Restraints Education for Nurses and Physicians

8/4/2019 Restraints Education for Nurses and Physicians

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Restraints Education

Comprehensive Assessment

Placing a patient in restraints requires clinical justification. A comprehensive

assessment is needed to identify the clinical justification. The comprehensive

assessment will:

identify the behaviors that put the patient at risk for restraint use. Patient hasbehaviors such as agitation, restlessness, or cognitive impairment that interfere

with therapy or overall safety

identify triggers or factors that are causing the patients behaviors (pain;delirium caused by infection, hypoxia, drug/alcohol withdrawal, electrolyte

imbalances, general medical conditions; etc.) . Ask patients what they want orneed or knowledgeable others if the patient is unable to communicate

determine how past events and coping behaviors contribute to risk for restraintsby reviewing the patients health history and healthcare record

evaluate medication list to determine if any medication(s) contribute tocognitive dysfunction, movement disorders, and falls.

assess the functional, mental, and psychosocial status of the patient, as well asthe environment surrounding the patient (noise level, lighting, floor surfaces,

equipment, furniture, visual cues, barriers to mobility, area for privacy and

socialization, and clothing

Patient and Family Notification

The patient and family are to be notified for reason for the patient being placed in

medical surgical or behavioral health restraints.

Interventions

Understanding the patients behavior and the meaning behind the behavior is

essential to prevent the need for restraints. The focus of nursing interventionsincludes:

treating and/ or eliminating the cause for restraint use meeting the expressed need of the patient and collaborating with team members


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Common interventions address physical/physiological issues, psychological issues,

and environmental modifications.

Interventions that address physical/physiological issues include:

discontinue therapeutic devices as soon as possible or secure the devices in amanner in which the devices are less likely to be intolerable

explain treatment techniques to the patient and the family hourly rounding offer prn medications ordered to reduce anxiety, agitation and confusion offer PRN medications prior to a painful procedure to reduce pain and calm

the patient

request that physician order medication for alcohol/drug withdrawal at theonset of withdrawal symptoms

give prn medication as ordered for alcohol/drug withdrawal symptoms place long -sleeve robes or gowns to hide the IV catheter site/ tubing and the

Foley

provide physical activities to divert the patients behaviors use reality orientation with patients who are delirious provide constant observation exercise program nursing assessment of patients risk for falls ensure use of canes, walkers, and wheelchairs


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prevent dehydration push oral fluids as indicated, seek assistance fromVascular Access Team for patients needing IV fluids and venous access is

difficult

prevent fluid and electrolyte imbalances prevent hypoxia by ensuring that patient is using oxygen as ordered,

patients position in bed is not obstructing breathing, asthmatics get orderedinhalers when SOB

prevention of UTI by avoiding use of urinary catheterization nursing assessment of the patients risk for falls collaborate with physician and pharmacist about whether medication iscausing changes in mental status or causing the patient to fallInterventions that address psychological issues include:

Involve family in care. Family might be able to interpret the meaningbehind the patients behavior

Provide for familiarity by encouraging family members to make audiotapesfor the patient and to place family photographs in the patients room, byreminiscing about the past with the patient, and by arranging, if possible for

to same staff to take care of the patient

verbal interventionencourage verbalization about feelings and help patientidentify positive ways of coping with distressing situations

give prn medications for agitation/psychosis

decrease stimulation

Interventions that address environmental issues include:

ensure call light, water, bed pan, and commode, are accessible


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respond quickly when the patient requests for assistance provide adequate lighting move the patient closer to the nurses station use pressure sensitive alarm bed leave bedrail(s) down put bed in lowest position develop patient specific toileting routines to reduce risk of falls reduce excessive noise ensure the patient uses eyeglasses, hearing aids, and other assistive devices so

they are able to correctly interpret environmental stimuli

provide non-skid slippers

Examples of situations in which the patient may be placed in medical surgical

restraints

Brain -Injured patient who becomes combative the first time he/she awakensafter brain injury.

ICU patient who attempts to extubate himself/herself upon awakening froman anesthetic.

Patient pulls at IV line, tubes, drains, dressings, and/or Foley afterexperiencing confusion caused by an adverse drug reaction, a general

medical condition, dementia, or delirium.

Medical Surgical restraints are used until all organic causes for patients selfharm/harm to others have been eliminated. Example A schizophrenic patient

who is in delirium from septicemia and has attempted to harm self/others

after hearing command hallucinations result of should be in medical surgical

restraints, while being treated for the infection and psychosis.

Medical Surgical Restraint Order/Assessment

The nurse needs to notify the doctor within one hour after placement of the

restraints about the patients change in condition, the need for restraints, and obtain


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an order for restraints. Nurses are allowed to take telephone orders for the initial

placement of restraints. The physician has up to 24 hours to do the face- to-face

assessment and sign a telephone order for the medical surgical restraint. It is

recommended that the orders for restraint renewals are obtained from theprimary team daily by 1300. Nurses are to perform an assessment on the patient

requiring initiation or renewal of restraints and use the SBAR format to

communicate to the physician why the patient requires the restraint order. The

nurses use ofthe SBAR format to communicate the patients change in condition

and need for restraints can help the physician understand why it is necessary to see

the patient quickly.

Behavioral Health Restraint Order/Assessment

The patient who is exhibiting violent or self destructive behavior that jeopardizes

the immediate physical safety of the patient, staff, or others needs an order forbehavioral health restraints. Time limits for behavioral health restraints are

according to age of the patient:

4 hours for adults ages 18 and above 2 hours for children and adolescents between the ages of 9 and 17 or 1 hour for children below the age of 9

The physician is to perform a face to face assessment of the patient requiringrestraints for management of violent or self destructive behavior that jeopardizes

the immediate physical safety of the patient staff and others within one hour of the

initiation of the restraints. A physician order is to be obtained within one hour of

the initiation of the restraints.

