Therapuetic Play, Safety & Restraints 2008 2

8/8/2019 Therapuetic Play, Safety & Restraints 2008 2

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Diana Parsons McIntyreDiana Parsons McIntyreMarch 17, 2008March 17, 2008

THERAPUETIC PLAY,THERAPUETIC PLAY,

SAFETY &SAFETY &RESTRAINTSRESTRAINTS

THERAPUETIC PLAY,THERAPUETIC PLAY,

SAFETY &SAFETY &RESTRAINTSRESTRAINTS


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Introduction Childrens play is their work and children

work diligently at their play. Children at

play provide those observing with a windowto their inner feelings, beliefs, thoughts,and fears. Children at play communicate tothe observer how their life apart from

play has been and how they desire theirlife to be in the future.


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Introduction Over time, children at play develop a

theme to their play, demonstrate

rules and boundaries, provide specificresponses to good and evil, and modelbehaviors they have themselves

experienced (Timberlake & Cutler,2001).


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Therapeutic Play

Play is to a child what work is to an adult: Itis what they do. It is through play thatchildren learn about their world and thethings in it. Play allows children the chance to

explore their environment, to learn how itworks and how they relate to it.

A child can express feelings and emotionsthrough various types of play activities (play,art, stories, etc.) far earlier than they canexpress them in words.


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Therapeutic Play For older children, play may be the

outlet through which they convey

emotions that they are eitherunwilling to share verbally or do nothave the sufficient vocabulary to

express. Through play children can beanyone, at anyplace, at anytime.


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Therapeutic Play

Play is now widely recognised as beingbeneficial in the emotionaldevelopment of children. It has a

therapeutic value. With the growthof play therapy, play work and the useof therapeutic play skills there iswidespread confusion about the roles

of each and the skills required to be aproficient practitioner.


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Therapeutic Play Play is a means of communication for

children. Child Life specialists use

play to help reduce patient's stress,allow children to express theirfeelings and to help them feel

comfortable with other children inthe hospital.


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Therapeutic Play

Within the therapeuticrelationship of child andtherapist, play is interactive and

at best, nondirective. Theprofessional begins where thechild is and follows the childslead. Early in the therapeutic playrelationship, the shared space ofthe child and therapist provides asafe environment for developing

attachment and bonding.


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Therapeutic Play

Therapeutic play may also beused as a method of detectingmore serious problems that may

be dealt with by referring on toa play therapist, childpsychotherapist or other mentalhealth specialist. A therapeutic

relationship is established andbecause there is some degreeof clinical responsibility clinical

supervision is essential.


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Therapeutic Play Anyone using therapeutic play

skills should be bound by a codeof ethics, or an equivalent

professional organization whichwould normally be laid down bythe employing agency.

Therapeutic play has a valuablefunction in preventing slight ormild problems becoming worse.


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When to Refer??

There is no easy way to know when childrenneed to be referred to a qualified professionalfor continued intervention. Below is a list of

behaviors that could indicate just such a need: When the child verbalizes or indicatesextreme anger, desire to hurt self or others,suicidal ideation/wishes, or past delinquentacts.

Consistently expresses self in somber orself-deprecating terms

Repeated reliance on dark colors and themesin artwork


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Safety Measures

Safety implies a wide range ofactivities used to protect childrenfrom harm and danger. During

procedures, safety principles relatedto aseptic techniques, restraints andtransportation are extremelyimportant.


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Safety Measures

Education for the children andparents in the primary setting/community is also important- theuse of helmets, seatbelts, sexualpractices. Teach the parents aboutsafety in the homes storage ofmedication, locking away of harmfulsubstances, not to leave childrenunattended in any situations such as??


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Safety Measures

For the nurses we too need to protectour clients proper hand washing andgloving are important duringprocedures. Wash hands betweenpatients etc. use all general universalprecautions in the hospital or healthcare settings.

Safety measures also means proper use

of bed rails and constant observationof clients under our care. This includeswhen restraints are being used.


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What is a Restraint Any manual method or physical or

mechanical device, material, or

equipment attached or adjacent tothe resident's body that theindividual cannot remove easily which

restricts freedom of movement ornormal access to one's body.


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Restraints Terms "Therapeutic Physical Restraint"

means the acceptable use of a staff

member's body to immobilize orreduce the free movement of achild/youth's arms, legs, torso, orhead, in order to ensure the physical

safety of a child/youth or otherindividual in the facility.


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Restraints Terms The term does not include: (A)

briefly holding a person in order to

calm or comfort the person; (B)restraint involving the minimumcontact necessary to safely escort

the person from one area to another.


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Restraints Terms

"Mechanical restraint" means anyapproved mechanical restriction thatimmobilizes or reduces the freemovement of a child/youth's arms,

legs, torso, or head in order to hold achild/youth safely including:

(A) medical devices, including, but notlimited to, supports prescribed by ahealth care provider to achieveproper body position or balance;


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Restraints Terms

(B) helmets or other protective gearused to protect a person frominjuries due to a fall; or

(C) helmets, mitts and similardevices used to prevent self injurywhen the device is part of adocumented treatment plan and isthe least restrictive means availableto prevent such self injury.


