Nurses' Notes
1410: The client became disoriented and repeatedly reached toward a newly placed arterial catheter. Staff first used reorientation and a trained observer remained at the bedside. The client continued pulling at the catheter despite these measures. At 1420, the practitioner entered an individualized restraint order after less restrictive interventions were ineffective. The order also states soft wrist restraints may be used standing for agitation throughout the admission. The nurse checks skin color, warmth, sensation, and pulses at the interval required by policy. During care, each wrist is released separately for range of motion and skin assessment. The plan of care is updated with the behavior that prompted the intervention. At 1500, another nurse states that restraints should remain because repeated call-light use interrupts medication rounds. The client is offered fluids, toileting, and repositioning. At 1530, the right restraint strap is secured to the movable side rail. The left strap is attached to the approved stationary bed location. At 1600, the client follows directions and no longer reaches for the catheter. The nurse then discontinues the restraints when the immediate safety threat has resolved. The nurse documents the response to less restrictive measures. The family receives an explanation of the current safety plan.
護理紀錄
1410：個案變得定向力障礙，反覆伸手觸碰新放置的動脈導管。工作人員先使用重新定向和一位受過訓練的觀察員留在床邊。儘管採取這些措施，個案仍持續拉扯導管。1420，醫師開立在較不具約束性的介入措施無效後的個別化約束醫囑。醫囑也註明軟式手腕約束帶可在整個住院期間因躁動而長期使用。護理師依政策要求的間隔檢查皮膚顏色、溫度、感覺和脈搏。照護期間，每隻手腕分別鬆開以進行關節活動度和皮膚評估。照護計畫已更新，記錄引發介入的行為。1500，另一位護理師表示因為重複使用呼叫燈打斷給藥巡房，應繼續約束。個案獲得飲水、如廁和翻身協助。1530，右側約束帶固定在可移動的床欄上。左側約束帶固定在核准的固定床架位置。1600，個案遵從指示，不再伸手觸碰導管。護理師隨後在立即安全威脅解除後停止約束。護理師記錄對較不具約束性措施的反應。家屬獲得現行安全計畫的說明。