2D. Restraints in Geriatrics

Initiation of restraint or seclusion

-In emergency situation, RN can initiate a restraint or seclusion -Non-violent restraint order must be signed within 24 hours following the initiation of restraint.

Restraints and seclusion must be

-discontinued as soon as safely possible -use the least restrictive alternative for the least amount of time

Procedure statements summary (8)

1.Attempt less restrictive interventions first (e.g., calming) 2.Initiate restraint if necessary 3.Assess in-person & document 4.Continue assessment & documentation every 2 hours (non-violent) or every hour (violent) 5.Monitor 6.Educate 7.Update plan 8.Renew if necessary

It is is against the law for a SNF to....

to use physical or chemical restraints, unless it's necessary to treat your medical symptoms

Violent restraint or seclusion renewed for limits up to

total 24 hours

Nursing home shall provide a physical restraint to a resident only

upon signed consent

Non-violent restraint

•All restraint other than the violent restraint defined above, used to ensure the physical safety of the non-violent patient. Some examples include pulling at lines or tubes, removing equipment or dressings, or attempting to disconnect from a ventilator

Chemical restraint examples (2)

•Antipsychotic butyrophenones (Haldol, Droperidol) Benzodiazepine sedatives (Lorazepam, Midazolam)

Physical/mechanical restraint-Definition:

•Any manual method, physical or mechanical device, material, or equipment that immobilizes or reduces the ability of a patient to move his/her arms, legs, body, or head freely that the patient cannot easily remove

Mayo scope:

•Applies to qualified staff when performing violent or non-violent restraint activities in the hospital inpatient and hospital-based outpatient setting.

Chemical restraint-Definition:

•Can include a drug or medication when used as a restriction to manage the patient's behavior or restrict the patient's freedom of movement and is not a standard treatment or dosage for the patient's condition

Exclusions to restraint (3)

Do not include devices that involve the physical holding of a patient to: •conduct routine physical exams or tests •protect the patient from falling out of bed •permit the patient to participate in activities without risk of physical harm

Take home point on side rails

Not only do side rails pose a hazard, they do not prevent falls when no hazard is experienced

Injury and death associated with hospital bed side-rails

head/neck injuries most common 65% with death between side-rail and mattress or through side-rail bars

When a patient is restrained or secluded an ______must be performed

individualized patient assessment

What also needs to be updated?

plan of care or treatment plan

Restraints may not be used (SNF)

punish or for the convenience of the SNF staff.

Initiation and application must be done by

qualified staff

Who can consent to restraints? SNF

residents, family members of residents who are not competent, and legally appointed conservators, guardians, and health care agents

Freedom from maltreatment

Every patient and resident shall also be free from nontherapeutic chemical and physical restraints, except in fully documented emergencies, or as authorized in writing after examination by a patient's or resident's physician for a specified and limited period of time, and only when necessary to protect the resident from self-injury or injury to others.

_____hour for children under 9 years of age

One

______ for children and adolescents 9 to 17 years of age

Two

Medical symptoms SNF falling

a concern for the safety of the resident fear of falling

Authorized providers ordering restraint or seclusion must have

a working knowledge of policy

SNF Nursing home reform act of 1987 stated

be free from physical restraints

Qualified staff must have

completed training requirements

Nursing home providing restraint must (3)

document monitor reevaluate

Assessment, reassessment and ongoing monitoring must be

documented in medical record

______ for adults 18 years of age or older

four

Exclusion examples ():

•IV arm board to stabilize an IV line, unless armboard is tied down •Mechanical support to achieve proper body position, balance or alignment so as to allow greater freedom of mobility •Medically necessary positioning or securing device to maintain position, limit mobility or temporarily immobilize pt. during medical, dental, diagnostic or surgical procedures and during recovery from anesthesia •Age or developmentally appropriate protective safety interventions such as stroller safety belts, swing safety belts, high chair lap belts, raised crib rails or crib covers to protect infant, toddler, preschool-aged child •Physical escort using a "light" escapable grasp to escort the patient •Side rails in multiple situations •Forensic and corrective devices or restrictions used primarily for security purposes and applied by security or law enforcement

Risks of restraints (4)

•Lead to cuts/bruising •Lead to pressure injuries (difficulty unloading pressure points) •Lead to incontinence •Have consequences related to mental health (social withdrawal, anxiety, depression)

Side rails restraint exclusions (5)

•On stretcher •Recovery from anesthesia •Patients experiencing involuntary movement •Seizure precautions with padded side rails •To prevent the patient from falling out of bed (side rails are NOT being used to restrict the pt's freedom to exit the bed)

Authorized prescriber

•Physicians, clinical psychologists, and other licensed independent practitioners authorized to order restraint or seclusion through hospital procedure in accordance with law and regulation

Violent restraint

•Restraint used for an emergency situation to manage violent or self-destructive behavior that jeopardizes the immediate physical safety of the patient or others

Purpose

•To ensure that restraint and seclusion on patients is used in the least restrictive manner and that patient safety, dignity, sense of wellbeing, and protection of individual rights is honored. Additionally, ensure that the decision to restrain or seclude is based on a comprehensive patient assessment and only used when warranted by patient behavior that threatens the physical safety of the patient, staff, or visitors justified, not as a means of coercion, discipline, retaliation, or out of convenience.

Chemical restraints are typically

•antipsychotic medications given to residents with dementia in order to sedate them and control behavior •Not medically necessary for treatment •Tool for convenience of staff members

Examples of restraints

•posey vests, wrist ties, lap belts, trays in chairs, soft padded limb restraints, bedrails, hand mitts, seat belt on chair

"Easily remove"

•the patient can intentionally remove the manual method, device, material or equipment in the same manner as it was applied by the staff considering the patient's physical condition and ability to accomplish the removal