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SECLUSION
Definision : solitary containment in a fully protective environment with close surveillance by
nursing staff for purposes of safety or behavior management.
Activities :
Obtain a physician’s order, if required by institutional policy, to use a physically restrictive
intervention
Designate one nursing staff member to communicate with the patient and to direct other staff
Identify for patient and significant others those behavior which necessitated the intervention
Explain procedure, purpose, and time period of the intervention to patient and significant
others in understandable and nonpunitive terms
Explain to patient and significant others the behaviors necessary for termination of the
intervention
Contract with patient (as patient is able) to maintain control of behavior
Instruct on self-control methods, as appropriate
Assist in dressing in clothing that is safe and in removing jewelry and eyeglasses
Remove all items from seclusion area that patient might use to harm self or nursing staff
Assist with needs related to nutrition, elimination, hydration, and personal hygiene
Provide food and fluids in nonbreakable containers
Provide appropriate level of supervision/surveillance to monitor patient and to allow for
therapeutic actions, as needed
Acknowledge your presence to patient periodically
Administer PRN medication for anxiety or agitation
Provide for patient’s psychological comfort, as needed
Monitor seclussion area for temperature, cleanliness, and safety
Arrange for routine cleaning of seclusion area
Evaluate, at regular intervals, patient’s need for continued restrictive intervention
Involve patient, when appropriate, in making decisions to move to a more/less restrictive
intervention
Determine patient’s need for continued seclusion
Document rationale for restrictive intervention, patient’s response to intervention, patient’s
physical condition, nursing care provided throughout intervention, and rationale for
terminating the intervention
Process with the patient and staff, on termination of the restrictive intervention, thr
circumstances that led to the use of the intervention, as well as any patient concerns about
the intervention itself
Provide the next appropriate level of restrictive intervention (e.g.,physical restraint or area
restriction), as needed.
SECURITY ENHANCEMENT
Definition : intensifying a patient’s sense of physical and psychological safety
Activities :
Provide a nonthreatening environment
Demostrate calmness
Spend time with patient
Offer to remain with patient in a new environment during initial interaction with others
Stay with patient in a new environment during initial interactions with others
Present change gradually
Discuss upcoming changes (e.g., an interward transfer) before event
Avoid causing intense emotional situations
Give pacifier to infant, as appropriate
Hold a young child or infant, ass appropriate
Facilitate a parent’s staying overnight with the hospitalized child
Facilitate maintenance of patient’s usual bedtime rituals
Encourage family to provide personal items for patient’s use or enjoyment
Listen to patient’s/family’s fears
Encourage exploration of the dark, as appropriate
Leave light on at night, as needed.
Discuss specific situations or individuals that threaten the patient or family
Explain all tests and procedures to patient/family
Answer questions about health status in an honest manner
Help the patient/family identify what factors increase sense of scurity
Assist patient to identify usual coping responses
Assist patient to use coping responses that have been successful in the past


SEDATION MANAGEMENT
Definition : administration of sedatives, monitoring of the patient’s response, and provision of
necessary physiological support during a diagnostic or therapeutic procedure
Activities :
Review patient’s health history and results of diagnostic test to determine if patient meets
agency criteria for conscious sedation by a registered nurse
Ask patient or family about any previous experiences with conscious sedation
Check for drug allergies
Determine last food and fluids intake
Review other medications patient is taking and verify absence of contraindications for
sedation
Instruct the patient and/or family about effects of sedation
Obtain informed written consent
Evaluate the patient’s level of consciousness and protective reflexes before administering
sedation
Obtain baseline vital signs, oxygen saturation, EKG, height and weight
Ensure emergency resuscitation equipment is readily available, specifically a source to
deliver 100% O², Emergency medication, and a defibrillator
Initiate an IV line
Administer medication as per physician’s order or protocol, titrating carefully accourding to
patient’s response
Monitor the patient’s level of consciousness and vital signs, oxygen saturation, and EKG as
per agency protocol
Monitor the patient for adverse effects of medicatio, including agitation, respiratory
depression, hypotension, undue somnolence, hypoxemia, arrhythmias, apnea, or
exacerbation of a preexisting condition
Ensure availability of and administer antagonists, as appropriate per physician’s order or
protocol
Document actions and patient, as per agency protocol
Provide written discharge instructions, as per agency protocol.


