RESTRAINTS & SECLUSION



RESTRAINTS & SECLUSION

Definitions:

A restraint is any manual method, physical or mechanical device, material, or equipment that immobilizes or reduces the ability of the patient to move his/her arms, legs, body, or head freely.

~ Physical Restraint – Physical restriction of freedom of movement, activity, or

normal access to one’s body – may be mechanical devices, human contact or

a combination of both.

~ Chemical Restraint – A drug or medication when it is used as a restriction to

manage the patient’s behavior or restrict the patient’s freedom of movement

and is not a standard treatment or dosage for the patient’s condition.

~ Seclusion – the involuntary confinement of a person in a room physically

preventing the person from leaving i.e. locked room.

It is a patient’s right to be as restraint free as possible. Restraints should only be used when necessary to ensure the physical safety of the patient, a staff member or others.

Types of restraint orders include:

~ Non-Behavior- Implemented to ensure the safety of the patient

~ Behavioral - Implemented to control violent behavior that threatens the safety

of the patient, staff or others

What is a restraint:

Wrist and leg restraints

Vest restraints

A geri chair that is not being used for eating or activity purposes

A recliner only if the patient can not easily get out of the chair by them self

Use of side rails to prevent a patient from getting out of bed

Tucking in sheets so tightly the patient can not move

Medications that are used as a restriction to manage behaviors

What is not a restraint:

IV arm board

Surgical dressings or bandages

Protective helmets or equipment

The upper side rails that have the bed controls

An enclosed crib used for toddlers or any age appropriate protective safety device

Medical restraints used during recovery from anesthesia

Mechanical devices to achieve proper body positioning or securing during

procedures to temporarily immobilize: traction, papoose boards,

surgical straps

Medications that are used to manage behaviors as a standard of treatment for

the patient’s condition.

Handcuffs, manacles, shackles or other restraint devices applied by non-

hospital employees such as law enforcement officials

4 side rails up that are padded to protect a seizure patient

Risks in Using Restraints:

Psychological:

* Increased agitation, hostility, combativeness

* Feelings of humiliation, loss of hope

* Increased confusion, fear

* Depression, anxiety

* Cognitive deterioration

* Worsening dementia

Physical:

* Reduced heart capacity = orthostatic hypotension

* Reduced lung capacity = pneumonia

* Sleep disturbance

* Pressure ulcers

* Incontinence & possible UTI

* Increased risk of VTE

* Effects musculoskeletal system = decreased bone density, muscle strength

* Immobility = increased weakness, decreased flexibility

* Restraints and immobility cause patients pain which may never resolve

Every 24 hours of immobility causes a 5% loss of functioning in a normal person!

Restraining a patient increases their chances of health related complications, falls, and mental deterioration.

Prior to the Application of Restraints:

~ Physical Assessment:

The decision to use restraints is not driven by diagnosis but by a comprehensive individual patient assessment. Therefore, prior to the application of a restraint the patient must have a comprehensive physical assessment that includes identifying factors that may be causing a change in the patient’s behavior such as:

Hypoxia

Hypoglycemia / hyperglycemia

Electrolyte imbalance

Drug interactions or side effects

Constipation

Dehydration

Temperature elevations / infections

Sleep deprivation

Pain

Cardiovascular insufficiency

Environmental factors

~ Use of Less Restrictive Alternatives Attempted:

Restraints or seclusion may only be used when less restrictive interventions have been determined to be ineffective to protect the patient, staff or others from harm.

Selection of these interventions should be based on the individual assessment.

Examples of less restrictive alternatives include but are not limited to:

Toileting q 1-2 hours

Watchful family at bedside

Bed/chair alarms

Low beds

Sitters

Distractions / activities

Alternating periods of rest and activity

Covering IV sites, tubes, drains

Verbal reorientation

Ambulating the patient

Change in medications

Environmental modifications

Providing orienting stimuli such as a newspaper, television, personal items

from home

The Process of Implementing Restraints:

~ The physical assessment and use of least restrictive alternative must be

completed before implementation of restraints.

~ A physician order must be obtained ASAP

~ Restraint orders are never prn

~ The restraint ordered must be the least restrictive technique possible

~ The physician must do a face to face evaluation

~ Only trained personnel can apply restraints

~ There is no trial release of restraints. If the restraint is removed due to an

improvement in the patient’s assessment, a new order must be obtained to

reapply them.

Documentation:

~ Documentation must be individualized to indicate the exact behaviors exhibited

and alternatives used

~ A care plan must be implemented and updated daily

~ Documentation must include:

* Behaviors the patient exhibited to justify the initiation of restraints

* Behaviors that justify continued use of restraints

* The less restrictive alternatives tried prior to implementation

* The effects of the less restrictive alternatives tried

* A description of the impact of the intervention on the patient’s behavior

* An assessment of the patient’s psychological response to the restraints

* As assessment of the physical needs of the patient at regular intervals that

include but are not limited to: respiratory and circulatory status, skin

integrity, vital signs, nutritional and hydration needs, toileting needs.

