12/28/13

Procedure of Using Restraints

Procedure of Using Restraints

Equipment:
■ Restraint of the appropriate size: belt, vest, wrist, ankle, or mitt.
■ Soft gauze or cotton padding for bony prominences.

Assessment:
■ Assess the need for restraints; that is, that the immediate physical safety of the patient, a staff member, or others is threatened.
■ Assess the patient’s risk for falls, including mobility status and level of awareness.
■ Determine that all less-restrictive measures have been tried unsuccessfully.
■ Identify the appropriate restraint; one that:
■ Is the least restrictive possible.
■ Does not interfere with care or exacerbate the patient’s medical condition.
■ Does not pose a safety risk to the patient.
■ Can be changed easily to keep it clean.

Post-Procedure Reassessment
■ Assess the initial restraint placement, circulation, and skin integrity.
■ Check the restraint every 30 minutes (more often for a behavioral restraint). Observe for pallor, cyanosis, and coolness of extremities.
■ Reassess the restraint, circulation, the patient’s response to the intervention, and the continuing need for the restraint every 2 hours; remove it as soon as it is no longer needed.

Key Points:
■ Follow agency policy, state laws, and professional guidelines.
■ Try alternative interventions first (e.g., bed/chair alarms, patient sitters hired to watch the patient).
■ Use the least restrictive method among the various types of restraints:
■ Verbal.
■ Chemical (e.g., antipsychotic or sedative medication).
■ Seclusion (safe containment to de-escalate).
■ Physical (4-point devices, tie-on, Velcro, leather).
■ Use restraints only to protect a patient and/or caregiver from injury;
not for the convenience of the caregiver or as a punishment.
■ Obtain the required consent form.
■ Obtain a medical order before restraining, except in an emergency.
■ Be Safe! Secure restraints in a way that allows for quick release.
■ Be Safe! Tie bed restraints to the bed frame, not to the siderails.
■ Be Safe! Ensure that restraints do not impair circulation or tissue integrity.
■ Be Safe! Check restraints every 30 minutes.
■ Be Smart! A prescriber must reassess and reorder the restraints every 24 hours.
■ Release restraints and assess every 2 hours (more often for behavioral restraints).

Documentation:
■ Document the following on fall risk assessment sheet, restraint flowsheet, and nursing notes per agency policy:
■ All nursing interventions that were done to eliminate the need for the restraint (e.g., moving patient closer to the nurses’ station, asking a family member to remain with the patient).
■ Reasons for placing the restraint (e.g., patient behaviors).
■ The initial restraint placement, including location, circulation, and skin integrity.
■ Patient and family teaching.
■ Circulation checks, range of motion, and restraint removal per agency protocol.

A quick-release knot
A vest restraint
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Using a Bed Monitoring Device

Using a Bed Monitoring Device

Equipment:
■ Bed or chair exit monitoring device (types: pressure sensitive, posture indicator, motion sensor, and pull-cord alarms). Assessment
■ Identify factors that increase risk for more severe injury in the case of a fall (e.g., anticoagulants, osteoporosis).
■ Check the alarm on the monitor to ensure that it is working properly.
■ Assess for factors that increase fall risk.
■ Intrinsic Factors, Examples:
• Age > 75.
• History of falls.
• Incontinence.
• Cognitive impairment.
• Dizziness.
• Medications.
• Medical problems (e.g., dementia, arthritis, depression).
■ Extrinsic (Environmental) Factors, Examples:
• Equipment.
• Wet/uneven floors.
• Footwear.
• Poor lighting.
• Clothing.
• Lack of grab rails.
• Furniture/adaptive aids in disrepair (e.g., bed rails)

Post-Procedure Reassessment:
■ Monitor fall risk per agency policy and as indicated by the patient’s physical and mental status.
■ If a fall occurs, perform a post-fall assessment to identify possible causes, and monitor more closely for 48 hours.

Key Points:
■ Select the correct type of alarm for your patient.
■ Explain to patient and family that a monitoring device alerts the staff when the patient tries to get out of the chair or bed.
■ Apply/place the device; connect the control unit to the sensor pad.
■ Connect the control unit to the nurse call system, if possible.
■ Explain that the patient will need to call for help when he wants to get up.
■ Place the patient on fall risk precautions according to agency policy.
■ Assess the sensitivity of the monitoring device, and adjust as needed to ensure that the alarm is activated if the patient tries to get out of the bed or chair.
■ Disconnect or turn off the alarm before assisting the patient out of the bed or chair.
■ Reactivate the alarm after helping the patient back to the bed or chair.
■ Be Safe! Bed alarms alone do not prevent falls; they are used to improve the timeliness of staff response. Patients who are at risk for falls require increased observation and surveillance.

