Interpret the Evidence
Assessment
Assessment is a critical component in the use of restraints and must never be replaced by restraints themselves, therapeutic communication, adequate observation, or staffing.
REx-PN
REx-PN
Assessment is a critical component in the use of restraints and must never be replaced by restraints themselves, therapeutic communication, adequate observation, or staffing. When a patient repeatedly attempts to climb out of bed, it is essential to assess for underlying causes such as pain, delirium, or the need to use the toilet, as these require appropriate treatment. Consent for restraint use does not justify unsafe or unnecessary application, nor does it eliminate the need for repeated reassessment. Immediate restraint may be applied in cases of immediate danger, but this does not permit continuation without thorough assessment, documentation, monitoring, and prompt review. The RPN's role includes assessing the patient, implementing authorized interventions, monitoring, documenting findings, and communicating any deterioration within the applicable scope and policy. Assessment should include vigilance for sudden changes in behaviour accompanied by drowsiness, unequal strength, abnormal speech, low oxygen saturation, or unstable vital signs, as these may indicate acute deterioration rather than a behavioural issue. After applying a restraint, the patient must be reassessed beyond simply confirming that the device remains fastened. Each reassessment must address...
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