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Sagot :
The charge nurse is observing new nurse care for a client who is at high risk for falls. Actions by the new nurse would require the charge nurse to intervene while waiting outside of the closed bathroom door while the client uses the toilet.
When all other therapies have failed, medical teams may use restraints to prevent patients from hurting themselves or others, among other purposes. When other safety measures, such as de-escalation and crisis management, have failed to keep the person and others safe, restraints should only be used for the shortest amount of time.
When there is a substantial risk of injury to the patient or others and all other interventions have failed, nurses may use restraints in an emergency without the patient's consent. The health care team should regularly evaluate the use of restraints and should reduce or end them as soon as practicable.
Interprofessional teams should do a debriefing with the patient, the patient's family, or a substitute decision-maker after ending restraints in order to go over the current intervention, any past interventions, and restraint alternatives.
Nurses must be careful to actively involve the patient, the patient's family, alternate decision-makers, and the larger healthcare team with any intervention, such as the use of restraints. The documentation of nursing care, including assessment, planning, intervention, and evaluation, is another duty of nurses.
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