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Restraints Terms

"Seclusion" means the involuntaryconfinement of a child/youth in aroom in a covered facility, whetheralone or with staff supervision, in a

manner that prevents thechild/youth from leaving. This definition does not pertain to

the use of "time out" as an

acceptable form of short-termbehavioral management nor does itpertain to covered facilities wherethe terms of seclusion are definedpursuant to particular judicial

decrees.


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Restraints Terms

"Time out" means the briefseparation of a child/youth fromthe group not to exceed twenty(20) minutes, designed to de-escalate the child/youth. Duringthe "Time out," a child/youth's

freedom of movement is notrestricted and the child/youthneed not be directly supervised,

but must be visually monitored.


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Two main methods of restraints are:1. Physical2. Chemical

Chemical restraint involves the useof psychotropic drugs or sedativesor paralytic agents. Physical

restraint involves the use ofphysical or mechanical devices torestrain movement.

Methods of Restraints


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Physical Restraints

"Physical Restraint" means restrictingthe movement of a child, or restrictingthe movement or normal function of aportion of the child's body asdescribed in agency-approved trainingmethods, by forcefully andinvoluntarily depriving the child of freeliberty to move about.

Simple physical redirection, such as

hand on back to redirect or brieflyholding the upper arm(s) or clasping ofthe hand, should not be consideredphysical restraint.


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Physical Restraints Physical restraints may be cloth,leather, metal handcuffs or shackles,car seats, or seat belts. This statementis limited to the use of physicalrestraint in children and adolescents inthe acute care or nonpsychiatric

inpatient setting.


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Planned use of physical restraint mayonly be used as an emergency

measure in response to imminentdanger to self or others, and when noalternate actions are

sufficient to intervene in a child oryoung adult's challenging behaviors.


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Purpose of Restraints

Following craniofacial surgeries suchas cleft lip and palate repairPrevents pulling stitches, bandages,eye patches, etc.Prevents scratching and damaginginjured or burned skinPrevents pulling NG tubes & IV tubes

Prevents self inflicted injuryUse in place of IV BoardsControls arm movementDuring training to stop thumb sucking


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Restraints

Children and adolescents may need tobe physically or chemically restrainedfor various procedures, because ofdisruptive behavior, or to preventinjury to themselves or others.

The use of restraint for a child oradolescent requires clear indications,

safe application, reassessmentguidelines, and use only after theconsideration of alternative methods.


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Situations that may require theshort-term use of restraint in a

child or adolescent includeextreme, disruptive, self-injurious, or aggressive behavioras a result of drug intoxication,head injury, cerebrovascularhemorrhage, multiple trauma, oracute psychiatric disorder.

RESTRAINTS


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Patients in status epilepticus mayrequire short-term physical

restraint to prevent injury to selfor others until the seizure iscontrolled with antiepilepticagents. The use of the restraint,however, should not place a childor adolescent at risk of injury ordeterioration of the medical

condition.

RESTRAINTS


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Policy Guidelines

Policies for the use of physicalrestraint of children andadolescents in the acute care or

inpatient setting should includethe following:

1. An explanation to children whyrestraint is necessary, with theopportunity for children torespond to therapeutic holdingwhen appropriate and safe.


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Policy Guidelines

2. A physician's written or verbalorder specifying the type ofrestraint to be used and the

importance of adequaterestraint in relationship to itsindication, with an estimate ofduration.

This order should be reviewedon an ongoing basis in theemergency department setting.


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Policy Guidelines

3. An immediate documented explanationto parents or family members as towhy restraint is necessary.

4. An assessment according to hospitalguidelines of those who have beenrestrained, assuring that therestraints are correctly applied, thatskin integrity and neurovascular status

remain intact, that restraintsaccomplish the purpose for which theywere applied, and that the need forrestraint continues.


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The decision to use restraints formedical/surgical reasons or forbehavioral health care reasons is notbased on the treatment setting buton the situation the restraint isbeing used to address.

The acute medical and surgical carerestraint standards would apply tomedical care, post-surgical care, and

in situations in which behaviorchanges are caused by medicalconditions or symptoms, for example,for confusion or agitation. In suchcases protective interventions may

be necessary.

RESTRAINTS


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Monitoring/Observation Monitoring a client in restraint or

seclusion is done to ensure that the

client is physically safe in restraints orin the seclusion room. Continuous meansuninterrupted observation of thatclient.


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Monitoring/Observation

For a client in restraint this observationmust be done in-person as long as theindividual is in restraint. For the client

in seclusion, the in-person observationcan progress to audio and visualmonitoring after the first hour inseclusion.