Documentation:
■ Document on the fall risk assessment sheet, restraint flowsheet, and nursing notes according to agency policy.
■ Document the initial sensor placement, including type of sensor used and location of placement.
■ Follow agency policy for ongoing documentation of the use of a bed exit monitor.
■ Usually, the minimum documentation is every 8 hours.

Chair monitor
Leg sensor
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10/30/12

Applying a Mummy Restraint

Goal: The patient is constrained by the restraint, remains free from injury, and the restraint does not interfere with therapeutic devices.

1. Determine need for restraints. Assess patient’s physical condition, behavior, and mental status. Refer to review material in the chapter introduction.

2. Confirm agency policy for application of restraints. Secure an order from the primary care provider or validate that the order has been obtained within the past 24 hours.

3. Perform hand hygiene and put on PPE, if indicated.

4. Identify the patient.

5. Explain reason for use to patient and family. Clarify how care will be given and how needs will be met. Explain that restraint is a temporary measure.

6. Open the blanket or sheet. Place the child on the blanket, with edge of blanket at or above neck level.

7. Position the child’s right arm alongside the child’s body. Left arm should not be constrained at this time. Pull the right side of the blanket tightly over the child’s right shoulder and chest. Secure under the left side of the child’s body.

8. Position the left arm alongside the child’s body. Pull the left side of the blanket tightly over the child’s left shoulder and chest. Secure under the right side of the child’s body.

9. Fold the lower part of blanket up and pull over the child’s body. Secure under the child’s body on each side or with safety pins.

10. Stay with child while mummy wrap is in place. Reassure child and parents at regular intervals. Once examination or treatment is completed, unwrap child.

11. Remove PPE, if used. Perform hand hygiene. Excellent Satisfactory Needs Practice
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Applying an Elbow Restraint


Goal: The patient is constrained by the restraint, remains free from injury, and the restraint does not interfere with therapeutic devices.

1. Determine need for restraints. Assess patient’s physical condition, behavior, and mental status. Refer to review material in the chapter introduction.

2. Confirm agency policy for application of restraints. Secure nan order from the primary care provider or validate that the order has been obtained within the past 24 hours.

3. Perform hand hygiene and put on PPE, if indicated.

4. Identify the patient.

5. Explain reason for use to patient and family. Clarify how care will be given and how needs will be met. Explain that restraint is a temporary measure.

6. Apply restraint according to manufacturer’s directions:
a. Choose the correct size of the least restrictive type of device that allows the greatest possible degree of mobility.
b. Pad bony prominences that may be affected by the restraint.
c. Spread elbow restraint out flat. Place middle of elbow restraint behind patient’s elbow. The restraint should not extend below the wrist or place pressure on the axilla.
d. Wrap restraint snugly around patient’s arm, but make sure that two fingers can easily fit under restraint.
e. Secure Velcro straps around restraint.
f. Apply restraint to opposite arm if patient can move arm.
g. Thread Velcro strap from one elbow restraint across the back and into the loop on the opposite elbow restraint.

7. Assess circulation to fingers and hand.

8. Remove PPE, if used. Perform hand hygiene.

9. Assess the patient at least every hour or according to facility policy. An assessment should include the placement of the restraint, neurovascular assessment, and skin integrity. Assess for signs of sensory deprivation, such as increased sleeping, daydreaming, anxiety, inconsolable crying, and panic.


10. Remove restraint at least every 2 hours or according to agency policy and patient need. Remove restraint at least every 2 hours for children ages 9 to 17 years and at least every 1 hour for children under age 9, or according to agency policy and patient need. Perform ROM exercises.

11. Evaluate patient for continued need of restraint. Reapply restraint only if continued need is evident.

12. Reassure patient at regular intervals. Keep call bell within easy reach.
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Applying a Waist Restraint


Goal: The patient is constrained by the restraint, remains free from injury, and the restraint does not interfere with therapeutic devices.

