VIOLENT/SELF DESTRUCTIVE RESTRAINT FLOW SHEET

A BC

PROVIDENCE HOSPITAL
6801 Airport Boulevard, Mobile AL 36608,
251/633−1000

VIOLENT/SELF DESTRUCTIVE
RESTRAINT FLOW SHEET

Date:
Patient Assessment:

Initials

Describe alternative methods attempted:

J Reality−Orienting J Family to sit J Frequent patient observations J Structured and consistent routines

J Safe familiar & J Sitter J Medication review J Correct electrolyte imbalance
J Other:
uncluttered environment J Undisturbed rest J Alleviate fears
J Diversion
J Decrease sensory overload

Type of restraint applied: (Check each one that applies)

Posey Vest J

Soft Wrist Right J Left J Leather Wrist Right J Left J
Soft Ankle Right J Left J Leather Ankle Right J Left J

Other (explain)

Supervisor notified (name)________________________________; (date/time)____________________
J Patient and/or J Family have been informed of application of restraint and reason.

If not informed, please explain.

Restraints initially applied: Date/Time Physician must see patient within 1 hour of restraint.
Current restraint order expires: Date/Time
Written order for restraints are limited to:
G 4 hours for adults
G 2 hours for ages 9−17
G 1 hour for under 9 years

Nurse may accept 1 verbal order to extend above hours.

Signature/Title Initials Signature/Title Initials Signature/Title Initials

Date Printed:

Developed: 4/09 nsgviolent

A BC

PROVIDENCE HOSPITAL
6801 Airport Boulevard, Mobile AL 36608,
251/633−1000

PATIENT OBSERVATIONS

* Document patient observations every 15 minutes.
* Document nursing intervention as appropriate and a minimum of every two hours.

Document • Loosen restraints • Address nutrition, hydration and hygiene needs
Intervention every • Reposition • Reassess need to continue restraints
1−2 hours: • Check skin and circulation • Circulation check and ROM
• Toileting Offered

Patient Observations every 15 minutes:

A. Awake D. Talking G. Crying J. Trying to get up M. Other:
K. Incoherent
B. Sleeping E. Reading H. Shouting L. Confused

C. Non−verbal F. WatchingTV I. Refuses Care

Record Initials in appropriate column. (Do not check boxes.)

Time Patient Circulation Restraints Skin Care Range of Reposi− Fluids Toileting Continue Comments
Restraints
Observations Checked Released Provided Motion tioned Offered Offered (RN only)

Date Printed: REV 12/00
nsgviolentback

A BC PO1004 PHYSICIANS ORDERS Page 1 of 1
.
r*PO10 4*rPROVIDENCEHOSPITALDATE HOUR Violent/Self Destructive Behavior Restraints
6801 Airport Boulevard, Mobile AL 36608,
251/633−1000 TIME LIMITED RESTRAINT ORDER

Patient’s Condition:
__________ Aggressive or violent behavior/immediate danger to others.

__________ Self Destructive behavior .

TYPE OF RESTRAINT:

__________ Soft

__________ Wrist

__________ Ankle
__________ Posey
__________ Other

Physicians must see patient within 1 hour of initiation of restraints.
This Time Limited Restraint Order must be renewed every:

G 4 hours for adults
G 2 hours for 9−17 years old
G 1 hour for under 9 years old

Nurse may accept one verbal order to extend above hours.

______________________________ ___________ ___________

RN or PA Signature Date Time

______________________________ ___________ ___________

Physician’s Signature Date Time

Developed: April 1996
Revised: October 2009
Reviewed: August 2012

PH−VSDR−0812PH Date Printed: PHY00396