SEIZURE MANAGEMENT
Definition : care of a patient during a seizure and the postictal state
Activities :
Guide movements to prevent injury
Minitor direction of head and eyes during seizure
Lousen clothing
Remain with patient during seizure
Maintain airway
Establish IV access, as appropriate
Apply oxygen, a appropriate
Monitor neurological status
Minitor vital signs
Reorient after seizure
Record length of seizure
Record seizure characteristics : body parts involved, motor activity, and seizure progression
Decument information about seizure
Administer medication, as appropriate
Administer anticonvulsants, as appropriate
Monitor antiepileptic drug levels, as appropriate
Monitor postictal period duration and characteristics

SEIZURE PRACAUTIONS
Definition : prevention or minimization of potential injuries sustained by a patient with a
known seizure disorder
Activities:
Provide low-height bed, as appropriate
Escort patient during off-ward activities, as appropriate
Monitor drug regimen
Monitor compliance in taking antiepileptic medications
Have patient/significant other keep record of medications taken and occurence of seizure
activity
Instruct patient not to drive
Instruct patient about medication and side effects
Instruct family/significant other about seizure first aid
Monitor antiepileptic drug levels, as appropriate
Instruct patient to carry mediction alert card
Remove potentially harmfull objects from the environment
Keep suction at bedside
Keep ambu bag at bedside
Keep oral or nasopharyngeal airway at bedside
Use padded side rails
Keep said rails up
Instruct patient on potential precipitating factors
Instruct patient to call if aura occurs

SELF-AWARENESS ENHANCEMENT
Definition : assisting a patient to explore and understand his/her thoughts, feelings,
motivations, and behaviors.
Activities :
Encourage patient to recognize and discuss throught and feelings
Assist patient to realize that everyone is unique
Assist patient to identify the values that contribute to self-concept
Assist patient to identify usual feelings about self
Share observation or thoughts about patient’s behavior or response
Facilitate patient’s identification of usual response patterns to various situations
Assist patient to identify life priorities
Assist patient to identify the impact of illness on self-concept
Verbalize patient’s denal of reality, as appropriate
Confront patient’s ambivalent (angry or depressed) feelings
Make observation about patient’s current emotiona; state
Assist patient to accept dependency on others, as appropriate
Assist patient to change view of self as victim by defining own rights, as appropriate
Assist patient to be aware of negative self-statements
Assist patient to identify guilty feelings
Help patient identify situations that precipitate anxiety
Explore with patient the need to control
Assist patient to identify positive attributes of self
Assist patient/family to identify reasons for improvement
Assist patient to identify abilities, learning styles
Assist patient to reexamine negative perceptions of self
Assist patient to identify source of motivation
Assist patient to identify behaviors that are self-destructive
Facilitate self-expression with peer group
Assist patient to recognize contradictory statements


SELF-CARE ASSISTANCE
Definition : Assisting another to perform activities of daily living
Activities :
Consider the culture of the patient when promoting self-care activities
Consider age of patient when promoting self-care activities
Monitor patient’s ability for independent self-care
Monitor patient’s need for adaptive devices for personal hygiene, dressing, grooming,
toileting, and eating
Provide a therapeutic environment by ensuring a warm, relaxing, private, and personalized
experience
Provide desired personal articles (e.g., deodorant, toothbrush, and bath soap)
Provide assistance until patient is fully able to assume self-care
Assist patient in accepting dependency needs
Use consistent repetition of health rountines as a means of establishing them
Encourage patient to perform normal activities of daily living to level of ability
Encourage independence, but intervene when patient is unable to perform
Teach parents/family to encourage independence, to intervence only when the patient is
unable to perform
Establish a rountine for self-care activites


