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RESTRAINTS

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					Restraints


Updated 01/07
     All Staff
   Self- Learn Packet
 Revised November 2002
                      OBJECTIVES
At the conclusion of the self-learning packet, the learner will
     be able to:

1.  Define the difference between Behavioral Restraints and
    Medical/Surgical Restraints.
2. State three benefits of limiting restraint use.
3. List at least four myths concerning the use of restraints.
4. Identify factors which increase the use of restraints.
5. State two situations in which restraints might be useful in
    patient care.
6. List three complications of restraint use.
7. Assess a patient for the least restrictive form of restraint.
8. Identify six alternatives to restraint use.
9. State the age-related differences in evaluation and
    renewal of restraints.
10. State GBMC’s philosophy for the use of restraints.
11. State GBMC’s policies for restraints use.                      2
         WHAT ARE RESTRAINTS?

Definitions
   Restraints are any method, physical or mechanical
    device, materials or equipment attached or adjacent to
    the patient’s body that her or she cannot easily remove
    which restricts a person’s movement, physical activity, or
    normal access to his or her body.




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           Name Change
 Non-Behavioral has been changed to


         “Medical/Surgical”

This follows what JCAHO uses in their
 standards

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       PURPOSE FOR RESTRAINTS
Two types of restraints defined by JCAHO are
based on the purpose for the restraints

1.   Behavioral Restraint (Almost exclusively in ER)
      Used for the control of aggressive/violent
       behavior or behavior that is dangerous to self or
       others.
2.   Medical/Surgical Restraint (Most common on units)
      Used for care management for a patient who is
       exhibiting behavior that is interfering with
       treatment (e.g. pulling on IV, Foley, or dressings).

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When Physical Restraints are NOT
Considered to be Restraint Devices
When used for the purposes of security, detention or
public safety on patients under forensic custody
(under police guard).
When used as a voluntary mechanical support to
achieve proper body position, balance, or
alignment.
When used as a positioning or securing device to
maintain position, limit mobility or temporarily
immobilize a patient during medical, diagnostic, or
surgical procedures (less than 30 minutes in
children).


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         Types of Physical Restraints
          Restraints may be made of soft or harder
          material
           Neoprene (for Behavioral Restraints only)
           Soft Foam Wrist or ankle straps
           Roll Belts
           All 4 side rails up on a bed
           Mitts (secured or unsecured to bed frame)




All 4 bed rails up   Mitts   Roll Belt   Wrist/Ankle          7
                                                       “Neoprene”
               WHY LIMIT THE USE OF
                  RESTRAINTS?
Because doing so:
  Benefits the patient
  Being able to move about freely is important for the patient’s health and
  a sense of dignity.
  Helps the Hospital
  It allows the hospital to comply with laws and meet accepted care
  standards.
  Standards and Laws limit the use of restraints
       1. JCAHO
       2. Federal Omnibus Budget Reconciliation Act
          (OBRA) of 1987 (long-term care facilities)
       3. CMS (formerly HCFA) Standards (Medicare/Medicaid)
       4. State Law
                                                                      8
   MYTHS ABOUT RESTRAINTS

Decreases risk of falls
Increases sense of security
Decreases lawsuits
Lowers staff costs
Improves quality of life
No other alternative


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SOMETIMES RESTRAINTS CAN BE USEFUL

  Allow Needed Treatment (Medical/Surgical)
  A combative or confused patient may have to be restrained
  so staff can:
   Perform an exam

   Treat a wound

   Administer an IV

   Give other needed medical treatment

  Keep the Patient and Others Safe (Behavioral)
     A violent patient may need to be restrained temporarily if no other
      calming efforts work.
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          RESTRAINTS CAN ALSO CAUSE
                SERIOUS HARM
Injuries from improperly positioned restraints
   Patients get tangled in straps and choke
   Patients struggle to get free and end up broken bones, cuts, concussions,
    or other injuries as a result
Medical complications from keeping the body and
limbs in the same position for long periods can cause:
   Poor circulation
   Incontinence
   Constipation
   Weak muscles and bones
   Pressure Sores
Mental and Emotional Problems
Restrained patients often feel humiliated or imprisoned and become
 Depressed

 Agitated
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 Uninterested in eating, sleeping, and socializing
          ASSESSING THE PATIENT IS THE FIRST STEP
The health team’s goal in restraint use is to find the safest, least
restrictive way to care for the patient.
   Discover the Cause of the Problem
       If the patient wanders, try to figure out what he or she is seeking.
       If the patient is unsteady, look for underlying problems, such as poor shoes,
        side effects of medications, or bad eyesight.
   Learn About the Patient’s Interests
       A confused or agitated patient may be happier if allowed to follow familiar
        routines.
   Give the Patient a Say
       Discuss problems openly with the patient..
       If possible, ask the patient how he/she would solve the problem.
   Involve Family Members
       They can provide information about the patient’s habits.
       They can take part in his or her daily activities.
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   Document a Care Plan
       Alternative Interventions
Alternative means of meeting the patients needs
should be attempted first.
   Move patient closer to nurses station
   Keep patient door open
   Bed in low position
   Call bell within reach
   Reorient patient to environment
   Conceal IV site & tubing with Stretch Netting
   Decrease noise/minimize stimulation
   Bed/Exit alarms with sensor pads (Posey Sitter II)
   Encourage family involvement
                                                         13
    More Alternative Interventions

   Wrap Around Belt may be applied as long as it is
    documented patient can “demonstrate” self release with
    Velcro.
   Exit Alarms with sensor pads for beds or chairs
   Bed Alarms if available on beds.