The order for behavioral health restraint may be renewed one time after

reassessment by the RN or physician. If additional restraint is needed because the

behavioral emergency continues, a physician must perform the face-to-face

assessment of the patient before giving a new order.

All patients who are in behavioral health restraints require one to one coverage.

All Restraints

If a medical surgical restraint or a behavioral health restraint is discontinued and

again is needed for an emergency situation, then a new restraint order is required to


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initiate restraint.

Federal Regulation Definition of a Restraint

A restraint is defined as any manual method, physical, or mechanical device,

material, or equipment that immobilizes or reduces the ability of a patient to move

his/her arms, legs, body, or head freely. This definition applies to all uses of

restraint in all hospital care settings. Common hospital devices or practices that

could meet this federal regulation of restraint include, but are not limited to:

tucking the sheets in so tightly that the patient is unable to move using a net bed or enclosed bed to prevent the patient from freely

leaving the bedexception putting a toddler in an enclosed or domed

crib using freedom splints that immobilize the patients limb using the side rails to stop a patient from voluntarily getting out of the bed Geri chairs or recliners, only if the patient cannot easily take off the

restraint appliance and get out of the chair without assistance

A device is not generally considered a restraint if the patient can intentionally take

off the device in the same manner the staff applied the device (examples includeside rails put down, not climbed over, buckles are intentionally left unbuckled, ties

or knots are intentionally not tied by the staff) while considering the patients

physical status and ability to accomplish an objective (examples - patient can

transfer to a chair, patient can get to the bathroom on time).

The following devices are not restraints:

orthopedically prescribed devices surgical dressings or bandages protective helmets physical holding for the purpose of conducting routine physical

examinations or tests or

devices to protect the patient from falling out of the bed or allow the patientto participate in activities without risk of physical injury


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The following methods and devices are not restraints:

an IV arm board that is not tied down or attached to the bed to stabilize anIV line

a mechanical support to attain proper body posture, balance or alignment, orto permit greater mobility such as the use of leg braces to allow a patient to

walk or the use of a neck , head, or back brace to allow the patient to sit

upright

a medically necessary securing or positioning device that is used to maintainthe position , limit mobility, or temporarily immobilize a patient who is

undergoing a medical, dental, diagnostic or surgical procedure

hand mitts that are not pinned, attached to a bed, that are not used inconjunction with a restraint, that are not applied so tightly that the patient is

unable to move his/her fingers or hands, or that are not so bulky that thepatient s ability to use his/her hands is reduced.

stroller safety belts, swing safety belts, high chair lap belts and crib coversutilized to protect an infant , toddler, or pre-school child

forensic and corrective restriction used for security

References

Agency for Health Care Administration: Aspen Federal Regulations Set: A 19.03 Acute Care

Hospitals (03-01-10). Retrieved 07-12-11.

Bernstein, K.S. & Saladino, J.P. (2007). Clinical Assessment and Management of PsychiatricPatients Violent and Aggressive Behaviors inGeneral Hospitals, MedSurg Nursing, 16(5).

Caple, C. (2011). Delirium in Acute and Post Acute Care, CINAHL Nursing Guide, Cinahl

Information System. Retrieved from Nursing Reference Database 07-14-11

Caple, C. , Schub, T., & Pravikoff, D. (2011). Substance Withdrawal Syndrome, CINAHLNursing Guide. Retrieved from Nursing Reference Database 07-14-11.

Fick, D.M., Cooper, J.W., Wade, W.E., Waller, J.L., Maclean, R., & Beers, M.H. (2003).

Updating the Beers Criteria for Potentially Inappropriate Medication Use in Older Adults,Archives of Internal Medicine, 163(22), pp. 2716-2724. Retrieved from Duke Clinical Research

website 07-12-11.


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Halm, M.A. (2009). Hourly Rounds: What does the Evidence Indicate, American Journal of

Critical Care, 18(6), p581-584.

Kratz, A. (2008). Use of the Acute Confusion Protocol A ResearchUtilization Project,

Journal of Nursing Care Quality, 23(4), p 331-337.

Minnick, A. F., Mion, L.C. , Johnson, M,E. , Catrambone, C., & Leipzig, R. (2007).

Prevalence and Variation of Physical Restraint Use in Acute Care Settings in the US, Journal

of Nursing Scholarship, 39(1), p.30-37.

Park, M. & Tang, J.H. (2007). Evidence-Based Guideline Changing the Practice of Physical

Restraint Use in Acute Care, Journal of Gerontological Nursing, p. 9-16.

Rutledge D; Schub T; Pravikoff D; Cinahl Information Systems, 2011 Feb 11 (2p) Fall

Prevention in Hospitalized Patients(evidence-based care sheet) CINAHL AN: 5000000248

Retrieved 06-21-11.

Schofield, I. (2008). Delirium: challenges for clinical governance, Journal of Nursing

Management, 16, 127-133.

Schub, T., Cabrera, G., & Pravikoff, D. (2011). Alcohol Withdrawal Syndrome, CINAHL

Nursing Guide. Retrieved from Nursing Reference Database 07-14-11.

UHS Corporate Policy Number 9.13 Restraints and Seclusion effective 07-27-09.

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Restraints Education for Nurses and Physicians