Chapter 11: Restraints

Physical restraints confine the person to a bed or chair, or they prevent movement of a body part. Some furniture or barriers also prevent freedom of movement. What are some examples?

- a device used with a chair that the person cannot remove easily; the device prevents the person from rising (trays, tables, bars, belts, etc.) - any bed or chair placed so close to the wall that the person cannot get out of the bed or chair - bed rails that prevent the person from getting out of bed (example: 4 half-length bed rails are raised - they are restraints if the person cannot lower them) - tucking in or using Velcro to hold a sheet, fabric, or clothing so tightly that freedom of movement is restricted

What are some ways you can practice safety when applying restraints?

- apply a restraint only after being directed about its proper use - position the person in good alignment before applying the restraint - check the person at least every 15 minutes for safety, comfort, and signs of injury

Wrist restraints limit arm movement, and can be used for those who...

- are at risk for pulling out tubes used for treatment (IV infusions, feeding tubes) - are at risk for pulling at devices used to monitor vs - scratches at, pulls at, or peels the skin, a wound, or a dressing

Along with the CMS, the FDA, state agencies, and the TJC do not actually FORBID restraint use - rather, they demand to always try all other appropriate alternatives FIRST before applying a restraint. List some alternatives for restraint use.

- ensure that food, fluid, hygiene, and elimination needs are met - the person can be moved to a room that is closer to the nurse's station - all staff are aware of persons who tend to wander (this includes staff in housekeeping, maintenance, the business office, dietary, and so on) - floor cushions are placed next to beds - their time is spent in supervised areas (dining room, lounge, by the nurse's station, etc.)

Often, there are causes and reasons for harmful behaviors. Knowing and treating the cause can prevent restraint use. The nurse tries to find out what the behavior means. What are some questions the nurse can ask himself/herself?

- is the person in pain, ill, or injured? - are body fluids, secretions, or excretions causing skin irritation? - are drugs causing the behaviors?

The restrained person must be kept safe. What are some key rules to follow when making an effort to ensure the person's safety?

- observe for increased confusion/agitation - protect the person's quality of life - follow the manufacturer's instructions - apply restraints with enough help to protect the person and staff from injury - observe the person at least every 15 minutes, or as often as noted in the care plan - remove or release the restraint, re-position the person, and meet basic needs at least every 2 hours (or do so as often as noted on the care plan)

You are applying a belt restraint to a patient. The person is confused and resists your efforts. What should you do?

Do not use force in applying the restraint; if a person is confused or agitated, I would ask a co-worker for help and report issues to the nurse at once.

True or False: Bed rails are left down when a vest restraint is used.

False.

True or False: Restraint alternatives fail to protect a person. You can apply a restraint.

False.

True or False: Restraints are tied to bed rails.

False.

True or False: You can apply restraints when you think they are needed.

False.

True or False: Drugs and drug dosages can be used to discipline the person and for staff convenience.

False. In addition, they CANNOT be used if they affect physical or mental function in any way.

The nurse tells you to apply a wrist restraint to a patient's right wrist. You do not understand why the restraint is being used. What should you do?

I would politely ask "why?" If I were to apply an unneeded restraint, I could be charged with false imprisonment.

True or False: A restraint restricts a person's freedom of movement.

True.

True or False: Bed rails are restraints if the person cannot lower them.

True.

True or False: In an EMERGENCY, a nurse can decide to apply a restraint before getting a doctor's order.

True.

True or False: Restraints can increase confusion and agitation.

True.

True or False: Restraints must be completely discontinued as soon as possible.

True.

If you do not know how to apply a certain restraint, what should you do?

ask the nurse to show me the correct way, and have him/her watch me apply it

How often do you need to check the person's circulation if mitt, wrist, or ankle restraints are used?

at least every 15 minutes

A jacket restraint is applied with the opening in the _____.

back

A ____ restraint may be used when injuries from falls are a risk or for positioning during a medical procedure. The person cannot get out of bed or out of a chair. The belt is applied around the waist and secured to the bed or chair. It is applied over a garment.

belt

A _____ _____ is any drug used for discipline or convenience and not required to treat a medical symptom.

chemical restraint

List some other risks that can stem from restraint use.

