Restraints N.F. Pgs. 372 - 376. Definition of a restraint The use of major tranquilizers or physical means to prevent patients from harming themselves.

RestraintsN.F.

Pgs. 372 - 376

Definition of a restraint

• The use of major tranquilizers or physical means to prevent patients from harming themselves or others

• FDA says it’s a “device” used for medical purposes that limits a pt’s movements to the extent necessary for treatment, exam or protection of the pt

Restraint devices are…

• Wrist

• Ankle

• Vest

• Jacket or posey

• Or other strap to secure a pt in place such as a lap belt

Vest Restraints (Posey Vest)

Lap Belt

ElbowRestraints

Mitt Restraint

Mummy Restraint

Application of restraint

• Restraints should be fitted properly

• They should be applied in the manner that they WILL not cause accidental injury or harm to the pt such as strangling or smothering if pt slips down in the bed , wheelchair or chair

Why Limit Restraint Use?

• It’s the law– JCAHO– Federal Omnibus Budget Reconciliation Act

(long term care only)– State and Local Standards

• It causes confusion and agitation

• It limits mobility and thus health

• Cause Injury

Negative effects of restraint use…

• Increases confusion

• Constipation

• Incontinence

• Pressure sores d/t non-movement

• Decreased inability to perform ADL’s or ROM

Assessment of patient

• A full assessment of pt is a MUST• Determine pt’s state of mind such as

confusion, delirium, depression• Is pt dizzy upon standing alone, is

assistance required• Assess pt for need of restraint…does pt

have tubes he/she is trying to pull out, is pt trying to escape the facility

Restraint protocol

• Each facility has a restraint protocol, must become familiar with your institution

• JCAHO approves each facilities protocol

• FOLLOW IT or write up on your part will occur

Medical order

• You must follow your institution’s protocol however,

• A nurse must notify a physician of the need for restraints. The physician has the ultimate say in whether a restraint will be used. Nurse cannot just apply the restraint

The order…

• Must specify the type of restraint• Must state the reason why the restraint is needed• Must state the criteria for removal of it• Must state the length of time the restraint is to

remain on• THE ORDER MUST BE RENEWED q 24HRS

AFTER THE DR. PHYSICALLY EXAMINES THE PT

How to prepare to use restraints…

• Assessment of pt and their needs

• Assessment of their skin, bony prominences that will be effected. If so, padding the restraint will be required

• Permission from patient or pt’s guardian prior to the use of restraints is necessary

• Attempt to explain the restraint to the pt

Monitoring and documentation

• Your facility will have paperwork designed to record restraint use, USE IT, it’s a legal record

• Nurse must assess and record the effects of restraints on:

• Pt behavior • Neurovascular effects distal to the site of

the restraint EVERY 30 – 60 MINUTES

Where to tie the restraint?

• To the MOVEABLE part of the bed

• If you tie it to the non-moveable part, it may injure the patient.

Removing the restraint

• The nurse must remove (one at a time) each restraint EVERY 2 hours to assess:

• Skin and circulation

• Perform ROM

• Evaluate the continued need for the restraint

Restraint Alternative

• Are protective or adaptive devices that promotes pt safety and postural support but which can be released independently by the pt

Types of restraint alternatives…

• 1) Electronic bed and seat monitors that alarm when the pt gets up

• 2) Seat inserts• 3) Gripping materials that prevent slipping• 4) Support pillows• 5) Seat belt or harness with front-releasing velcro• 6) Tilt wedges• 7) Companion at bedside to help protect and

remind pt

Self-Release

• PT MUST BE ABLE TO RELEASE THIS ALTERNATIVE DEVICE INORDER FOR IT TO NOT BE CLASSIFIED AS A RESTRAINT

• PT MUST BE ABLE TO GET OUT ON OWN

Documentation:Initial act - Alternatives tried - Results (This Supports the use of the restraints if they are applied)

1000- Pt Confused, Rt side is flaccid, pt pulls on PEG tube with left hand, light protective covering to peg site with 4X4’s, use of activity blanket encouraged.

1030- pt remains confused and becoming agitated. back rub given, pt repositioned to L. sims position.

Documentation After application of restraints:

Reason for restraining-assessment of pt status (especially R/T restraint type)-Results

1100-PEG tube site is swollen and red. Sm. amt. ofred drainage noted at site. Pt. conts to pull at tube.Dr. notified as well as pt’s guardian, Left Wrist restraint applied. Skin on L. Wrist is intact, warm and pink, cap refill is < 3 secs. Call bell in reach.PN will reassess pt again in 30 minutes

• 1130 – pt resting comfortably, extremities

• warm and pink with + pulses

Follow Up charting-Condition of Pt R/T restraint-If restraining is continuing

1230-released l. wrist restraint, area remains intactand warm, assisted pt to BR, ROM done to Wrist, continues to pull PEG tube, restraint reapplied

What to do if incident occurs

• Check ABC’s

• Call for help from staff

• Assist pt

• Notify M.D.

• Write incident report

• Nursing documentation

Restraint

Restraint-Error

When to check on a patient?

• Every 1 hour

• Remove restraint and offer food, drink, B.R.

• NCLEX wants you to be aware of neurovascular checks and condition of skin

• Safety must come first

Orders

• A new restraint order must be given by the Dr. EVERY 24 hours

The End