The Safe Use of Patient Restraints

Mandatory Annual Review Course

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Definitions

Restraint is:Restraint is:

Medical (Non-behavioral)

Restraint:

Medical (Non-behavioral)

Restraint:

Any method of physically restricting a person’s freedom of movement, physical activity or normal access to his or her body.

Patient immobilization that is a normal component of a procedure is not considered restraint.

A manual method, physical or mechanical device, material, or equipment that immobilizes or reduces the ability of a patient to move his or her arms, legs, body or head freely.

A drug used solely as a restrictions to manage the patient’s behavior or restrict freedom of movement.

Click each button for details

Behavioral HealthRestraint:

Behavioral HealthRestraint:

The restriction of patient movement in response to severely aggressive, destructive, violent or suicidal behaviors that place the patient or others in imminent danger.

Restraint is not:Restraint is not: Forensic restriction used by law enforcement for

security purposes.

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Side Rails – Restraint or Not?

The use of side rails may pose risk to patient’s safety. Clinical judgment determines whether or not the use of side rails is considered restraints.

Raising all four side rails to prevent the patient from exiting the bed

Click the answer

Restraint NotRestraint

Four or full side rails to prevent the patient from rolling our of bed

Patient actively seizing Post-op patient recovering from

anesthesia Patient on a gurney

RestraintNot

Restraint

Raising fewer than four side rails (when bed has more than two)

RestraintNot

Restraint

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Alternatives to Restraints

Restraints must never be used as a substitute for good nursing care or staff convenience. Restrained patients require MORE CARE and INCREASED DOCUMENTATION.

PHYSICAL MEASURES SPIRITUAL NEEDS

Relaxation techniquesPromote normal sleep patternsUse of lap belt in chair as a reminderProvide glasses, hearing aid, denturesTape foley to abdomen of male patientUse Activity ApronExercise and activitiesAnticipate and provide for basic needs

PSYCHOLOGICAL MEASURESProvide for companionship: family, friendsOrient to realityExplain all proceduresUse TV, radio, music

Collaborate w/other healthcare membersProvide pain medication, eliminate itch

Contact patient’s pastor, minister, priest, rabbiOffer sacrament of Communion, Reconciliation, Anointing of the SickUse sitter or volunteer to read to patientUse audio tapes, CDs

ENVIRONMENTAL NEEDS1:1 communication Use of cushions to maintain safetyLocate patient next to Nurse’s stationUse appropriate lightingUse Geri chair, position commode, walker, near bedsideDecrease noise, control activity levelPlace Call light within reachPosition tubes/drains out of site

Initiate frequent bathroom roundsReview medications for side effects & interactions

PHYSIOLOGICAL MEASURES

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Patient Assessment

Attempt Alternatives Use safe, effective and least restrictive method of restraint Clinical Justification based on observed patient actions or behaviors

Interference with therapy or patient care Pulling tubes Picking at wounds Removing dressings

Activity or thoughts with a reasonable probability of harm to self Wandering Unsteady gait (high risk for falls) Suicidal

Activity or thoughts with a reasonable probability of harm to others Confused patient striking out at others Homicidal attempt or talks about killing/harming someone Violent patient in alcohol or drug withdrawal

To Determine the NEED for RESTRAINT USE:

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Restraint Orders

Reason for the restraint.

Be time specific

Include type of restraint.

Reflect least restrictive manner.

Be in accordance with safe and appropriate restraining techniques.

Be discontinued at the earliest point in time.

Never be written as a standing order or PRN.

Restraints will be initiated or continued on the order of a treating physician. The order must meet the following criteria:

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Medical vs. Behavior Health Orders

Medical Behavioral Health

Time Limitations

24 hours 4 hours 18yrs or older

2 hours 9-17yrs

1 hour 8yrs and under

RN Assessment

Every 2 hours or sooner Continuously document every 15 mins

MD Assessment

Every 24 hours prior to writing new order

Every 8 hours 18yrs or older

Every 4 hours 17yrs and younger

Emergency Application by RN

Notify MD ASAP, within 1 hour MD must provide telephone or written order. MD must assess patient ASAP, within 24 hours.

Notify MD ASAP, within 1 hour MD must assess patient and write order.

Restraint Reapplication

Requires new order, and MD assessment. -Even if original order has not exceeded its “time limit.” This does not include the temporary release that occurs for patient assessment.

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Observation & Monitoring

The patient’s physical and emotional well-being .

