Restraints

Clinical Application Use of a restraint to promote medical/surgical healing or removal of a line or tube –Related to cognitive deficiency –Related to high risk for falls due to functional deficits

Behavior Application Use of restraint for behavior health reasons to manage an unanticipated outburst of severely aggressive or destructive behavior that poses an imminent danger to patient or others

Restraint Procedure Does not apply to the following situations: –Limitation of mobility –Adaptive support –Protective device –Forensic and corrective restrictions

Alternative Interventions Environmental Distraction Staff/family interaction Nursing care

PCA Responsibilities-Clinical Assist in placement of restraints Every 2 hours –Release and exercise limbs –Attend to hygiene and elimination needs –Offer fluid/foods –Reposition patient Take Vital Signs q4h

PCA Responsibilities-Behavioral Assist in the placement of restraints Monitor the patient on 1:1 basis Observe and assist patient q15min Every 2 hours –Release and exercise limbs –Attend to hygiene and elimination needs –Offer fluid/food –Reposition patient –TAKE VITAL SIGNS

Approved Restraints Soft limb restraints Belts Vest Body net –Limited to staff who are trained in usage Vail bed

Unacceptable Restraint Devices Tape of any kind Metal wrist or ankle restraint/cuff –Except patients in custody of Law Enforcement Agencies Long ties/leashes Bed sheets

Unacceptable Restraint Positions Restraining a patient in a standing position Restraining a patient with their upper extremities above the head Hands and feet tied together behind the patient’s back

Sizes of Vest (Posey) Restraint Determine correct size based on patient weight –X-small—up to 110 pounds –Small—110 to 130 pounds –Medium—120 to 160 pounds –Large—150 to 185 pounds –X-large—175 to 200 pounds –XX-large—200+ pounds

Tip Never secure restraint straps to the bed rails or to the head of the bed!!!