NUR 2349Nursing I Study Guide Exam 1/SCORE A

Medications that put patients at risks for falls o ACE inhibitors, antipsychotics (atypical), beta blockers, angiotensin II receptor antagonists, Antipsychotics/Neuroleptics, Calcium Channel blocker s , antiarrhythmic, anxiolytics, diuretics, anticonvulsants, benzodiazepines (long & intermediate acting), opioid analgesics, antidepressants, and skeletal muscle relaxants. Restraints o Mechanical device/material/equipment such as cloth vests or side rails o Chemical restraint such as medication- sedatives and psychotropic. o Devices such as casts and traction are not considered restraints o Avoid when possible, use the lowest level of restraint available for the least amount of time needed o Maintain one-on-one viewing of patient in restraints/seclusion, document episodes specifically in detail for documentation and future orders. o Remove restraints q 2 hours to provide skin care. Reapplication of restraints can be delegated to an AP, a new order for restraints must be given at least every 24 hours. Re-evaluation is every 4 hours.