Restraint Alternatives and Safe Restraint Use Chapter 14 Restraint Alternatives and Safe Restraint Use

Some persons need extra protection. Every attempt is made to protect the person without using restraints. Restraints are used only as a last resort to protect persons from harming themselves or others. To meet the person’s safety needs, a resident care conference is held. The health team reviews and updates the person’s care plan.

History of Restraint Use Until the late 1980s, restraints were thought to prevent falls. Research shows that restraints cause falls. Injuries are more serious from falls in restrained persons. Older persons were restrained more often than younger persons were. Their purpose was to protect a person. They can cause serious harm, even death. Falls occur when persons try to get free of the restraints. Injuries are more serious from falls in restrained persons than in those not restrained. Restraints also were used to prevent wandering or interfering with treatment. They were often used for persons who showed confusion, poor judgment, or behavior problems. Review the risks of restraints listed in Box 14-1 on p. 167 in the textbook.

Every center has policies and procedures about restraint use. OBRA, the Centers for Medicare & Medicaid Services (CMS), the U.S. Food and Drug Administration (FDA), The Joint Commission (TJC), state laws, and accrediting agencies have guidelines about restraint use. They do not forbid the use of restraints. They require trying all other appropriate alternatives first. Every center has policies and procedures about restraint use. CMS rules protect the person’s rights and safety. This includes the right to be free from restraint or seclusion. The Joint Commission is an accrediting agency. Recall that OBRA means Omnibus Budget Reconciliation Act of 1987. Policies and procedures about restraints identify persons at risk for harm, harmful behaviors, restraint alternatives, and proper restraint use. Staff training is required.

Centers for Medicare and Medicaid Services (CMS) Terminology Physical Restraint Chemical Restraint Freedom of Movement Remove easily CMS rules protect the person’s rights and safety. Restraints may only be used: To treat a medical symptoms or for the immediate physical safety of the person or others When less restrictive measures fail to protect the person or others Restraints must be discontinued at the earliest possible time. Physical restraint is 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 which restricts freedom of movement or normal access to one’s body. Chemical restraint is any drug that is that is used for discipline or convenience and not required to treat medical symptoms. Freedom of movement is any change in place or position of the body or any part of the body that the person is physically able to control. Remove easily means that 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.

Restraint Alternatives Often there are causes and reasons for harmful behaviors. Knowing and treating the cause can prevent restraint use. Restraint alternatives for the person are identified. Restraint alternatives become part of the care plan. It restraint alternatives do not protect the person, the doctor may need to order restraints. The nurse tries to find out what the behavior means. This is very important for persons who have speech or cognitive problems. Review the questions in the text under “Restraint Alternatives” that are posed when trying to determine what is causing the behavior. Review Box 14-2 on p. 168 in the textbook.

Safe Restraint Use Restraints can cause serious injury and even death. Centers must follow: OBRA guidelines CMS guidelines FDA guidelines Accrediting agency guidelines State laws Restraints are not used to discipline a person or for staff convenience. Discipline is any action that punishes or penalizes a person. Convenience is any action that: Controls or manages the person’s behavior Requires less effort by the center Is not in the person’s best interests

According to OBRA, restraints are used only when necessary to treat a person’s medical symptoms. Sometimes restraints are needed to protect the person or others. Physical restraint: May be any manual method, physical or mechanical device, material, or equipment Is attached to or next to the person’s body Restricts freedom of movement or access to one’s body Cannot be easily removed by the person The CMS defines a medical symptom as an indication or characteristic of a physical or psychological condition. Symptoms may relate to physical, emotional, or behavioral problems. Physical restraints are applied to the chest, waist, elbows, wrists, hands, or ankles. They confine the person to a bed or chair. Or they prevent movement of a body part. Some furniture or barriers also prevent freedom of movement. For examples, review the list on p. 170 in the textbook.

Drugs are restraints if they: Control behavior or restrict movement Are not standard treatment for the person’s condition Complications of restraint use Injuries occur as the person tries to get free of the restraint. Injuries occur from using the wrong restraint, applying it wrong, or keeping it on too long. The most serious risk is death from strangulation. There are also mental effects. Drugs cannot be used for discipline or staff convenience. They cannot be used if not required for the person’s treatment. They cannot be used if they affect physical or mental function. Sometimes drugs can help persons who are confused or disoriented. They may be anxious, agitated, or aggressive. The doctor may order drugs to control these behaviors. The drugs should not make the person sleepy and unable to function at his or her highest level.