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      USE RESTRAINTS AS A LAST RESORT

Use Restraints only when:
  You have exhausted all alternative interventions
  Vital treatments depend on their use
  There is a clear and present danger
           IF RESTRAINTS MUST BE USED
  Protect the patient’s rights and dignity
  Choose the least restrictive method
  Document each occurrence of restraint use
  Only properly trained and authorized staff may apply and remove
  restraints
  Choose the correct restraint size - if too small, restraints may cause
  increased agitation and if too large, the patient can slide down in the
  restraint which could lead to asphyxiation.
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            GBMC RESTRAINT POLICIES
The following policies apply to the use of
restraints:
2.   Physician orders cannot be written as “standing” or “prn”.
3.   Restraints will not be used for the convenience of the
     staff.
4.   The use of restraints will only be used to prevent the
     patient from harming themselves or others or when the
     patient is interfering with treatment.




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          PHYSICIAN’S ORDER CRITERIA FOR
             BEHAVIORAL RESTRAINTS
1. Physician must be informed and a face-to-face assessment with
    counter signed orders within ONE hour.
2. Order must include:
     Start and stop time

     Date

     Reason for restraint

     Type of restraint used

     Signature of Physician

     Maximum duration 4 hours ages adults 18 and older

                           2 hours ages 9-17 years old
                           1 hour 0-8 year old
4. The physician must make a face to face re-evaluation and
   orders renewed every     8 hours for Adults and older
                   every    4 hours for Children 17 and younger


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         PHYSICIAN’S ORDER CRITERIA FOR
          MEDICAL/SURGICAL RESTRAINTS
1. Order must be obtained within 12 hours of initiation by the
     register nurse.
 2. Physician must make face-to-face evaluation within 24 hours of
     initiation of restraints and sign order.
 3. Order must include:
      Start and stop time

      Date

      Reason for restraint

      Type of restraint used

      Signature of Physician

      Maximum duration of order is 24 hours




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   Least to most restrictive
4 Side Rails up
Roll Belt
Mittens
1 or 2 point soft restraint
4 point soft restraint



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             APPLYING RESTRAINTS

Mittens
   Place hands in each mitt and secure strap ABOVE wrist bone.
Roll Belt
   Position patient in the middle of the mattress. Use quick release
    straps to secure to bed frame.
Limb Restraint
   Using a padded limb restraint, wrap the limb with the restraint and
    secure the plastic clip.
   Tighten the restraint so that the patient is unable to pass his/her
    wrist through the restraint, being careful not to restrict blood flow to
    the extremity.


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    Initiation of Restraints
Only a RN may initiate the first time
application of restraints.

A NST or LPN may remove and reapply
restraints as needed for safety and
hygiene.


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          Documentation
RN or Unit Secretary MUST use Order Entry
in Meditech and select type of restraint
ordered: Med/Surg or Behavioral.
This will generate the proper flowsheet in
PCS
 Med/Surg Restraint Assessment Flowsheet
 Behavioral Restraint Assessment Flowsheet



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        Documentation
Behavioral Restraints
 Q1h Assessment by RN/LPN in Meditech
 Q15 mins.Observation by RN/LPN or NST
  on paper bedside flowsheet
Med/Surg Restraints
 Q8h Assessment by RN/LPN in Meditech
 Q2h Observation by RN/LPN or NST in
  Meditech
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               RESTRAINTS MONITORING
          BEHAVIORAL                             MEDICAL/SURGICAL
Use Prevention Management of Aggressive Behavior (PMAB) interventions for escalating
                        behaviors in all clinical settings.

 Observe every 15 minutes for                Observe every 2 hours for
 behaviors and physical                    behaviors and physical conditions
 conditions and document on                and document in Meditech
 BehavioralRestraint/Seclusion
 Flowsheet
 Offer liquid, nutrition, comfort,            Offer liquid, nutrition, comfort,
 and bathroom every 2 hours                and bathroom every 2 hours
 Remove restraints every 2 hour               Remove restraints every 2
                                           hours for no less than 10 minutes
 for no less than 5 minutes for            for range of motion and skin care.
 range of motion and skin care.

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       Congratulations!
You have completed the Restraints
self-learning packet.
Complete the post test.




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