1. Restraints N.F. Pgs

2. Definition of a restraint
The use of major tranquilizers or physical means to prevent patients from harming themselves or others
FDA says it’s a “device” used for medical purposes that limits a pt’s movements to the extent necessary for treatment, exam or protection of the pt

3. Restraint devices are…
Wrist
Ankle
Vest
Jacket or posey
Or other strap to secure a pt in place such as a lap belt

6. Vest Restraints (Posey Vest)

7. Lap Belt

8. Elbow
Restraints

9. Mitt Restraint

10. Mummy Restraint

11. Application of restraint
Restraints should be fitted properly
They should be applied in the manner that they WILL not cause accidental injury or harm to the pt such as strangling or smothering if pt slips down in the bed , wheelchair or chair

12. Why Limit Restraint Use?
It’s the law
JCAHO
Federal Omnibus Budget Reconciliation Act (long term care only)
State and Local Standards
It causes confusion and agitation
It limits mobility and thus health
Cause Injury

13. Negative effects of restraint use…
Increases confusion
Constipation
Incontinence
Pressure sores d/t non-movement
Decreased inability to perform ADL’s or ROM

14. Assessment of patient A full assessment of pt is a MUST
Determine pt’s state of mind such as confusion, delirium, depression
Is pt dizzy upon standing alone, is assistance required
Assess pt for need of restraint…does pt have tubes he/she is trying to pull out, is pt trying to escape the facility

15. Restraint protocol
Each facility has a restraint protocol, must become familiar with your institution
JCAHO approves each facilities protocol
FOLLOW IT or write up on your part will occur

16. Medical order You must follow your institution’s protocol however,
A nurse must notify a physician of the need for restraints. The physician has the ultimate say in whether a restraint will be used. Nurse cannot just apply the restraint

17. The order… Must specify the type of restraint
Must state the reason why the restraint is needed
Must state the criteria for removal of it
Must state the length of time the restraint is to remain on
THE ORDER MUST BE RENEWED q 24HRS AFTER THE DR. PHYSICALLY EXAMINES THE PT

18. How to prepare to use restraints…
Assessment of pt and their needs
Assessment of their skin, bony prominences that will be effected. If so, padding the restraint will be required
Permission from patient or pt’s guardian prior to the use of restraints is necessary
Attempt to explain the restraint to the pt

19. Monitoring and documentation
Your facility will have paperwork designed to record restraint use, USE IT, it’s a legal record
Nurse must assess and record the effects of restraints on:
Pt behavior
Neurovascular effects distal to the site of the restraint EVERY 30 – 60 MINUTES

20. Where to tie the restraint?
To the MOVEABLE part of the bed
If you tie it to the non-moveable part, it may injure the patient.

21. Removing the restraint
The nurse must remove (one at a time) each restraint EVERY 2 hours to assess:
Skin and circulation
Perform ROM
Evaluate the continued need for the restraint

22. Restraint Alternative
Are protective or adaptive devices that promotes pt safety and postural support but which can be released independently by the pt

23. Types of restraint alternatives…
1) Electronic bed and seat monitors that alarm when the pt gets up
2) Seat inserts
3) Gripping materials that prevent slipping
4) Support pillows
5) Seat belt or harness with front-releasing velcro
6) Tilt wedges
7) Companion at bedside to help protect and remind pt

24. Self-Release
PT MUST BE ABLE TO RELEASE THIS ALTERNATIVE DEVICE INORDER FOR IT TO NOT BE CLASSIFIED AS A RESTRAINT
PT MUST BE ABLE TO GET OUT ON OWN

25. Documentation:
Initial act - Alternatives tried - Results
(This Supports the use of the restraints if they
are applied)
1000- Pt Confused, Rt side is flaccid, pt pulls on
PEG tube with left hand, light protective covering
to peg site with 4X4’s, use of activity
blanket encouraged.
1030- pt remains confused and becoming agitated.
back rub given, pt repositioned to L. sims position.

26. Documentation After application of restraints:
Reason for restraining-assessment of pt status
(especially R/T restraint type)-Results
1100-PEG tube site is swollen and red. Sm. amt. of
red drainage noted at site. Pt. conts to pull at tube.
Dr. notified as well as pt’s guardian, Left Wrist
restraint applied. Skin on L. Wrist is intact, warm
and pink, cap refill is < 3 secs. Call bell in reach.
PN will reassess pt again in 30 minutes

27. 1130 – pt resting comfortably, extremities
warm and pink with + pulses

28. Follow Up charting-Condition of Pt R/T restraint-
If restraining is continuing
1230-released l. wrist restraint, area remains intact
and warm, assisted pt to BR, ROM done to Wrist,
continues to pull PEG tube, restraint reapplied

29. What to do if incident occurs
Check ABC’s
Call for help from staff
Assist pt
Notify M.D.
Write incident report
Nursing documentation

30. Restraint

31. Restraint-Error

32. When to check on a patient?
Every 1 hour
Remove restraint and offer food, drink, B.R.
NCLEX wants you to be aware of neurovascular checks and condition of skin
Safety must come first

33. Orders
A new restraint order must be given by the Dr. EVERY 24 hours

34. The End