Understanding how to provide a safe environment for the patient is fundamental for nursing practice.

No matter what type of patient you care for, safety is a high priority. One of the most common risks is that of fall.

It is important that nurses be aware of the potential for injury and promote safety at all time.

Risk for injury: fall RT:

The patient will:

Definition:◦A physical or mechanical device used to

limit or prevent a patient’s movement.

◦FDA – device that limits movement to the extent necessary for treatment, examination, or protection of the patient

Most commonly used to: 1. Prevent the client from falling and

sustaining injury

2. Position and protect patient during treatments and to maintain ongoing care

3. Protect patients who are combative and agitated and may cause harm to self or others

The use of restraints is generally not

advocated and should be used only as a last

resort

1. Mechanical/Physical ◦ Wrist, ankle, elbow restraints◦ Mitten restraints◦ Belts◦ Locked leather

**Use of vest restraints is no longer advocated

2. Chemical

◦ Medications used to calm an individual’s behavior – tranquilizers and hypnotics

3. Environmental

Side rails Locked units Locking devices on

wheelchairs Grab bars

Emotional issue on the part of the patient, family, and staff

The patients response to being restrained is rarely submissive

Many view restraints as a personal physical assault, and are frightened, and respond by becoming combative.

The application of restraints may subject the nurse to allegations of false imprisonment,

battery, and lack of informed consent.

The Joint Commission has identified misuse of protective restraints as one of the main sentinel events (unexpected occurrence involving death or serious physical or psychological injury, or the risk thereof).

Since the Joint Commission began tracking sentinel events in 1996, the Accreditation Committee of the Joint Commission's Board of Commissioners has reviewed many cases related to deaths of patients who were being physically restrained. Most of the events occurred in psychiatric hospitals, followed by general hospitals and long term care facilities.

Death related to the misuse of protective restraints were mainly due to:

◦asphyxiation while in restraints

◦Strangulation

◦Cardiac arrest

◦Fire

Increase the monitoring frequency

Provide a familiar environment

Prevent the need to get out of bed unassisted

Institute Safety Measures

Change the treatment Plan

See Box 23-1 for details pp. 559

The order must clearly define:

◦ the type of restraint to be used

◦The Purpose of the restraining device

◦A Time limit

What do I do if the patient needs a restraint and I do not have a physician’s order?

a. Patient’s behavior that supported the need for the restraint and what was used before applying restraints

b. Type of restraint used

c. Explanation of purpose of using the restraint to the patient and or family

d. If patient or family refuses the restraint

e. Exact time that the restraint was applied

f. Continued assessment of the patient every 2 hours

g. Care given while in the restraint

h. Notification of the physician

The Joint Commission found that some of the main reasons that patients died while in restraints was that the staff had:

insufficient training lack of competence

in the use of restraining devices and monitoring of patients while restrained.

1. Apply ONLY for the safety of the patient, NEVER for convenience of the nurse

2. Apply with care to avoid damaging tissue and causing harm to the patient

3. Recognize the physiological and psychological effects of applying restraints

4. Explain reason to the patient and family

5. Review the policy and procedure manual

6. Choose the restraint that fits the need

7. Check on the patient every 2 hours

8. Maintain proper body alignment

9. Never tie to the side rails—always on the frame

10. Be sure does not interfere with proper functioning of tubes or equipment

11. Must have a quick release!! Never knotted

12. Never restrain a patient with decreased level of consciousness on his back with limbs restrained on either side

Food and Drug Administration requires that manufacturers label “prescription only” to decrease the number of restraint- related injuries

Increase risk of falls Hydrostatic pneumonia Skin abrasions, edema, pressure

injuries Ischemia and nerve damage Contractures from immobility Shoulder dislocation Loss of self esteem, humiliation,

fear and anger Death via strangulation, asphyxia,

entrapment, fire

See Procedure in Harkreader p. 556-558.

Falls are a common cause of morbidity and the leading cause of nonfatal injuries and trauma-related hospitalizations in the United States.

Falls occur in all types of healthcare institutions and to all patient populations.

In hospitals, falls consistently make up the largest single category of reported incidents.

Nearly half of all residents in nursing homes fall each year, with many sustaining fractures.

In order to increase patient safety the Joint Commission designated a National Patient Safety Goal on reduction of risk of harm from falls:

Goal 9◦Reduce the risk of patient harm resulting from

falls.◦9B - ◦ Implement a fall reduction program including an

evaluation of the effectiveness of the program. .

Definition of a Fall A fall is defined as a sudden, uncontrolled,

unintentional, downward displacement of the body to the ground or other object, excluding falls resulting from violent blows or other purposeful actions.

  A near fall is a sudden loss of balance that does not

result in a fall or other injury. This can include a person who slips, stumbles or trips but is able to

regain control prior to falling.

An un-witnessed fall occurs when a patient is found on the floor and neither the patient nor anyone else knows how he or she got there.

Patients should be assessed for their fall risk:◦On admission to the facility◦On any transfer from one unit to another

within the facility◦Following any change of status◦Following a fall◦On a regular interval, such as monthly,

biweekly or daily

 

There are many risk assessment tools available. The Hendrich Fall Risk Assessment is one example: Risk Factor Scale Score

Recent History of Falls Yes 7No 0

Altered Elimination (incontinence, nocturia, frequency)

Yes 3

No 0Confusion / Disorientation Yes 3

No 0Depression Yes 4

No 0Dizziness / Vertigo Yes 3

No 0Poor Mobility / Generalized Weakness Yes 2

No 0Poor Judgment (if not confused) Yes 3

No 0

Orient to new surroundings Keep two side rails up (depending on policy) Keep call light, bedside table, water, glasses,

etc. within easy reach Use a night light Keep bed in low position Make sure patient has non-skid footwear Teac fall prevention techniques

Ambulate only with assistance when appropriate

Locate patient close to the nurses station