Transcription of Pharmacologic Restraint Management Worksheet Form
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Pharmacologic Restraint Management Worksheet Form
19676(Rev2019-03) Pharmacologic Restraint Management WorksheetDate (yyyy-Mon-dd) _____ o Initial Review o ReassessmentTarget behaviour: description, time, frequency, why is this behaviour a problem? What is the risk of harm? What is the goal?_____Family/Alternate Decision-maker: goals, possible underlying needs and care strategies:_____Supportive interventions attempted, and effectiveness_____Possible underlying reasons for target behaviouro Delirium and other medical conditions ( dehydration, blood sugar Management , nutrient deficiencies) _____o Unmet needs & patterns informed by behavior map, health record, staff: Physical ( lack of sleep, constipation, pain, elimination, hunger, thirst, too hot or cold), Psychosocial ( stress threshold, loneliness, depression, post-traumatic events), Environmental ( over/under stimulation, inconsistent routine), Staff ( approach, gender) _____o Medication review by pharmacist/prescriber ( possible side effects/interactions, PRN usage, anticholinergic effects)_____Interdisciplinary team recommendationso Assessment behaviour map _____o Additional supportive interventions _____o Further investigation consults, lab work _____o Medication changes _____o Other _____o Next review _____Reviewer Name (Last Name, First Name)SignatureReviewer Name (Last Name, First Name)SignatureNext Steps, by whomo Side-effect monitoring _____
• Behaviour that places self/others at risk of injury (consider distraction, approach/re-approach, offering choices) (Short term use may be appropriate …
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