Restraints & Seizures

Physical Restraint

-A mechanical or physical device used to immobilize a patient or extremity, restricting the freedom of movement or normal access to the body, and is not a usual part of the treatment plan

Postictal phase the patient may experience

-Amnesia/confusion -Deep sleep

Removal

-Continue to use less restrictive measures to gain patient cooperation so restraints can be discontinued. Assessment by the RN is ongoing and restraints can be removed based on the assessment.

Collaborate

-Discuss with other nurses, physicians, OT, PT, SS, etc. -Utilize all resources in developing less restrictive measures

Documentation

-Document all aspects when restraints are used -Close documentation is indicated for a patient when restraints are used -Carefully follow procedures and protocols for initiating and monitoring the sure of restraints. Legal ramifications if improperly utilized

Assessment

-Every 15 minutes when a patient is in a physical restraint (can be delegated out) -RN assessment every 2 hours -Be attentive to patient needs/conditions: toileting, eating, distal pulses, skin integrity-bruising, irritation, etc. -Release of restraint every 2 hours -Restraints are tied to bed frame, not moveable part of bed

Seizure

-Hyperexcitation and disorderly discharge of neurons in the brain leading to a sudden, violent, involuntary series of muscle contractions that is paroxysmal and episodic, causing loss of consciousness, falling, tonicity (rigidity of muscles), and clonicity (jerking of muscles)

Less Restrictive Meaures

-Identify underlying clinical problem that can be corrected; meds, infection, pain, electrolyte imbalance -Reorient patient as needed -Attention needs: toileting, eating, activities -Let the patient be on "their" schedule -Eliminate tube/drains as early as possible or make them less apparent -Family supervision -Reality links: TV, newspaper, calendar -Pain management -Relocate patient

Restraint

-Involuntary method (chemical or physical) of restricting an individual's freedom of movement, physical activity, or normal access to the body

Standards for Safe Restraint Use

-Must try less restrictive measures before physical restraints are used -Must collaborate with health care team members to initiate use of restraint -Physician order is required for a physical restraint -Must explain reason for use of restraint to the patient and family -Routine assessment of a client in restraint is critical to prevent injury -Document thoroughly

Physician Order

-Necessary -Must be written -Patient must be seen if placed in restraints by nurse -No PRN orders -Orders are time limited: they expire in 24 hours or LESS, depending on age of patient

Aura

-Often a bright light, smell, or taste serving as a warning that a seizure is about to occur- not all patients have auras

Notification

-Patient is given an explanation of why restraint is being used -Family is contacted also if not present

Patient Bill of Rights

-Patients have a right to be free from restraints unless a restraint is necessary to treat their medical symptoms or to prevent patients form harming themselves or others

Protecting Patient During a Seizure

-Position patient safely: guide to floor if sitting/standing. Protect head by cradling in lap or placing pad under head -Clear surrounding area of furniture/clutter & provide privacy -May need to turn patient onto one side with head tilted slightly forward -DON'T RESTRAIN, loosen clothing -Never force apart clenched teeth or place any objects into patients mouth such as fingers, medicine, tongue depressor -Insert a bite-block or oral airway in advance only if you recognize the possibility of a tonic-clonic seizure -As patient regains consciousness, reorient and reassure -Head-to-toe assessment including an inspection of oral cavity for breaks in mucous membranes from bites or broke teeth and assess for bruising/injury to bone/joints

During a seizure a patient may experience

-Shallow breathing -Cyanosis -Loss of bladder and bowel control

Examples of physical restraints

-Soft wrist/ankle -Leather wrist/ankle -Handcuffs -Hand mitts -Vest restraint -Geri Chair -Net bed

When can restraints be used?

-To prevent a patient from harming them self or others *This includes behaviors that are preventing medical healing: pulling out IV, NG, dressing *Emergency situations: intoxication and belligerent, anxiety, pain, restless while in flight

Seizure Precautions

-Use of padded side rails -Bed in low position -Oxygen, suction set-up, and oral airway should be readily available in room

Chemical Restraint

-Use of sedating psychotropic drug to manage or control behavior

Examples of chemical restraints

-Versed -Lorazepam -Haldol -Valium -Ativan