Page 2327 - Saunders Comprehensive Review For NCLEX-RN

that have an impact on the client’s
ability to relate to the environment
2. Use of restraints and seclusion
a. Restraints and seclusion should never
be used as punishment or for the
convenience of the health care staff.

b. Restraints and seclusion are

used when behavior is physically
harmful to the client or others and
when alternative or less restrictive
measures are insufficient in protecting
the client or others from harm.
c. Restraints and seclusion are

used when the health care team
anticipates that a controlled
environment would be helpful and
requests restraints or seclusion.
d. The nurse must document the behavior
leading to the use of restraints or
seclusion.
e. In most settings, a primary health care
provider’s prescription is required
prior to the use of restraints
f. In an emergency, a qualified nurse may
place a client in restraints or seclusion
and obtain a written or verbal
prescription as soon as possible
thereafter.
g. Per state guidelines, within 1 hour of
the initiation of restraints or seclusion,
the psychiatrist must make a face-to-
face assessment and evaluation of the
client and must continuously
reevaluate the need for continued
restraints or seclusion.
h. While in restraints or seclusion, the
client must be protected from all
sources of harm.

i. The client in restraints or

seclusion needs constant one-to-one
supervision; physical, safety, and
comfort needs must be assessed every
15 to 30 minutes, and these
observations are also documented

2327