The Nurse Is Preparing to Write the Nursing Progress Notes

The nurse is preparing to write the nursing progress notes for a patient who has wrist restraints. Which chart entries will the nurse include in the progress notes? Select all that apply.

A) Family teaching initiated regarding the need for patient restraint
B) Restraint removed once per shift to assess skin color, sensation, and movement of extremity
C) Prescription for wrist restraint received from the primary care provider
D) Wrist restraints applied because of the patient's increasing confusion
E) Double knot used to tie restraints to bed frame