The Safe Use of Patient Restraints

1. The Safe Use of Patient Restraints Mandatory Annual Review Course

2. Click each button for details Definitions • Any method of physically restricting a person’s freedom of movement, physical activity or normal access to his or her body. • Patient immobilization that is a normal component of a procedure is not considered restraint. Restraint is: Medical (Non-behavioral) Restraint: • A manual method, physical or mechanical device, material, or equipment that immobilizes or reduces the ability of a patient to move his or her arms, legs, body or head freely. • A drug used solely as a restrictions to manage the patient’s behavior or restrict freedom of movement. Behavioral Health Restraint: • The restriction of patient movement in response to severely aggressive, destructive, violent or suicidal behaviors that place the patient or others in imminent danger. Restraint is not: • Forensic restriction used by law enforcement for security purposes.

3. Side Rails – Restraint or Not? Click the answer The use of side rails may pose risk to patient’s safety. Clinical judgment determines whether or not the use of side rails is considered restraints. Not Restraint • Raising all four side rails to prevent the patient from exiting the bed Restraint • Four or full side rails to prevent the patient from rolling our of bed • Patient actively seizing • Post-op patient recovering from anesthesia • Patient on a gurney Not Restraint Restraint Not Restraint Restraint • Raising fewer than four side rails (when bed has more than two)

4. Alternatives to Restraints Restraints must never be used as a substitute for good nursing care or staff convenience. Restrained patients require MORE CARE and INCREASED DOCUMENTATION. PHYSIOLOGICAL MEASURES

5. Patient Assessment To Determine the NEED for RESTRAINT USE: • Attempt Alternatives • Use safe, effective and least restrictive method of restraint • Clinical Justification based on observed patient actions or behaviors • Interference with therapy or patient care • Pulling tubes • Picking at wounds • Removing dressings • Activity or thoughts with a reasonable probability of harm to self • Wandering • Unsteady gait (high risk for falls) • Suicidal • Activity or thoughts with a reasonable probability of harm to others • Confused patient striking out at others • Homicidal attempt or talks about killing/harming someone • Violent patient in alcohol or drug withdrawal

6. Restraint Orders Restraints will be initiated or continued on the order of a treating physician. The order must meet the following criteria: • Reason for the restraint. • Be time specific • Include type of restraint. • Reflect least restrictive manner. • Be in accordance with safe and appropriate restraining techniques. • Be discontinued at the earliest point in time. • Neverbe written as a standing order or PRN.

7. Medical vs. Behavior Health Orders

8. Observation & Monitoring Assessment will include: • The patient’s physical and emotional well-being . • Comfort and care needs, including hygiene, elimination, hydration, nutrition • The appropriateness of restraint application, removal, and reapplication • Assessment of the need for continuingor discontinuing restraint • Patient death associated with restraint use: • RN will immediately notify Nurse Manager or House Supervisor • Complete a UOR (unusual occurrence report) • Hospitals AR&L Director or designee will notify CMS

9. Application of Restraint • Must have quick-release application • Use the correct size • Note “front” and “back” of device • Secure to bed springs or frame, not mattress or bed rails • Do not apply one-sided restraints • Do not restrain feet while their hands are free • Place call light and necessary items within reach • Do not position pregnant patients 20 weeks or greater on their back, nor should chest or waist restraints be used Restraints should be discontinued as soon as it is no longer indicated by the patient’s actions.

10. Documentation Patient basic needs must be attended to, including: • Hygiene • Elimination • Hydration • Nutrition • Circulation • Range of motion Document the following in Patient’s record in KP Health Connect: • Physician’s order • Initial assessment by the RN and 1 hour in-person evaluation by MD • Patient’s actions or condition that indicated the initial and continued use of restraint • Less restrictive alternatives considered • Patient monitoring and response to interventions used • Significant changes in the patient’s condition • Reassessment/observations, discontinuation of restraints • Educationand information about restraints provided to the patient and family

11. Post Test

12. Quiz Answer True or False • Application of restraints should be the initial nursing intervention when caring for the confused or disoriented patient. True False • Restraints are utilized to prevent disruption of treatment or significant harm to persons. True False • The care of a patient in restraints requires more nursing time. True False • Once restraints are applied, they are not to be removed by anyone without a physician’s order. True False

13. Quiz Answer True or False • Bed rails can either be restraints or a protective device, depending on the intent of use. True False • Use of restraints can be harmful to patients and can result in such outcomes as impaired skin integrity, incontinence, increased falls, etc. True False • When appropriate, the use of alternatives is attempted in an effort to use restraints as a last resort. True False • Reassessment is ongoing and occurs at a minimum of q 4 hours for patients in medical restraints in an effort to discontinue the restraints early whenever possible. True False

14. Quiz Answer True or False • Four-point soft restraints for an actively suicidal patient requires the same 15-minute observation checks as leather or hard restraints. True False • A physician’s order for a behavioral health restraint must be time specific with a maximum limit of 4 hours for the adult, 2 hours for children ages 9-17, and 1 hour for children 8 and under. True False • RNs may discontinue restraints before the ordered time frame, but must obtain a new order if the patient again meets indications that justify restraint. True False • RNs can apply a restraint without a physician order, but must obtain a verbal phone order within 1 hour of the initiation of the medical restraint. True False

15. Quiz Answer True or False • Bed rails should be used on all patient at all times to keep them from falling or getting out of bed. True False Select the Correct Answer • Which of the following observations intervals is incorrect? • Every 30 minutes for a patient in four-point restraints to prevent combative behavior. • Every 15 minutes for a patient in leather restraints for violent behavior to prevent injury. • Every 2 hours for a patient with soft wrist ties to prevent dislodgment of NG tube. • Every 2 hours for bed rails up on a patient to prevent them from continued wandering.

16. Quiz Select the Correct Answer • Which of the following are types of protective devices and not considered restraints? • Portable table top chair to prevent the patient from slipping out of the chair. • Safety belt on a gurney. • Knee immobilizer. • All of the above. • The nurse should assess and address which of the following at least every two hours for patients who are restrained: • Hydration and nutrition • Hygiene and elimination • Continuance or termination of restraint • Circulation and ROM • All of the above.

17. Quiz Select the Correct Answer • Which of the following is not a clinically justified use of restraints? • Patient continues to pull at the NG tube after reorientation and explanation. • Combative patient in DTs. • Patient is 75 years old and is weak and confused. • Patient removes abdominal dressing despite use of abdominal binder. • Which of the following is not an example of an alternative to restraint use? • Medicate patient to induce sleeping. • Tape foley to abdomen of male patient. • Provide adequate pain medication. • Use TV, radio, or music as diversion.

18. Select the Correct Answer Quiz • A 9-year-old requires transport via gurney to radiology for a MRI. The gurney rails are placed in the up position. This is not considered restraint because: • Children are allowed to sit up in gurneys. • The child can see through side rails. • Side rails are to be up during patient transports of all types regardless of age and are a protective/safety device. • The child will be transferred to an exam table upon arrival so it doesn’t matter. • Which of the following employees would need documented competency for restraints? • A transportation aide that unties and reties wrist restraints for transport to radiology. • A physical therapist that releases and reties a patient restraint in order to exercise a patient. • A RN that monitors the patient in restraints. • An unlicensed assistant that removes and reapplies restraints to bathe a patient. • All of the above.