restraints

What is not considered a restraint?

"safety devices"- used for a particular treatment and are not considered a restraint, even though they limit freedom of movement. -rm immobilizers, helmets, all side rails up with seizure pads, boots/slings/wrist braces, swaddles. - Devices used to immobilize a pt. temporarily during a diagnostic procedure. - Orthopedic supportive devices. - Helmets or age appropriate protective equipment, such as strollers or cribs.

Goals within restraint use

**The optimal goal for all patients is a restraint-free environment and to ensure patient safety** - Always consider and implement alternatives to restraints first. - Individualize your approach for each patient - Use least restrictive restraint for situation. - ONLY use restraints if all other strategies to ensure pt. safety has been exhausted. - Restraints are NOT a solution to a pt. problem but rather a temporary means to maintain pt. safety.

what needs to be documented

- A complete head-to-toe assessment. - The HCP restraint order. Including the time, date, and behavior evidence of medical evaluations and nursing reassessments. - Number and type of restraints; where they are placed. - Education provided to pt. and family. - Continuous assessment of the pt.'s need for restraint. - Assessment of the pt.'s mental and physical status at regular and frequent intervals. - The frequency with which the restraints are removed. (should be Q2) - The neurovascular assessment. - Extremity range of motion. - Pt.'s vital signs - The skin assessment of limbs or other body parts covered by the restraints. - Monitor 4-point restrains Q15mins - Food, fluid, & toileting offered. *Including all reassessments during the use of the applied restraint. (should be Q30min/Q1)*

Application of Soft Restraints

- Always us quick release knot - Tie to non-moveable portion of bed frame - Call light within reach - NEVER use something that is not a restraint as a restraint.

alternatives to restraints

- Having a sitter; staff of family member sitting with them at all times using: * Distractions* De-escalating strategies* Offering re-assurance - Use bed or chair alarms - Administer certain medications - Simply talk with the patient to understand any anxiety, depression, pain or fear causing the behavior.

violent physical restraints

- Lock and Key or Buckle system - Leather restrains: Wrist & Ankle, and Chest. (4-point). *To remove 4-point restraint start slowly with the ankles then go to the arms. Re-orient pt. after removed.

Acceptable use of a restraint

- The patients *current* behavior determines if and when a restraint is needed. Meaning continuous assessment is vital with restraints. - Decision must be based on a current thorough medical and psychological nursing assessment. - Determining the risks of using it (physical/psychological) vs. the risk of not using it (patient safety). - History of violence or a previous fall alone is NOT enough to support using a restraint

provide to patient during restraints

-toileting -nutrition -repositioning

Release restraints at least every ____ hours.

2

Seclusion

A patient is held in a room involuntarily and prevented from leaving. - Used only for patients who are: behaving violently and only in the ED or Psych units.

restraint

Any device or drug that prevents the patient from moving freely and must be prescribed by a health care provider/physician.

when house violent restraint

Devices or interventions for pt.'s who are violent, aggressive self-destructive behavior such as, but not limited to: - Threatening to hit - Striking staff - Banging their head on the wall - Need stopped from causing further injury to themselves or others.

Nurse's responsibilities before placing a restraint

First, the nurse should have knowledge and understandings of all of the facilities laws, rules, policies and procedures pertaining to the use of restraints. 1.) Exploring alternatives- Document the trial/use of the alternative used, and its results. 2.) Obtain a physician's order. (this is exempt in emergency situations, but nurse should still obtain order directly prior to applying restraint) - Educate the patients and family with: * The purpose of the restraint * Expected plan of care * Precautions to be aware of * In some cases, informed consent.

chemical restraint

Involves use of a drug that: - Restrict a patients movement or behavior - The drug dosage used isn't an approved standard of treatment for the pt.'s condition.

when to use a restraint

Only resort to physical restraint once you've implemented appropriate alternatives that have been proven insufficient, ineffective, or deemed potentially unsuccessful

Types of Restraints

Physical- Violent and Non-violent Chemical- Medicated Seclusion- Placed in confined/alone condition

when to use non violent restraint

Used for non-self destructive behaviors. Nursing interventions to enhance patient care and to prevent the patient from: - Pulling at tubes, drains, & lines - Ambulating when unsafe to do so

non violent restraint

Vail bed - Soft wrist/ankle restraint- tied to bed frame - Vest - Mitts

examples of restraints to watch out for

Wrist, ankle, & waist restraint. - Tucking in the sheets very tightly so the pt. can't move. - Keeping all side rails up to prevent the pt. from getting out of bed. - Enclosure bed (Vail bed) - Restricting the movement of a pt. by holding them down (limb, full body, head) for medical treatment. If the pt. can easily remove the device, it doesn't qualify as a restraint.

imprisonment

any use of restraint when not appropriate

take of restraints

as soon as patient behavior improves as soon as possible!!

All side rails up

considered restraint (can only be used when ordered or if client asks)

visually asses patient

every 15 mins

enclosure bed

sit with patient to help them get adjusted before zipping up -high risk of falling

physicians job

to write order -must come after 24 hours if restraints are still on to reassess and maybe rewrite order