SELF-CARE ASSISTANCE: BATHING/HYGIENE
Definition : Assisting patient to perform personal hygiene
Activities :
Consider the culture of the patient when promoting self-care activities
Consider age of patient when promoting self-care activities
Determine amount and type of assistance needed
Place towels, soap, deodorant, shaving equipment, and other needed accessories at
bedside or in bathroom
Provide desired personal articles (e.g., deodorant, toothbrush, bath soap, shampoo, lotion,
and aromatherapy products)
Provide a therapeutic environment by ensuring a warm, relaxing, private, and personalized
experience
Facilitate patient’s brushing teeth, as appropriate
Facilitate patient’s bathing self, as appropriate
Monitor cleaning of nails, according to patient’s self-care ability
Monitor patient’s skin integrity
Maintain hygiene rituals
Facilitate maintenance of patient’s usual bedtime routines , presleep cues/props, and familiar
objects (e.g., for children, a favorite blanket/toy, rocking, pacifier, or story; for adults, a book
to read or a pillow from home), as appropriate
Encourage parent/family participation in usual bedtime rituals, as appropriate
Provide assistance until patient is fully able to assume self-care

SELF-CARE ASSISTANCE : DRESSING/GROOMING
Definition : Assisting patient with clothes and appearance
Activities :
Consider the culture of the patient when promothing self-care activities
Consider age of patient when promoting self-care activities
Inform patient of available clothing for selection
Provide patient’s clothes in accessible area (e.g.,at bedside)
Provide personal clothing, as appropriate
Be available for assistance in dressing, as appropriate
Facilitate patient’s combing hair, as appropriate
Facilitate patient’s shaving self, as appropriate
Maintain privacy while the patient is dressing
Help with laces, buttons, and zippers, as needed
Use extension equipment for pulling on clothing, if appropriate
Offer to hang up clothing, as necessary
Place removed clothing in laundry
Offer to hang up clothing or place in dresser
Offer to rince special garments, such as nylons
Provide fingernail polish, if requested
Provide makeup, if requested
Rainforce efforts to dress self
Facilitate assistane of a barber or beautician, as necessary

SELF-CARE ASSISTANCE : FEEDING
Definition : Assisting a person to eat
Activities :
Monitor patient’s ability to swallow
Identify prescribed diet
Set food tray and table attractively
Create a pleasant environment during mealtime (e.g., put bedpans, urinals, and suctioning
equipment out of sight)
Ensure proper patient positioning to facilitate chewing and swallowing
Provide physical assistance, as needed
Provide for adequate pain relief before meal, as appropriate
Provide for oral hygiene before meals
Fix food on tray, as necessary, such as cutting meat or peeling an egg
Open packaged foods
Avoid placing food on a person’s blind side
Describe location of food on tray for person with vision impairment
Place patient in comfortable eating position
Protect with a bib, as appropriate
Provide a drinking straw, as needed or desired
Provide foods at most appetizing temperature
Provide preferred foods and drinks, as appropriate
Monitor patient’s weight, as appropriate
Monitor patient’s hydration status, as appropriate
Encourage patient to eat in dining room, if available
Provide social interaction as appropriate
Provide adaptive devices to facilitate patient’s feeding self (e.g.,long handles, handle with
large circumference, or small strap on utensils), as needed
Use a cup with a large handle, if necessary
Use unbreakable and weighted dishes and glasses, as necessary
Provide frequent cueing and close supervision, as appropriate


SELF-CARE ASSISTANCE TOILETING
Definition : Assisting another with elimination
Activities :
Consider the culture of the patient when promoting self-care activities
Consider age of patient when promoting self-care activities
Remove essential clothing to allow for elimination
Assist patient to toilet/commode/bedpan/fracture pan/urinal at specified intervals
Consider patient’s response to lack of privacy
Provide privacy during elimination
Facilitate toilet hygiene after completion of elimination
Replace patient’s clothing after elimination
Flush toilet/cleanse elimination utensil (commode, bedpan)
Institute a toileting schedule, as appropriate
Instruct patient/ appropriate others in toileting rountine
Institute bathroom rounds, as appropriate and needed
Provide assistive devices (e.g., external catheter or urinal), as appropriate
Monitor patient’s skin integrity


SELF-CARE ASSISTANCE : TRANSFER
Definition : Assisting a patient with limitation of independent movement to learn to change
body location
Activities :
Review chart for activity orders
Determine current ability of patient to transfer self (e.g.,mobility level, limitations for
movement, endurance, ability to stand and bear weight, medical or orthopedic instability,
level of consciousness, ability to cooperate, ability to comprehend instructions)
Select transfer technique that is appropriate for patient
Instruct patient in all appropriate techniques with the goal of reaching the highest level of
independence

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