constipation contractures decline in physical function (ability to walk/muscle condition) decubitous ulcers falls social and mental health problems

Drugs and drug dosages are considered chemical restraints if they...

control behavior restrict movement are not standard treatment for the person

The nurse restrains a resident to the chair in the person's room so he can make rounds without being interrupted. This action is unacceptable because it is for ______.

convenience

Injuries can occur as the person tries to get free of the restraint. Injuries also can occur from using the wrong restraint, applying it wrong, or keeping it on too long. Cuts, bruises, and fractures are common. The most serious risk is...

death from strangulation

List 9 mental effects of restraint use.

depression delirium agitation anger loss of dignity loss of self-respect embarrassment withdrawal reduced social contact

An ______ is a device that limits freedom of movement but is used to promote independence, comfort, or safety.

enabler

When applying a restraint to the person's chest, you must...

ensure that the person can breathe easily

Before applying a restraint to a person, what should you say?

explain to the person what I am going to do; then I tell the person what I am doing step-by-step as I'm doing it, and always check for safety and comfort ("Is it too tight? Too loose?")

Restraints are made of cloth or leather. Leather restraints are only applied to the wrist and ankles. Leather restraints are only used for...

extreme agitation and combativeness

_______ ____ _______ is any change in place or position of the body or any body part that the person is able to control.

freedom of movement

For a vest restraint, the "V neck" is in ____ and the vest crosses in the ___.

front front

List the legal aspects of restraints.

informed consent is required a doctor's order is mandatory restraints must protect the person the least restrictive method is used restraints are only used if all possible alternatives are deemed ineffective unnecessary restraint is false imprisonment

Restraints can be used ONLY when...

less restrictive measures are deemed ineffective a doctor's order is involved it is in the person's best interest

Sometimes, drugs can benefit people who are confused or disoriented. They may be anxious, agitated, or aggressive. The doctor may order drugs to control these behaviors. However, the drugs given CANNOT...

make the person drowsy or make the person unable to function at their highest level

According to the CMS, physical restraints include these points...

may be any manual method, physical or mechanical device, material or equipment are attached to or next to the person's body cannot be easily removed by the person restrict freedom of movement or normal access to one's body

____ restraints have the same purpose as wrist restraints, except they prevent finger use.

mitt

_____ _____ is any manual method or physical or mechanical device, material, or equipment attached to or near the person's body that he or she CANNOT remove easily and that restricts freedom of movement or normal access to one's body.

physical restraint

The Centers for Medicare and Medicaid Services (CMS) has rules for using restraints. Like OBRA, CMS rules...

protect the person's rights and safety - this includes the right to be free from restraint

____ _____ is the manual method, device, material, or equipment used to restrain a person that can be removed intentionally by the same person in the same manner it was applied.

remove easily

Some devices are restraints and enablers. When the person can easily remove the device AND it helps the person function, it is an enabler. A chair or wheelchair with a lap-top tray is used for meals, writing, and so on. The chair is an enabler. But if it used to limit freedom of movement, the chair is a _____. A person chooses to have bed rails. The bed rails are used to move in bed and to prevent falling out of bed. The bed rails are ______.

restraint enablers

Restraints are NOT used for...

staff convenience discipline

Explain why you should never secure restraints to the bed rails.

the person can reach bed rails to release buckles or knots injury to the person is likely when raising or lowering bed rails

A resident's doctor writes an order for a restraint. What information does the doctor's order contain?

the reason for the restraint what body part to restrain what to use how long to use it

What is the purpose of bed rail covers and gap protectors?

they prevent entrapment between the bed rails or bed rail bars

When the person is sitting in a chair/wheelchair, straps to prevent sliding should always be over the _____, NOT around the chest or waist. The straps should be secured to the chair under the seat, NOT around behind the back. If the belt or vest is too loose or applied around the waist, the person may slide partially off the seat.

thighs

You are applying a wrist restraint. The person is in bed. Where should you tie the straps?

to the movable part of the bed frame out of the person's reach

Restraints may be used for...

treating a medical symptom the immediate physical safety of the person/others

___ and ___ restraints are applied to the chest. They have the same purpose as belt restraints. The person cannot turn in bed or get out of a chair.

vest jacket