* Ongoing documented assessments that the restraint is still necessary and

remains as the least restrictive way to protect the patient

* That the patient and their family were informed of changes in the plan of

care and the need for restraints

* The patient’s mental status

~ Documentation must include an individual plan of care that includes:

* Reflection of the process of assessment, intervention and evaluation

* The goal of the intervention

* Description of the intervention

* Any changes to the plan of care

Comparison of Non-Behavioral and Behavioral Restraints:

| |Non-Behavioral |Behavioral |

|Reason for restraint |Non-violent patient |Manage violent or self destructive behavior |

| |Used to prevent injury or maintain | |

| |treatment | |

|Physician face to face assessment |As soon as possible |Within 1 hour |

|Maximum time limit for |Every 24 hours |4 hours – age 18 and older |

|re-ordering of restraint | |2 hrs age 9-17 |

| | |1 hr children under 9 |

|How often the patient is monitored for VS, |Every 2 hrs |Every 15 minutes |

|respiratory & cardiac status, skin integrity, | | |

|etc. | | |

Identification & Response to Distress:

First Aid Techniques and Certification of CPR:

~ All clinical staff are required to have a current certification as Healthcare

Providers by the American Heart Association (AHA).

~ Limb restraints must be removed every 2 hours with the documentation of the

skin condition, toileting and nutritional needs.

~ If the patient’s assessment indicates any type of distress the nurse should provide

the appropriate intervention.

Identifying Distress:

~ Assess the patient for the following:

Change in vital signs

Change in color

Malposition of limbs, head or neck

Change in mental status

Change in mood/ affect

Change in responsiveness

Providing First Aid:

Patient may require first aid for a number of reasons. They must have both a physical and mental assessment to determine the appropriate interventions. If the patient is in restraints – remove them and proceed with the assessment and interventions as indicated.

Choking:

Release or remove restraint

Check for signs of mild or severe airway obstruction

Follow the guidelines from AHA’s Healthcare Provider

Dial “Code Blue” - 1345 if indicated

Assess patient for other injuries

Notify physician

Broken Bones and Sprains:

Check for signs of shock

Do not try to straighten any injured part of the body

Call the physician for possible X-ray and other orders

Cover any open wound with a sterile dressing

If indicated, ice the affected area up to 20 minutes

Head Injuries:

Check breathing and circulation

Begin CPR and call a Code Blue if indicated

Check for signs of shock

Immobilize the neck and head

If required to move patient – support the head, neck, and body in a straight

line so that they do not twist, bend or turn in any direction

Call the physician

Emotional Distress:

Reassure patient using calm voice

Allow patient to verbalize

Acknowledge feelings

Depending on the patient’s condition, release restraints and assist with ambulation as a distraction and to help maintain mobility,

strength and functioning.

Assess for continued need for restraint

Entrapment:

Release or remove restraint

Call for assistance and gently disengage entrapment

Check airway, breathing, circulation

Follow the guidelines from AHA’s Healthcare Provider

Dial “Code Blue” - 1345 if indicated

Assess patient for other injuries

Notify physician

EXAMPLES OF BED ENTRAPMENT

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FIGURE 1A. The patient's leg is moving off the bed

into the space between the upper and lower bedrails.

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Discontinuing Restraints:

~ An RN who is trained in the use of restraint may discontinue the

restraints based on the patient’s assessment.

~ Restraints must be discontinued at the earliest time possible.

~ Behaviors that may indicate that restraints may be discontinued include:

improvement in medical condition, less restlessness or agitation, decrease in

mental confusion.

~ A physician should be notified as soon as possible when restraints are no longer

required.

Restraint Tid- Bits:

~The use of restraints for the prevention of falls should not be considered as a routine part of a falls reduction program.

~ If a consulting physician ordered the restraints, the attending physician must be

notified as soon as possible.

~ Grove City Medical Center is required to report all deaths while the patient is in

restraints and if a death occurs within 24 hours after restraints have been

removed.

***** All clinicians that are direct caregivers are required to have hands- on training on the proper application and assessment of restraints. This will be a station during the live mandatories in March – if you did not attend these, please see your clinical manager or Julie Ryhal in the Education office – ext 7190. ******

This includes:

RNs, LPNs, Aids

PT/OT

Respiratory

Plant Operations

Security

Code 10 Responders

Lab

MI

References:

The CMS Hospital Conditions of Participation and Interpretative Guidelines, HCPro, 2010

resources/WVQIO/Toolkits_2009/WV%20Restraints%20Toolkit%209SOW.pdf

AHA Healthcare Provider manual, 2011

AHA First Aid manual, 2011

JCAHO & CMS Restraint Standards & Falls Prevention, Ann Newman, RN, MS, FNP, Cross Country Education, 2008

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FIGURE 1B. The patient is sliding into the space between the upper and lower bedrails.

FIGURE 1C. The patient is suspended with the thorax lodged and compressed in a 6-inch gap between the upper bedrail and the mattress frame.

FIGURE 2. The patient is found asphyxiated. Her torso is compressed between the bedrail and the mattress.

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