Comfort and care needs, including hygiene, elimination, hydration, nutrition

The appropriateness of restraint application, removal, and reapplication

Assessment of the need for continuing or discontinuing restraint

Assessment will include:

Patient death associated with restraint use: RN will immediately notify Nurse Manager or House Supervisor

Complete a UOR (unusual occurrence report)

Hospitals AR&L Director or designee will notify CMS

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Application of Restraint

Must have quick-release application

Use the correct size

Note “front” and “back” of device

Secure to bed springs or frame, not mattress or bed rails

Do not apply one-sided restraints

Do not restrain feet while their hands are free

Place call light and necessary items within reach

Do not position pregnant patients 20 weeks or greater on their back, nor should chest or waist restraints be used

Restraints should be discontinued as soon as it is no longer indicated by the patient’s actions.

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Hygiene

Elimination

Hydration

Documentation

Patient basic needs must be attended to, including:

Document the following in Patient’s record in KP Health Connect:

Physician’s order Initial assessment by the RN and 1 hour in-person evaluation by MD

Patient’s actions or condition that indicated the initial and continued use of restraint

Less restrictive alternatives considered

Patient monitoring and response to interventions used

Significant changes in the patient’s condition

Reassessment/observations, discontinuation of restraints

Education and information about restraints provided to the patient and family

Nutrition

Circulation

Range of motion

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POST TEST

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Quiz

Answer True or False

1. Application of restraints should be the initial nursing intervention when caring for the confused or disoriented patient.

True False

2. Restraints are utilized to prevent disruption of treatment or significant harm to persons.

True False

3. The care of a patient in restraints requires more nursing time.

True False

4. Once restraints are applied, they are not to be removed by anyone without a physician’s order.

True False

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6. Use of restraints can be harmful to patients and can result in such outcomes as impaired skin integrity, incontinence, increased falls, etc.

Quiz

Answer True or False

5. Bed rails can either be restraints or a protective device, depending on the intent of use.

True False

True False

7. When appropriate, the use of alternatives is attempted in an effort to use restraints as a last resort.

True False

8. Reassessment is ongoing and occurs at a minimum of q 4 hours for patients in medical restraints in an effort to discontinue the restraints early whenever possible.

True False

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Quiz

Answer True or False

9. Four-point soft restraints for an actively suicidal patient requires the same 15-minute observation checks as leather or hard restraints.

True False

10. A physician’s order for a behavioral health restraint must be time specific with a maximum limit of 4 hours for the adult, 2 hours for children ages 9-17, and 1 hour for children 8 and under.

True False

11. RNs may discontinue restraints before the ordered time frame, but must obtain a new order if the patient again meets indications that justify restraint.

True False

12. RNs can apply a restraint without a physician order, but must obtain a verbal phone order within 1 hour of the initiation of the medical restraint.

True False

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Quiz

Answer True or False

13. Bed rails should be used on all patient at all times to keep them from falling or getting out of bed.

True False

14. Which of the following observations intervals is incorrect?A. Every 30 minutes for a patient in four-point restraints to prevent

combative behavior.B. Every 15 minutes for a patient in leather restraints for violent behavior

to prevent injury.C. Every 2 hours for a patient with soft wrist ties to prevent dislodgment of

NG tube.D. Every 2 hours for bed rails up on a patient to prevent them from

continued wandering.

Select the Correct Answer

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Quiz

15. Which of the following are types of protective devices and not considered restraints?

A. Portable table top chair to prevent the patient from slipping out of the chair.

B. Safety belt on a gurney.

C. Knee immobilizer.

D. All of the above.

Select the Correct Answer

16. The nurse should assess and address which of the following at least every two hours for patients who are restrained:

A. Hydration and nutrition

B. Hygiene and elimination

C. Continuance or termination of restraint

D. Circulation and ROM

E. All of the above.

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Quiz

17.Which of the following is not a clinically justified use of restraints?

A. Patient continues to pull at the NG tube after reorientation and explanation.

B. Combative patient in DTs.

C. Patient is 75 years old and is weak and confused.

D. Patient removes abdominal dressing despite use of abdominal binder.

Select the Correct Answer

18.Which of the following is not an example of an alternative to restraint use?

A. Medicate patient to induce sleeping.

B. Tape foley to abdomen of male patient.

C. Provide adequate pain medication.

D. Use TV, radio, or music as diversion.

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Quiz

19. A 9-year-old requires transport via gurney to radiology for a MRI. The gurney rails are placed in the up position. This is not considered restraint because:A. Children are allowed to sit up in gurneys.B. The child can see through side rails.C. Side rails are to be up during patient transports of all types regardless of

age and are a protective/safety device.D. The child will be transferred to an exam table upon arrival so it doesn’t

matter.

Select the Correct Answer

20. Which of the following employees would need documented competency for restraints?A. A transportation aide that unties and reties wrist restraints for transport

to radiology.B. A physical therapist that releases and reties a patient restraint in order to

exercise a patient.C. A RN that monitors the patient in restraints.D. An unlicensed assistant that removes and reapplies restraints to bathe a

patient.E. All of the above.