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Check vitals, as there have been patients who have had cardiac attacks, (related to the wrestling match prior to, no doubt) and if elevated, check again in 15 minutes. In the USof A, we have an oversight body that expects us to maintain a 1:1 watch as long as the person is locked up, to try to avoid "sentinal events", like dying. If the patient is yelling profanities, you may not want to take vitals, but you can use the volumn and force to record that the patient is ventilating well. Note colour of skin, absence or presence of eye contact, and be sure to describe the precipitating event in such a way as to make it clear that there was no other way to handle the event. Describe the behavior, ie: pacing, seated, banging, whatever. One of the first nurses that coached me years ago said charting was as easy as A-B-C. Appearance, Behavior, Conversation. Kind of works when I'm stuck. And I always quote the patient, even if they are using words that I won't. If the chart ends up in court, direct quotes are much more meaningful that a vague statement like "Upset, using foul language." There are probably more, and I'll write again if I can add anything meaningful. And enjoy! Psych nursing as great.
narny
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Hi, This is my first post, I hope I'm doing it right. I am in my third and final semester, doing EEN, and would like some feedback on Mental Health. The question I would like help with is: What do you consider to be the five most important points as far as recording ( documenting ) a patient who is in seclusion?
Many thanks.