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Published byPierce Bradley Modified over 8 years ago
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02-041 Restraints
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02-04 2 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
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02-04 3 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
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02-04 4 Restraint Procedure Does not apply to the following situations: –Limitation of mobility –Adaptive support –Protective device –Forensic and corrective restrictions
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02-04 5 Alternative Interventions Environmental Distraction Staff/family interaction Nursing care
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02-04 6 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
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02-04 7 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
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02-04 8 Approved Restraints Soft limb restraints Belts Vest Body net –Limited to staff who are trained in usage Vail bed
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02-04 9 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
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02-04 10 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
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02-04 11 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
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02-04 12 Tip Never secure restraint straps to the bed rails or to the head of the bed!!!
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