Restraints are medical devices. The Safe Medical Device Act applies if a restraint causes illness, injury, or death. CMS requires the reporting of any death that occurs while a person is in restraints. Legal aspects Restraints must protect the person. A written 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. CMS also requires the reporting of any death that occurs within 24 hours after a restraint was removed, and within 1 week after a restraint was removed if the restraint may have contributed directly or indirectly to the person’s death. A restraint is used only when it is the best safety measure for the person. Restraints are not used to punish or penalize uncooperative persons. The care plan must include measures to protect the person and prevent harm to others. Many fall prevention measures are restraint alternatives. Review Focus on Communication: Legal Aspects (Unnecessary Restraint is False Imprisonment) on p. 171 in the textbook.

The least restrictive method is used. Allows the greatest amount of movement or body access possible. Some restraints attach to the person’s body and to a fixed (non-movable) object. Restricts freedom of movement or body access. Vest, jacket, ankle, wrist, hand, and some belt restraints are examples. Other restraints are near but not directly attached to the person’s body (bed rails or wedge cushions). Partially restrict freedom of movement. They allow access to certain body parts and are the least restrictive. The person must understand the reason for the restraint. The person is told how the restraint will help the planned medical treatment. The person is told about the risks of restraint use. If the person cannot give consent, his or her legal representative is given the information. Either the person or legal representative must give consent before a restraint can be used. The doctor or nurse provides the necessary information and obtains the consent.

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 more often as required by the care plan. Remove the restraint, reposition the person, and meet basic needs at least every 2 hours. Follow the care plan. Review Focus on Communication: Safety Guidelines (Observe for Increased Confusion and Agitation) on p. 172 in the textbook. The restrained person must be kept safe. Review Box 14-3 on pp. 172 and 173 in the textbook. Review Teamwork and Time Management: Safety Guidelines on p. 172 in the textbook.

Report and record: The type of restraint applied The body part or parts restrained The reason for the application Safety measures taken The time you applied the restraint The time you removed the restraint The person’s vital signs The care given when the restraint was removed Skin color and condition Condition of the limbs The pulse felt in the restrained part Changes in the person’s behavior Complaints of a tight restraint; difficulty breathing; and pain, numbness, or tingling in the restrained part (report these complaints to the nurse at once) Information about restraints is recorded in the person’s medical record. You might apply restraints or care for a restrained person.

Applying restraints Restraints are made of cloth or leather. Restraints may increase confusion and agitation in persons with dementia. Never use force to apply a restraint. Ask a co-worker to help apply the restraint if needed. Report problems to the nurse at once. Wrist restraints (limb holders) limit arm movement. Hands are placed in mitt restraints. Belt restraints are used when injuries from falls are risks or for positioning during a medical treatment. Review Residents with Dementia: Applying Restraints on p. 178 in the textbook. Review Delegation Guidelines: Applying Restraints on p. 178 in the textbook. Review Promoting Safety and Comfort: Applying Restraints on p. 178 in the textbook. Review the Applying Restraints procedure on pp. 179-180 in the textbook.

Cloth restraints (soft restraints) Mitts, belts, straps, jackets, and vests. Applied to the wrists, ankles, hands, waist, and chest. Leather restraints Applied to the wrists and ankles. Wrist restraints Used when a person continually tries to pull out tubes used for life-saving treatment. (intravenous infusion [IV], feeding tube) Mitt restraints Prevent finger use. Allow hand, wrist, and arm movements. Belt restraints Prevent person from getting 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 belt is applied around the waist and secured to the bed or chair (lap belt). It is applied over a garment. Leather restraints are used for extreme agitation and combativeness. Wrist restraint are also used when the person scratches at, pulls at, or peels the skin, a wound, or a dressing. This can damage the skin or the wound. Mitt restraints are used for the same reasons as wrist restraints. Most mitts are padded. The person can release a quick-release type belt restraint. It is less restrictive than those that only staff members can release.

Vest restraints and jacket restraints are applied to the chest. A jacket restraint is applied with the opening in the back. For a vest restraint, the vest crosses in front. The straps of vest and jacket restraints: Always cross in the front Never cross in the back Are always applied over a garment Have life-threatening risks You are advised to only assist the nurse in applying vest and jacket restraints. Death can occur from strangulation. Never use force to apply a restraint. If a person is confused or agitated, ask a co-worker to help apply the restraint. Report problems to the nurse at once. Vest and jacket restraints may be used to prevent injuries from falls. And they may be used for persons who need positioning for a medical treatment. The person cannot turn in bed or get out of a chair. If the person gets caught in the vest or jacket restraint, it can become so tight that the person’s chest cannot expand to inhale air. The person quickly suffocates and dies. Correctly applying vest and jacket restraints is critical. You are advised to only assist the nurse in applying them. The nurse should assume full responsibility for applying a vest or jacket restraint. Review Focus on Communication: Applying Restraints on p. 178 in the textbook.

Quality of Life Restraints lessen the person’s dignity. The restrained person depends on others for basic needs. Try to understand the person’s situation to better understand how the person with restraints feels. Treat the person with kindness, caring, respect, and dignity. Review Quality of Life on p. 180 in the textbook.