Chapter 14 Restraint Alternatives and Safe Restraint Use Jennifer Bettag RN, BSN

Today’s Agenda 01 02 03 04 05 Watch restraint video Introduce new material 02 Take Notes 03 Practice documentation 04 Practice Slip Tie Knot 05

TN State Standard 7 7) Review LTC facility policy and procedures pertaining to use of physical and mental restraints of residents. Drawing on evidence from health journals and patient rights advocacy organizations, develop an informational artifact discussing the types of restraints, reasons for their uses, restraint alternatives, any associated physical and psychological problems, and residents’ rights associated with restraints.

Today’s Objective By the end of class, you will understand how to document restraint use in resident’s in the LTC and practice this on a patient record. You will also be able to demonstrate how to tie the posey quick release tie.

Restraint Use Video https://moodle.gprc.ab.ca/videos/nursing_videos/mosby_4th_edition/Basi c/skill/I002.html

What is Restraint? Restraint is a method or device used to limit the freedom of movement of patients who are out of control It involves use of equipment or medicines to ensure that the patient does not move out of the prescribed area It may also include use of physical force, mechanical devices, chemicals and seclusion/isolation of patient

Restraint Orders

Documenting Restraints Complete patient documentation prior to restraint application Document assessment in medical records with: Rational for use The alternative, less restrictive interventions previously tried Frequency and duration of use of chemical, mechanical or physical restraint Patient’s reaction to the restraint, including physical and mental state upon release from restraint. Staff involved in implementing the restraint

Why Complete Documentation? Why would you need to make sure all documentation was complete for a patient in restraints?

Restraint Documentation Example

Time to practice…. Turn to your partner next to you Look at sample documentation of restraints and work with partner to highlight all areas needed in documentation are completed Note any areas missed at bottom of page

How to Tie Restraints to Bed? Does it matter how we tie the restraint to the bed or wheelchair? What do we do in an emergency to release patient? What if they escape due to poor restraint process?

Video of slip knot for restraints https://youtu.be/15PlocIzm94 Watch Mrs. Bettag tie a slip knot on chair

Group Practice Grab a piece of string and your check off paper Find partner and take turns working on check off When ready please let Mrs. Bettag know so she can check you off

Time for Review Grab a exit ticket paper and list the 5 assessment parts that have to be documented in the patient medical record for restraints.

Agenda for Today 1. Alternatives to Restraints 2. Chemical Restraints 3. Physical Restraints

TN State Standard Nursing Education 7) Review LTC facility policy and procedures pertaining to use of physical and mental restraints of residents. Drawing on evidence from health journals and patient rights advocacy organizations, develop an informational artifact discussing the types of restraints, reasons for their uses, restraint alternatives, any associated physical and psychological problems, and residents’ rights associated with restraints.

Objective Student will be able to identify alternatives to restraint use Student will be able to list various types of physical restraints and where to place Student will be able to list chemical restraints and their use

Alternatives to Restraints Alternative means of meeting the patients needs should be attempted first. Move patient closer to nurses station Keep patient door open Bed in low position Call bell within reach Reorient patient to environment Conceal IV site & tubing with Stretch Netting Decrease noise/minimize stimulation Bed/Exit alarms with sensor pads (Posey Sitter II) Encourage family involvement

Alternative Restraints Wrap Around Belt may be applied as long as it is documented patient can “demonstrate” self release with Velcro. Exit Alarms with sensor pads for beds or chairs Bed Alarms if available on beds.

Types of Physical Restraints Restraints may be made of soft or harder material Neoprene (for Behavioral Restraints only) Soft Foam Wrist or ankle straps Roll Belts All 4 side rails up on a bed Mitts (secured or unsecured to bed frame)

Physical Restraints Two types of restraints defined by JCAHO are based on the purpose for the restraints Behavioral Restraint (Almost exclusively in ER) Used for the control of aggressive/violent behavior or behavior that is dangerous to self or others. Medical/Surgical Restraint (Most common on units) Used for care management for a patient who is exhibiting behavior that is interfering with treatment (e.g. pulling on IV, Foley, or dressings).

Review Time List the 5 types of physical restraints to your partner across the table.

Chemical Restraints Drugs or drug dosages are chemical restraints if they: Control Behavior or Restrict Movement Are not standard treatment for the person’s condition Drugs cannot be used if they affect physical or mental function

When Physical Restraints are NOT Considered to be Restraint Devices When used for the purposes of security, detention or public safety on patients under forensic custody (under police guard). When used as a voluntary mechanical support to achieve proper body position, balance, or alignment. When used as a positioning or securing device to maintain position, limit mobility or temporarily immobilize a patient during medical, diagnostic, or surgical procedures (less than 30 minutes in children).

Enablers vs Restraints Enabler is a device that limits freedom of movement but is used to promote independence, comfort, or safety. Some devices are both restraints and enablers. Example: When the person uses a geriatric chair with a lap-top tray for meals, writing, and so on, the chair is an enabler. IF it is used to limit freedom of movement, it is a restraint.

Safety Guidelines Observe for increased confusion and agitation Protect the person’s quality of life Follow the manufacturer’s instructions Apply restraints with enough help to protect the person and staff from injury Observe the person at least every 15 minutes or as often as noted in care plan Remove or release the restraint, re-position the person, and meet basic needs at least every 2 hours or as often as noted in the care plan

Complications of Restraint Use Injuries from improperly positioned restraints Patients get tangled in straps and choke Patients struggle to get free and end up broken bones, cuts, concussions, or other injuries as a result Medical complications from keeping the body and limbs in the same position for long periods can cause: Poor circulation Incontinence Constipation Weak muscles and bones Pressure Sores Mental and Emotional Problems Restrained patients often feel humiliated or imprisoned and become Depressed Agitated Uninterested in eating, sleeping, and socializing

Legal Aspects Restraints must protect the person A doctor’s order is required The least restrictive method is used Restraints are used only after other measures fail to protect the person Unnecessary restraint is false imprisonment Informed consent is required