Restraints

CMS requires

- reason for restraint - type of restraint - informed consent - continued or discontinued - nutrition (foods or fluids) - circulation - movement - skin

safety

- regular rounding and assessments - proper application of the type of restraint used -- fit to the client -- applied to proper location -- single knot or quick release available

Alternatives to restraints

Alternatives include having staff or a family member sit with the patient, using distraction or deescalation strategies, offering reassurance, using bed or chair alarms, and administering certain medications.

Enclosure bed

An enclosure bed helps prevent patient injury by stopping the patient from getting out of bed unassisted. It may be a good option for patients who meet the criteria for this bed.

CMS

Centers for Medicare and Medicaid

Chest vests and lap belts

Chest vests and lap belts (also called waist belts) may be warranted for confused or impulsive patients who are continually trying to get out of bed or a chair after repeated redirection, when it's unsafe for them to get up unaided. Apply the vest or belt according to the manufacturer's instructions. Fasten it securely to an immovable part of the bed or chair

Hand mitts and freedom sleeves

If the patient is confused and impulsive and doesn't follow directions but can be redirected, consider hand mitts to decrease grabbing ability. Or consider "freedom sleeves" (also called soft splints). These are a good deterrent for patients trying to remove a medical device from the face or head (such as a nasogastric tube or drain). With freedom sleeves, patients have difficulty bending their arms

Limb restraints

Soft bilateral limb holders on both wrists may be appropriate for patients who are becoming increasingly agitated, can't be redirected with distraction, and keep trying to remove needed medical devices.

Restraints for violent, self-destructive behavior.

These restraints are devices or interventions for patients who are violent or aggressive, threatening to hit or striking staff, or banging their head on the wall, who need to be stopped from causing further injury to themselves or others. The goal of using such restraints is to keep the patient and staff safe in an emergency situation.

Categories of restraints

Three general categories of restraints exist—physical restraint, chemical restraint, and seclusion.

Restraints for nonviolent, nonself- destructive behavior

Typically, these types of physical restraints are nursing interventions to keep the patient from pulling at tubes, drains, and lines or to prevent the patient from ambulating when it's unsafe to do so—in other words, to enhance patient care.

Seclusion

a patient is held in a room involuntarily and prevented from leaving.

isn't a restraint

aren't considered restraints: • devices used to immobilize a patient temporarily during a diagnostic procedure • orthopedic supportive devices • helmets or age-appropriate protective equipment, such as strollers and cribs. Keeping all side rails up on a bed for seizure precautions and placing the patient on a narrow stretcher are considered safety interventions, not restraints.

improper restraint use

can lead to serious sanctions by the state health department, The Joint Commission TJC or both.

Chemical restraint

involves use of a drug to restrict a patient's movement or behavior, where the drug or dosage used isn't an approved standard of treatment for the patient's condition. For example, a provider may order haloperidol in a high dosage for a postsurgical patient who won't go to sleep.

A provider order

must be obtained for patient restraint.

use restraints

only to help keep the patient, staff, other patients, and visitors safe - and only as a last resort

determines when to use a restraint

patient's behavior

chart

per pollicy - routine: this means it must happen at regular intervals

Physical restraint

the most frequently used type, is a specific intervention or device that prevents the patient from moving freely or restricts normal access to the patient's own body. Physical restraint may involve: • applying a wrist, ankle, or waist restraint • tucking in a sheet very tightly so the patient can't move • keeping all side rails up to prevent the patient from getting out of bed • using an enclosure bed. Also, holding a patient in a manner that restricts movement (such as when giving an intramuscular injection against the patient's will)

TJC restraint risks

• Placing a restrained patient in a supine position could increase aspiration risk. • Placing a restrained patient in a prone position could increase suffocation risk. • Using an above-the-neck vest that's not secured properly may increase strangulation risk if the patient slips through the side rails. • A restraint may cause further psychological trauma or resurfacing of traumatic memories. To help reduce these risks, make sure a physical restraint is applied safely and appropriately.

documentation

• patient behavior that indicates the continued need for restraints • patient's mental status, including orientation • number and type of restraints used and where they're placed • condition of extremities, including circulation and sensation • extremity range of motion • patient's vital signs • skin care provided • food, fluid, and toileting offered. Also, include the education you provide to the patient and family. Remember—the goal is to remove the restraints as soon as possible.