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

2. 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

3. 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.

4. 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.

5. Restraint Use Video
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6. 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

7. Restraint Orders

8. 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

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

10. Restraint Documentation Example

11. 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

12. 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?

13. Video of slip knot for restraints
Watch Mrs. Bettag tie a slip knot on chair

14. 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

15. 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.

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

17. 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.

18. 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

19. 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

20. 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.

21. 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)

22. 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).

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

24. 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

25. 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).

26. 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.

27. 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

28. 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

29. 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