Chp. 13: Promoting a Restraint-Free Environment
the person who is restrained must be observed every
15 minutes
drugs are restraints if they
A) aren't required for the person's treatment B) are used for discipline or staff convenience
when you remove the restraints every 2 hours, what are the basic needs that should be met?
A) measure vital signs B) meet elimination needs C) offer food and fluids D) meet hygiene needs / give skin care E) perform ROM exercises or help walk F) provide for physical and emotional comfort
restraints are used only as a last resort, when other measures have to do one or all of the following:
A) restrict the person from moving at all B) calming the person does not work C) an object makes the person mad
when using restraints, what information is reported and recorded?
A) type of restraint applied/ body part or parts restrained B) reason for application of restraint C) safety measure taken D) time you applied/ each time you took off E) person's vital signs F) care given when it was removed/released G) skin color and condition H) condition of limits I) pulse elt in restrained part J) changes in person's behavior K) complaints of discomfort
when you are delegated to apply restraints, what information do you need from the nurse and the care plan?
A) why the doctor ordered the restraint B) what type and size to use C) where to apply the restraint D) how to safely the restraint E) how to correctly position the person F) what bony areas to pad and how to pad them G) if bed rail covers or gap protectors are needed H) if bed rails are up or down I) what special equipment is needed J) if the person needs to be checked more often than every 15 minutes K) when to apply and release the restraint L) what observations to report and record M) when to report observations N) what specific patient and resident concerns to report at once
when you check the restrained person's circulation every 15 minutes, tell the nurse at one if you observe these signs or symptoms
A) you cannot feel a pulse B) fingers or toes are cold, pale, or blue in color C) the person complains of pain, numbness, or tingling in the restrained part D) the skin is red or damaged
elbow restraints are used
Ffor children to limit movements and prevent scratching and touching incisions
rules about using restraints are part of
OBRA, FDA, and CMS regulations
which of these is a type of restraint?
a geriatrics (Geri) chair with a tray
a belt restraint (in a w/c)
allows the person to turn from side to side
the straps of vest and jacket restraints
always cross in the front
persons restrained in a supine position must be monitored constantly because they are a great risk for
aspiration if vomiting occurs
a person's harmful behaviors may be caused by
being afraid of a new setting, being too hot or too cold, and being hungry or thirsty
the person with a __________, __________, or __________ restraint is at great risk for strangulation and suffocation if he or she gets caught in the restraint if the restraint is too tight.
belt, vest, jacket
research shows that restraints
cause falls
a belt restraint should be
checked to make sure the person is comfortable and in good alignment
restraints may increase
confusion and agitation
restraints are not used to
control the person's behaviors
the most serious risk from restraints is
death from strangulation
after receiving instructions about the proper use of a restraint you should
demonstrate proper application before using it on a person
__________, __________, and __________, may prevent accidents, injury, and restraint use
follow manufacturer's instructions, observe person at least every 15 min., and remove or release restraint every 2 hours
any change in place or position for the body that the person is physically able to control is called __________.
freedom of movement
the person must understand the reason for the restraints
informed consent is required for restraint use
if you are using padded mitt restraints, you should
make sure the person's hands are clean and dry
when elbow restraints are used
make sure you can slide two fingers between the restraint and the child's arm
an indication or characteristic of a physical or psychological conditon is a __________.
medical symtpom
what is not a legal aspect of restraint?
nurses can decide when to use restraints, what type restraints to use, and how long to use the restraints
restraints are used
only when other methods fail to prevent persons from harming themselves or others
for which persons are mitt restraints ordered?
patient that triest o take IV out, scratch at, pull at, or peel the skin, wound, or dressing
when applying wrist restraints
place the soft part toward the skin
wrist restraints are used when a person
pulls at tubs used in medical treatments
restraints are used for as short a time as possible, and needs are met with as little restraint as possible
quality of life must be protected
if a person with a best, jaket, or belt restraint is having difficulty breathing or is not breathing, you must __________.
release, reposition, and talk to nurse
__________ is a term used when a manual method device, material, or equipment can be removed intentionally by the person in the same manner it was applied by the staff.
remove easily
when a person is restrained, every 2 hours you should
remove the restraints, reposition the person, and meet basic needs
a __________ is any method that restricts freedom of movement of normal access to one's body. these methods may be physical, mechanical device, material, equipment attached to the body or sometimes drugs
restraint
explain what "the least restrictive device" means.
restraint that provides the most freedom to meet the needs of the patient
persons in immediate danger of harming themselves or others are restrained quickly.
restraints are applied with enough help to protect the person and staff from injury
the care plan must include measures to protect the person and to prevent the person from harming others
restraints are used only after other methods fail to protect the person
the doctor gives the reason for the restraint, what to use, and how long to use the restraint
restraints are used only after other methods fail to protect the person
restrained persons need repeated explanations and reassurance
restraints can increase a person's confusion and agitation
a restraint is used only when it is the best safety precaution for the person
restraints must protect the person
the involuntary confinement of a person alone in a room or area from which the person is physically prevented from leaving is called _________.
seclusion
what lifelong habits and routines could be included in the nursing care plan as alternatives to restraints?
shower before breakfast, reads in bathroom, walks outside/ watches TV before lunch
using a restraint requires informed consent. this consent is obtained by
the doctor or nurse
when restraints are needed, their use is determined by
the doctor or the using the nursing process
because they are the least restrictive, passive physical restraints should be used when possible.
the least restrictive method of restraint is used
the nurse gives you the manufacturer's instructions about applying and securing the restraint safely.
the manufacturer's instructions are followed
how does a restraint increase incontinent?
the patient will not be able to move or get out of their seat
when you check a person in a vest, jacket, or belt restraint, report at once if
the person is not breathing or is having difficulty breathing
injuries and deaths have occurred from improper restraint and poor observation
the person is observed at least every 15 minutes or more often as required by the care plan
when the restraint is removed, ROM exercises are done or the person is ambulated
the restraint is removed, the person repositioned, and basic needs are met at least every 2 hours
when using a vest restraint in bed
the straps are secured to the bed frame at waist
why would a person in restraints be at risk for dehydration?
they can't reach liquid
why would video tapes of family and friends or visiting with family be good alternatives to restraints?
this direct the patient's attention to something they are familiar with and like
what is the purpose of padded hip protectors and floor cushions?
this reduces a patient's chances or hurting themselves if they bump or fall
if told to apply a restraint, you must clearly understand the need for restraints and the risks
unnecessary restraint is false imprisonment
for which persons are vest or jacket restraints ordered?
used to prevent injuries from falls
what is an example of an active physical restraint?
vest
when restraining a combative and agitated person, it should be done
with enough staff to complete the task safely and efficiently
you should carry scissors with you because in an emergency
you can cut the tie, it will be easier than unknotting the tie