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Monitoring/Observation

In-person means that the observermust have direct eye contact with theclient. However, this can occur througha window or through a doorway, sincestaff presence in the room in which theclient is restrained or secluded could

be dangerous or add to the agitation ofa client .


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Types of Restraints

Restraints come in different sizesand forms and can be made of clothor leather. Cloth restraints are alsocalled soft restraints and include

vest restraints, straps and belts. They are most commonly used onwrists, ankles, hands, elbows andforearms, waist and chest. Leather

restraints are usually only used onwrists and ankles and for excessiveirritation or agitation.


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Types of Restraints

Wrist and ankle restraints come intwo, three, or four point design. Thenumber designates how manyextremities are being restrained. Forexample, the two-point restraint would

only restrict movement on the wrists.

Two fingers should always fit betweenthe restraint and the wrist to ensurecirculation is not being hampered.These types of restraints are usefulfor someone who pulls out tubing likeIV's or catheters.


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WRIST RESTRAINTS FOR INFANT


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Types of Restraints

Mitt restraints cover an entire hand andfingers typically go in one of five insidepockets unless the individual's hand could begrasping a towel inside the restraint. The goal

is to keep the hand and fingers open toprevent permanent damage to theextremities.

The goal with these restraints is also to keepsomeone from pulling out tubing and also toprevent scratching.


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Types of Restraints

Vest and jacket restraints always cross in the backof a person and are applied to the chest. Thisconfines a person to a bed or chair and preventsthem from moving. These can also be useful whenneeding to give medical treatment to someone.These restraints also carry the greatest risk to lifesince if a person tries to get out of the position theyare confined in, they can become strangulated anddie.

Belt restraints are used in a similar fashion as avest restraint, just not as restrictive in movement.The belt wraps around the waist and is secured to achair or bed.


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E.g. MITTS, JACKET/VEST & WRIST RESTRAINTS


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Types of Restraints

Elbow restraints restrict movement of the elbowsand are most useful for children to keep themfrom bending their elbows. These kind wraparound the elbow and can be pinned to clothing.

All the various restraints need to be used in asafe manner to ensure the best possibleoutcome for the person. A physicians' ordermust be in place before the restraint is used and

the individual being restrained must be checkedevery 15 minutes and repositioned every twohours if they are confined to one particularposition.


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Applied correctly Snuggle Wraps willsafelystay on ensuring that the newly repaired cleft

will heal properly and not be damaged by

little hands. It is securely fasten around the

wrist (like a watch) which keeps them from

sli in down over the hand.


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Abdominal

restraint


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Six point

restraints


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Safety Straps

EXAMPLES OF CHEMICAL


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RESTRAINTS

Psychotropic Medications

Drugs that affect brain activitiesassociated with mental processes and

behavior (also called psychoactive orpsychotherapeutic). Psychotropicmedications are divided into four broadcategories: anti-psychotic; anti-

depressant; anti-anxiety; and hypnoticmedications.



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RESTRAINTS

Anti-psychotic Drugs Used to treat various psychoses and

neurologic conditions.

Trade names Thorazine, Mellaril, Trilafon, Prolixin,

Stelazine, Navane, Haldol, Clozaril


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RESTRAINTS

Anti-depressant Drugs -Used in the treatmentof depression and agitation, and in lowdosages for insomnia. Side effects include

excessive sedation, anti-cholinergic effects(dry mouth, constipation, urinary retention,blurred near vision, rapid heart rate,confusion and disorientation) and orthostatic

hypotension. Trade Names: Norpramin, Adapin, Sinequan,

Prozac, Tofranil, Marplan, Ludiomil, Pamelor,Paxil, Nardil, Zoloft, Parnate, Desyrel



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RESTRAINTS

Anti-anxiety and Hypnotic Drugs Anti-anxiety drugs are used for the

short-term management of anxiety andinsomnia. Hypnotics are medications

used for short-term sleep aids. It isassociated with impairment of daytimefunctioning and may increase confusionand disorientation, and in turn

exacerbate problem behaviors.Trade names Dalmane, Librium, Tranxene, Valium,

Klonopin, Doral, Paxipam, Ativan, Serax,

Xanax


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Conclusion

Children are unique individualsrequiring specialized care based onevolving cognitive capabilities anddeveloping social awareness. Nurses

understanding of developmental goalsand milestones aids in planninginterventions for these unique needs.Whatever measures nurses employ

must cause no harm nor distress totheir clients


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References

Broadwell Jackson, D. & Saunders,R.B (1993) Child Health Nursing: AComprehensive Approach to the

Care of Children and Their Families.Philadelphia: Lippincott Marks, M.G. (1994) Broadribbs

Introductory Pediatric Nursing 4th

Ed. Philadelphia: J.B. Lippincott Marlow, D.R. & Redding, B.A. (1988)

Textbook of Pediatric Nursing 6thEd. Philadelphia: W.B. Saunders

Documents

Therapuetic Play, Safety & Restraints 2008 2