1. Determine need for restraints. Assess patient’s physical condition, behavior, and mental status. (Refer to Fundamentals Review 3-1, 3-2, 3-3, and 3-4 at the beginning of the chapter.)

2. Confirm agency policy for application of restraints. Secure an order from the primary care provider or validate that the order has been obtained within the past 24 hours.

3. Perform hand hygiene and put on PPE, if indicated.

4. Identify the patient.

5. Explain reason for use to patient and family. Clarify how care will be given and how needs will be met. Explain that restraint is a temporary measure.

6. Include the patient’s family and/or significant others in the plan of care.

7. Apply restraint according to manufacturer’s directions:
a. Choose the correct size of the least restrictive type of device that allows the greatest possible degree of mobility.
b. Pad bony prominences that may be affected by the waist restraint.
c. Assist patient to a sitting position, if not contraindicated.
d. Place waist restraint on patient over gown. Bring ties through slots in restraint. Position slots at patient’s back.
e. Pull the ties secure. Ensure that the restraint is not too tight and there are no wrinkles in it.
f. Insert fist between restraint and patient to ensure that breathing is not constricted. Assess respirations after restraint is applied.

8. Use a quick-release knot to tie the restraint to the bed frame, not side rail. If patient is in a wheelchair, lock the wheels and place the ties under the arm rests and tie behind the chair. Site should not be readily accessible to the patient.

9. Remove PPE, if used. Perform hand hygiene.

10. Assess the patient at least every hour or according to facility policy. An assessment should include the placement of the restraint, respiratory assessment, and skin integrity. Assess for signs of sensory deprivation, such as increased sleeping, daydreaming, anxiety, panic, and hallucinations.

11. Remove restraint at least every 2 hours or according to agency policy and patient need. Perform ROM exercises.

12. Evaluate patient for continued need of restraint. Reapply restraint only if continued need is evident and order is still valid.

13. Reassure patient at regular intervals. Provide continued explanation of rationale for interventions, reorientation if necessary, and plan of care. Keep call bell within easy reach.

14. Perform hand hygiene.
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Applying an Extremity Restraint


Goal: The patient is constrained by the restraint, remains free from injury, and the restraint does not interfere with therapeutic devices.

1. Determine need for restraints. Assess patient’s physical condition, behavior, and mental status. (Refer to Fundamentals Review 3-1, 3-2, 3-3, and 3-4 at the beginning of the chapter.)

2. Confirm agency policy for application of restraints. Secure an order from the primary care provider, or validate that the order has been obtained within the past 24 hours.

3. Perform hand hygiene and put on PPE, if indicated.

4. Identify the patient.

5. Explain reason for restraint use to patient and family. Clarify how care will be given and how needs will be met. Explain that restraint is a temporary measure.

6. Include the patient’s family and/or significant others in the plan of care.

7. Apply restraint according to manufacturer’s directions:
a. Choose the least restrictive type of device that allows the greatest possible degree of mobility.
b. Pad bony prominences.
c. Wrap the restraint around the extremity with the soft part in contact with the skin. If a hand mitt is being used, pull over the hand with cushion to the palmar
aspect of hand. Secure in place with the Velcro straps.

8. Ensure that two fingers can be inserted between the restraint and patient’s wrist or ankle.

9. Maintain restrained extremity in normal anatomic position. Use a quick-release knot to tie the restraint to the bed frame, not side rail. The restraint may also be attached to a chair frame. The site should not be readily accessible to patient.

10. Remove PPE, if used. Perform hand hygiene.

11. Assess the patient at least every hour or according to facility policy. Assessment should include the placement of the restraint, neurovascular assessment of the affected extremity, and skin integrity. In addition, assess for signs of sensory deprivation, such as increased sleeping, daydreaming, anxiety, panic, and hallucinations.

12. Remove restraint at least every 2 hours, or according to agency policy and patient need. Perform range-of-motion exercises.

13. Evaluate patient for continued need of restraint. Reapply restraint only if continued need is evident and order is still valid.

14. Reassure patient at regular intervals. Provide continued explanation of rationale for interventions, reorientation if necessary, and plan of care. Keep call bell within easy reach.
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Implementing Alternatives to the Use of Restraints


Goal: The use of restraints is avoided and the patient and others remain free from harm.

