Restraint Alternatives and Safe Restraint Use Chapter 14 Restraint Alternatives and Safe Restraint Use Copyright © 2012 by Mosby, an imprint of Elsevier Inc. All rights reserved.

The Centers for Medicare & Medicaid Services (CMS) Some persons may present dangers to themselves or others (including staff). The Centers for Medicare & Medicaid Services (CMS) have rules for using restraints. The rules apply to agencies receiving Medicare and Medicaid funds. Restraints may be used only to treat a medical symptom or for the immediate physical safety of the person or others. Restraints may be used only when less restrictive measures fail to protect the person or others. Restraints must be discontinued at the earliest possible time. Like the Omnibus Budget Reconciliation Act of 1987 (OBRA), CMS rules protect the person’s rights and safety. All patients and residents have the right to be free from restraint. Copyright © 2012 by Mosby, an imprint of Elsevier Inc. All rights reserved.

The Centers for Medicare & Medicaid Services (CMS) (cont’d) The CMS uses these terms. Physical Restraint—any manual method or physical or mechanical device, material, or equipment attached to or near the person’s body that he or she cannot remove easily and that restricts freedom of movement or normal access to one’s body. Chemical Restraint—any drug used for discipline or convenience and not required to treat medical symptoms. The drug or dosage is not a standard treatment for the person’s condition. Freedom of Movement—any change in place or position of the body or any part of the body that the person is able to control. Remove Easily —the manual method, device, material, or equipment used to restrain the person can be removed intentionally by the person in the same manner it was applied by the staff. Copyright © 2012 by Mosby, an imprint of Elsevier Inc. All rights reserved.

History of Restraint Use Restraints were once thought to prevent falls. Research shows that restraints cause falls. Injuries are more serious from falls involving restrained persons. Restraints also were used to prevent wandering or interfering with treatment. Restraints were viewed as necessary devices to protect a person. However, they can cause serious harm, even death. Falls occur when persons try to get free of the restraints. Restraints were often used for persons who showed confusion, poor judgment, or behavior problems. Older persons were restrained more often than younger persons were. Review the contents of Box 14-1 on p. 197 in the Textbook. Copyright © 2012 by Mosby, an imprint of Elsevier Inc. All rights reserved.

Types of Restraints Restraints are made of cloth or leather. Cloth restraints (soft restraints) are applied to the wrists, ankles, hands, waist, and chest. Leather restraints are applied to the wrists and ankles. Types: Wrist restraints (limb holders) limit arm movement. Mitt restraints (covers the hands)- they prevent finger use and most are padded Belt restraint (around waits) is used when there is risk of injury from falls and for positioning during medical treatment Vest Restraints-(applied to the chest)- prevent falls or for medical procedure. Be careful to check the patient’s breathing. Cloth restraints are mitts, belts, straps, jackets, and vests. Leather restraints are used for extreme agitation and combativeness. Wrist restraints may be used when the person: Is at risk for pulling out tubes used for life-saving treatment Is at risk for pulling at devices used to monitor vital signs Scratches at, pulls at, or peels the skin, a wound, or a dressing The person in a belt restraint cannot get out of bed or out of a chair. A roll belt allows the person to turn from side to side or sit up in bed. The person can release the quick-release–type belt restraint. Copyright © 2012 by Mosby, an imprint of Elsevier Inc. All rights reserved.

Types of Restraints Wrist restraint Vest Restraint Mitts Belt restraints Copyright © 2012 by Mosby, an imprint of Elsevier Inc. All rights reserved.

Safe Restraint Use (cont’d) Vest and jacket restraints are applied to the chest. A jacket restraint is applied with the opening in the back. The straps of vest and jacket restraints cross in the front. Vest and jacket restraints are never worn backward. The restraint is always applied over a garment. Vest and jacket restraints have life-threatening risks. You are advised to only assist the nurse in applying them. The nurse should assume full responsibility for applying a vest or jacket restraint. Never use force to apply a restraint. The person in a vest or jacket restraint cannot turn in bed or get out of a chair. Review the Focus on Children and Older Persons: Applying Restraints Box on p. 207 in the Textbook. Review the Focus on Communication: Applying Restraints Box on p. 207 in the Textbook. Review the Delegation Guidelines: Applying Restraints Box on p. 207 in the Textbook. Review the Promoting Safety and Comfort: Applying Restraints Box on p. 208 in the Textbook. Copyright © 2012 by Mosby, an imprint of Elsevier Inc. All rights reserved.

Safe Restraint Use (cont’d) Enablers A device that limits freedom of movement but is used to promote independence, comfort, or safety Some devices are both restraints and enablers. When the person can easily remove the device, and it helps the person function, it is an enabler. Enabler vs. Restraint A person chooses to use a geriatric chair with a lap-top tray for meals and writing. If used to limit freedom of movement, it is a restraint. A person chooses to have raised bed rails. The person uses the bed rails to move in bed and to prevent falling out of bed. The bed rails are enablers, not restraints. Copyright © 2012 by Mosby, an imprint of Elsevier Inc. All rights reserved.

Restraint Alternatives Ensure the patient does not have a need-toileting, pain, hunger, boredom, etc. Try alternatives to restraints first-sitters, coming to nurse’s station, walk outside, read a book, give a back massage, use alarm on bed or wrist monitor etc. Consider using matts on floors instead of side rails or vests The nurse tries to find out what the behavior means. This is very important for persons with speech or cognitive problems. Review the questions on p. 197 in the Textbook. Review the contents of Box 14-2 on p. 198 in the Textbook. Copyright © 2012 by Mosby, an imprint of Elsevier Inc. All rights reserved.

Restraint Safety Measures Secure to moveable part of bed frame Check the patient every 15 min Take off restraint and toilet, offer food/water and range of motion every 2 hours Check circulation of extremities Always use a quick release tie Ensure restraint is not to tight-flat hand for vest and one finger for wrist Copyright © 2012 by Mosby, an imprint of Elsevier Inc. All rights reserved.

Restraints are not used to discipline a person. Remember! Restraints are not used to discipline a person. Restraints require a doctor’s order Restraints are not used for staff convenience. Restraints are used only when necessary to treat a person’s medical symptoms. The most serious risk is death from strangulation. Copyright © 2012 by Mosby, an imprint of Elsevier Inc. All rights reserved.