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17 Cards in this Set
- Front
- Back
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restraints definition |
Device or method used for purpose of restricting a patient’s freedom of movement or access to his body, with or without his permission |
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types of restraints (3) |
Physical force Mechanical device Chemical (medication) |
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purpose of restraints |
Prevention of injury to self or othersUse for shortest duration necessaryUse only after all other less restrictive measures have failedMust follow federal, state, and facility policies |
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implications for use of restraints |
Confusion Combative Disorientation Self-harm Harm to others/surroundings Removal of medical devices |
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inappropraite use of restraints |
Convenience Punishment Physically or mentally unstable Inability to tolerate decreased stimulation of seclusion (aka they're claustrophobic and restraints will just make them more agitated) |
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basic principles of restraints |
Should not interfere with treatment or make condition worse Use the least restrictive possible Fit properly Be discreet Does not pose a safety risk Be easy to remove or change |
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how/when to use restraints |
Determine that dangerous behavior continues despite other attempts Obtain prescription Notify family (or they'll go crazy when they see grandma tied down) Pad bony prominences Apply appropriate restraint Use quick release knots |
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what to check for when using restraints |
Adjust restraints for good body alignment, comfort and safety Check every 15-30 minutes Release at least every 2 hours for skin care, exercise, toileting and hydration Assess for continued need for restraints Remove as soon as possible |
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examples of types of restraints |
Vest Limb and elbow MummyCrib Body Belt Mitten Bed bars Chemical |
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alternatives to restraints |
Provide consistency (same nurse, same room etc) Review medications (may be new med is making agitated; if meds corrected no need restraints) Provide relaxation and relieve anxiety Provide frequent assessment and surveillanceFind ways to communicate Modify the environment (calm, quiet) Anticipate unmet needs (may be getting oob to use bathroom. if youfollow sked, may be more coorperative) |
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complications from restraints |
Skin breakdown Circulatory damage Nerve damage Incontinence (BRP) Urinary retention(BRP) Constipation (BRP) Pneumonia (esp if laying flat/immoblie) Psychological effects |
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legal implications |
RegulatedProvider must prescribe in writing after face-to-face assessment |
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prescription must include: |
reason type location how long to use type of behavior that warrants the use Time limits Must renew in 24 hours May not write PRN Nurse must be aware of potential harm May restrain in emergency but must have prescription as soon as possible |
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lifespan considerations for children |
-Don’t make parents be the restrainers!Consider developmental tasks Use therapeutic play techniques Explain in terms the child understands |
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lifespan considerations for adults |
Consider developmental tasks Provide outlets for expression Treat with dignity and respect Consider difficulties of physical condition |
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nurse responsibilities |
Exhaust other measures first Obtain orderE xplain need for restraints Ask for consent Make pre-application assessments Correctly applyPad bony prominences Quick release knot Ensure adequacy of movement and circulationConduct ongoing assessmentEvery 15-30 minutes Remove and exercise every 2 hours Regularly determine continuing need Never leave client alone Document |
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documentation for restraints (RN) |
Describe precipitating events Alternative actions used Time of application Type of restraints and location Teaching performed Behavior while in restraints Type and frequency of care Condition of body part in restraints Client response at time of removal Medication administered |
