, as appropriate Assist patient to be aware of negative self-statements Assist patient to identify guilty feelings Help patient identify situations that precipitate anxiety Explore with patient the need to control Assist patient to identify positive attributes of self Assist patient/family to identify reasons for improvement Assist patient to identify abilities, learning styles Assist patient to reexamine negative perceptions of self Assist patient to identify source of motivation Assist patient to identify behaviors that are self-destructive Facilitate self-expression with peer group Assist patient to recognize contradictory statements
SELF-CARE ASSISTANCE Definition : Assisting another to perform activities of daily living Activities : Consider the culture of the patient when promoting self-care activities Consider age of patient when promoting self-care activities Monitor patients ability for independent self-care Monitor patients need for adaptive devices for personal hygiene, dressing, grooming, toileting, and eating Provide a therapeutic environment by ensuring a warm, relaxing, private, and personalized experience Provide desired personal articles (e.g., deodorant, toothbrush, and bath soap) Provide assistance until patient is fully able to assume self-care Assist patient in accepting dependency needs Use consistent repetition of health rountines as a means of establishing them Encourage patient to perform normal activities of daily living to level of ability Encourage independence, but intervene when patient is unable to perform Teach parents/family to encourage independence, to intervence only when the patient is unable to perform Establish a rountine for self-care activites
SELF-CARE ASSISTANCE: BATHING/HYGIENE Definition : Assisting patient to perform personal hygiene Activities : Consider the culture of the patient when promoting self-care activities Consider age of patient when promoting self-care activities Determine amount and type of assistance needed Place towels, soap, deodorant, shaving equipment, and other needed accessories at bedside or in bathroom Provide desired personal articles (e.g., deodorant, toothbrush, bath soap, shampoo, lotion, and aromatherapy products) Provide a therapeutic environment by ensuring a warm, relaxing, private, and personalized experience Facilitate patients brushing teeth, as appropriate Facilitate patients bathing self, as appropriate Monitor cleaning of nails, according to patients self-care ability Monitor patients skin integrity Maintain hygiene rituals Facilitate maintenance of patients usual bedtime routines , presleep cues/props, and familiar objects (e.g., for children, a favorite blanket/toy, rocking, pacifier, or story; for adults, a book to read or a pillow from home), as appropriate Encourage parent/family participation in usual bedtime rituals, as appropriate Provide assistance until patient is fully able to assume self-care
SELF-CARE ASSISTANCE : DRESSING/GROOMING Definition : Assisting patient with clothes and appearance Activities : Consider the culture of the patient when promothing self-care activities Consider age of patient when promoting self-care activities Inform patient of available clothing for selection Provide patients clothes in accessible area (e.g.,at bedside) Provide personal clothing, as appropriate Be available for assistance in dressing, as appropriate Facilitate patients combing hair, as appropriate Facilitate patients shaving self, as appropriate Maintain privacy while the patient is dressing Help with laces, buttons, and zippers, as needed Use extension equipment for pulling on clothing, if appropriate Offer to hang up clothing, as necessary Place removed clothing in laundry Offer to hang up clothing or place in dresser Offer to rince special garments, such as nylons Provide fingernail polish, if requested Provide makeup, if requested Rainforce efforts to dress self Facilitate assistane of a barber or beautician, as necessary
SELF-CARE ASSISTANCE : FEEDING Definition : Assisting a person to eat Activities : Monitor patients ability to swallow Identify prescribed diet Set food tray and table attractively Create a pleasant environment during mealtime (e.g., put bedpans, urinals, and suctioning equipment out of sight) Ensure proper patient positioning to facilitate chewing and swallowing Provide physical assistance, as needed Provide for adequate pain relief before meal, as appropriate Provide for oral hygiene before meals Fix food on tray, as necessary, such as cutting meat or peeling an egg Open packaged foods Avoid placing food on a persons blind side Describe location of food on tray for person with vision impairment Place patient in comfortable eating position Protect with a bib, as appropriate Provide a drinking straw, as needed or desired Provide foods at most appetizing temperature Provide preferred foods and drinks, as appropriate Monitor patients weight, as appropriate Monitor patients hydration status, as appropriate Encourage patient to eat in dining room, if available Provide social interaction as appropriate Provide adaptive devices to facilitate patients feeding self (e.g.,long handles, handle with large circumference, or small strap on utensils), as needed Use a cup with a large handle, if necessary Use unbreakable and weighted dishes and glasses, as necessary Provide frequent cueing and close supervision, as appropriate
SELF-CARE ASSISTANCE TOILETING Definition : Assisting another with elimination Activities : Consider the culture of the patient when promoting self-care activities Consider age of patient when promoting self-care activities Remove essential clothing to allow for elimination Assist patient to toilet/commode/bedpan/fracture pan/urinal at specified intervals Consider patients response to lack of privacy Provide privacy during elimination Facilitate toilet hygiene after completion of elimination Replace patients clothing after elimination Flush toilet/cleanse elimination utensil (commode, bedpan) Institute a toileting schedule, as appropriate Instruct patient/ appropriate others in toileting rountine Institute bathroom rounds, as appropriate and needed Provide assistive devices (e.g., external catheter or urinal), as appropriate Monitor patients skin integrity
SELF-CARE ASSISTANCE : TRANSFER Definition : Assisting a patient with limitation of independent movement to learn to change body location Activities : Review chart for activity orders Determine current ability of patient to transfer self (e.g.,mobility level, limitations for movement, endurance, ability to stand and bear weight, medical or orthopedic instability, level of consciousness, ability to cooperate, ability to comprehend instructions) Select transfer technique that is appropriate for patient Instruct patient in all appropriate techniques with the goal of reaching the highest level of independence