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
[pic] [pic]
FIGURE 1A. The patient's leg is moving off the bed
into the space between the upper and lower bedrails.
[pic] [pic]
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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[pic]
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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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