1. Perform hand hygiene and put on PPE, if indicated.

2. Identify the patient.

3. Explain the rationale for interventions to the patient and family/significant others.

4. Include the patient’s family and/or significant others in the plan of care.

5. Identify behavior(s) that place the patient at risk for restraint use. Assess the patient’s status and environment, as outlined above.

6. Identify triggers or contributing factors to patient behaviors. Evaluate medication usage for medications that can contribute to cognitive and movement dysfunction and contribute to increased risk for falls.

7. Assess the patient’s functional, mental, and psychological status and the environment, as outlined above.

8. Provide adequate lighting. Use a nightlight during sleeping hours.

9. Consult with primary care provider and other appropriate healthcare providers regarding the continued need for treatments/therapies and the use of the least invasive method to deliver care.

10. Assess the patient for pain and discomfort. Provide appropriate pharmacologic and nonpharmacologic interventions. (Refer to Chapter 10, Comfort.)

11. Ask a family member or significant other to stay with patient.

12. Reduce unnecessary environmental stimulation and noise.

13. Provide simple, clear, and direct explanations for treatments and care. Repeat to reinforce as needed.

14. Distract and redirect using a calm voice.

15. Increase the frequency of patient observation and surveillance; 1- or 2-hour nursing rounds, including pain assessment, toileting assistance, patient comfort, personal items in reach, and patient needs.


16. Implement fall precaution interventions. Refer to Skill 3-1.

17. Camouflage tube and other treatment sites with clothing, elastic sleeves, or bandaging.

18. Ensure the use of glasses and hearing aids, if necessary.

19. Consider relocation to a room close to the nursing station.

20. Encourage daily exercise/provide exercise and activities or relaxation techniques.

21. Make the environment as homelike as possible; provide familiar objects.

22. Allow restless patient to walk after ensuring that environment is safe. Use a large plant or piece of furniture as a barrier to limit wandering from designated area.

23. Consider the use of patient attendant or sitter.

24. Remove PPE, if used. Perform hand hygiene.
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Fall Prevention

Goal: The patient does not experience a fall and remains free of injury.

1. Perform hand hygiene and put on PPE, if indicated.

2. Identify the patient.

3. Explain the rationale for fall prevention interventions to the patient and family/significant others.

4. Include the patient’s family and/or significant others in the plan of care.

5. Provide adequate lighting. Use a night light during sleeping hours.

6. Remove excess equipment, supplies, furniture, and other objects from rooms and walkways. Pay particular attention to high traffic areas and the route to the bathroom.

7. Orient patient and significant others to new surroundings, including use of the telephone, call signal, patient bed, and room illumination. Indicate the location of the patient bathroom.

8. Provide a ‘low bed’ to replace regular hospital bed.

9. Use floor mats if patient is at risk for serious injury.

10. Provide nonskid footwear and/or walking shoes.

11. Institute a toileting regimen and/or continence program, if appropriate.

12. Provide a bedside commode and/or urinal/bedpan, if appropriate. Ensure that it is near the bed at all times.

13. Ensure that the call bell, bedside table, telephone, and other personal items are within the patient’s reach at all times.

14. Confer with primary care provider regarding appropriate exercise and physical therapy.

15. Confer with primary care provider regarding appropriate mobility aids, such as a cane or walker.

16. Confer with primary care provider regarding the use of bone-strengthening medications, such as calcium, vitamin D, and drugs to prevent/treat osteoporosis.

17. Encourage the patient to rise or change position slowly and sit for several minutes before standing.

18. Evaluate the appropriateness of elastic stockings for lower extremities.

19. Review medications for potential hazards.

20. Keep the bed in the lowest position during use. If elevated to provide care (to reduce caregiver strain), ensure that it is lowered when care is completed.

21. Make sure locks on the bed or wheelchair are secured at all times.

22. Use bed rails according to facility policy, when appropriate.

23. Anticipate patient needs and provide assistance with activities instead of waiting for the patient to ask.

24. Consider the use of an electronic personal alarm or pressure sensor alarm for the bed or chair.

25. Discuss the possibility of appropriate family member(s) staying with patient.

26. Consider the use of patient attendant or sitter.

27. Increase the frequency of patient observation and surveillance; 1- or 2-hour nursing rounds, including pain assessment, toileting assistance, patient comfort, personal items in reach, and patient needs.

28. Remove PPE, if used. Perform hand hygiene.
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