Date
of Last Review: 8/1/07
SME: Director of Nursing
All patients
have the right to be protected from physical and emotional harm. Close observation of agitated, violent or
potentially violent patients is necessary to preserve this right.
Criteria for
combative and/or destructive precautions are as follows, but not limited to:
1.
Patient is visibly agitated ex.
pacing, clenching fists
2.
Pressured and/or loud speech,
argumentative behavior
3.
Threatening others, hostile
4.
Slamming doors, kicking, throwing or
hitting objects
5.
History of violence
Procedure:
An order for
precautions is entered by the physician or a registered nurse as an independent
nursing intervention, and the physician notified of the patient's
condition. A physician's order must be
obtained within 24 hours of the nursing order. The order must include the precaution reason. The patient will be provided with a red armband denoting unit
restriction until precautions are discontinued.
Documentation
of the specific behavior necessitating precautions is made in the progress
notes. Thereafter, the RN will document
an assessment every shift on the Nursing
Flow Sheet/Progress Notes. The
patient is advised when precautions are being implemented and discontinued.
Combative/Destructive
Precautions require judgment on the part of the caregivers and include but are
not limited to:
1.
Assessments of patient mental status
and whereabouts.
2.
Documentation of the assessments every
15 minutes on the Precautions
Checklist.
All
precautions are reviewed daily by the physician and registered nurse. The order will saty active/valid until it is discontinued.
Suggested Guidelines:
1.
To remain on unit – Unit Restrictions
2.
Observe level of agitation every 15
minutes. Offer medication as needed.
3.
Offer 1:1 staff talk.
4.
Provide adequate personal space for
agitated aggressive, or potentially violent patient.
5.
When possible, place patient in room
alone.
6.
Recommend Direct Observation.
7.
Educate or positive Coping Skills
8.
Recommend Anger Management Group
9. Include in MTP.
Related Standards:
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