Restraints Education Comprehensive Assessment Placing a patient in restraints requires clinical justification.

A comprehensive assessment is needed to identify the clinical justification. The comprehensive assessment will: identify the behaviors that put the patient at risk for restraint use. Patient has behaviors such as agitation, restlessness, or cognitive impairment that interfere with therapy or overall safety identify triggers or factors that are causing the patients behaviors (pain; delirium caused by infection, hypoxia, drug/alcohol withdrawal, electrolyte imbalances, general medical conditions; etc.) . Ask patients what they want or need or knowledgeable others if the patient is unable to communicate determine how past events and coping behaviors contribute to risk for restraints by reviewing the patients health history and healthcare record evaluate medication list to determine if any medication(s) contribute to cognitive dysfunction, movement disorders, and falls. assess the functional, mental, and psychosocial status of the patient, as well as the environment surrounding the patient (noise level, lighting, floor surfaces, equipment, furniture, visual cues, barriers to mobility, area for privacy and socialization, and clothing Patient and Family Notification The patient and family are to be notified for reason for the patient being placed in medical surgical or behavioral health restraints. Interventions Understanding the patients behavior and the meaning behind the behavior is essential to prevent the need for restraints. The focus of nursing interventions includes: treating and/ or eliminating the cause for restraint use meeting the expressed need of the patient and collaborating with team members

Common interventions address physical/physiological issues, psychological issues, and environmental modifications. Interventions that address physical/physiological issues include: discontinue therapeutic devices as soon as possible or secure the devices in a manner in which the devices are less likely to be intolerable explain treatment techniques to the patient and the family hourly rounding offer prn medications ordered to reduce anxiety, agitation and confusion offer PRN medications prior to a painful procedure to reduce pain and calm the patient request that physician order medication for alcohol/drug withdrawal at the onset of withdrawal symptoms give prn medication as ordered for alcohol/drug withdrawal symptoms place long -sleeve robes or gowns to hide the IV catheter site/ tubing and the Foley provide physical activities to divert the patients behaviors use reality orientation with patients who are delirious provide constant observation exercise program nursing assessment of patients risk for falls ensure use of canes, walkers, and wheelchairs

 prevent dehydration push oral fluids as indicated, seek assistance from Vascular Access Team for patients needing IV fluids and venous access is difficult prevent fluid and electrolyte imbalances prevent hypoxia by ensuring that patient is using oxygen as ordered, patients position in bed is not obstructing breathing, asthmatics get ordered inhalers when SOB prevention of UTI by avoiding use of urinary catheterization nursing assessment of the patients risk for falls collaborate with physician and pharmacist about whether medication is causing changes in mental status or causing the patient to fall Interventions that address psychological issues include: Involve family in care. Family might be able to interpret the meaning behind the patients behavior Provide for familiarity by encouraging family members to make audiotapes for the patient and to place family photographs in the patients room, by reminiscing about the past with the patient, and by arranging, if possible for to same staff to take care of the patient verbal intervention encourage verbalization about feelings and help patient identify positive ways of coping with distressing situations give prn medications for agitation/psychosis decrease stimulation

Interventions that address environmental issues include: ensure call light, water, bed pan, and commode, are accessible

respond quickly when the patient requests for assistance provide adequate lighting move the patient closer to the nurses station use pressure sensitive alarm bed leave bedrail(s) down put bed in lowest position develop patient specific toileting routines to reduce risk of falls reduce excessive noise ensure the patient uses eyeglasses, hearing aids, and other assistive devices so they are able to correctly interpret environmental stimuli provide non-skid slippers

Examples of situations in which the patient may be placed in medical surgical restraints Brain -Injured patient who becomes combative the first time he/she awakens after brain injury. ICU patient who attempts to extubate himself/herself upon awakening from an anesthetic. Patient pulls at IV line, tubes, drains, dressings, and/or Foley after experiencing confusion caused by an adverse drug reaction, a general medical condition, dementia, or delirium. Medical Surgical restraints are used until all organic causes for patients self harm/harm to others have been eliminated. Example A schizophrenic patient who is in delirium from septicemia and has attempted to harm self/others after hearing command hallucinations result of should be in medical surgical restraints, while being treated for the infection and psychosis. Medical Surgical Restraint Order/Assessment The nurse needs to notify the doctor within one hour after placement of the restraints about the patients change in condition, the need for restraints, and obtain

an order for restraints. Nurses are allowed to take telephone orders for the initial placement of restraints. The physician has up to 24 hours to do the face- to-face assessment and sign a telephone order for the medical surgical restraint. It is recommended that the orders for restraint renewals are obtained from the primary team daily by 1300. Nurses are to perform an assessment on the patient requiring initiation or renewal of restraints and use the SBAR format to communicate to the physician why the patient requires the restraint order. The nurses use of the SBAR format to communicate the patients change in condition and need for restraints can help the physician understand why it is necessary to see the patient quickly. Behavioral Health Restraint Order/Assessment The patient who is exhibiting violent or self destructive behavior that jeopardizes the immediate physical safety of the patient, staff, or others needs an order for behavioral health restraints. Time limits for behavioral health restraints are according to age of the patient: 4 hours for adults ages 18 and above 2 hours for children and adolescents between the ages of 9 and 17 or 1 hour for children below the age of 9

The physician is to perform a face to face assessment of the patient requiring restraints for management of violent or self destructive behavior that jeopardizes the immediate physical safety of the patient staff and others within one hour of the initiation of the restraints. A physician order is to be obtained within one hour of the initiation of the restraints. The order for behavioral health restraint may be renewed one time after reassessment by the RN or physician. If additional restraint is needed because the behavioral emergency continues, a physician must perform the face-to-face assessment of the patient before giving a new order. All patients who are in behavioral health restraints require one to one coverage. All Restraints If a medical surgical restraint or a behavioral health restraint is discontinued and again is needed for an emergency situation, then a new restraint order is required to

initiate restraint.

Federal Regulation Definition of a Restraint A restraint is defined as any manual method, physical, or mechanical device, material, or equipment that immobilizes or reduces the ability of a patient to move his/her arms, legs, body, or head freely. This definition applies to all uses of restraint in all hospital care settings. Common hospital devices or practices that could meet this federal regulation of restraint include, but are not limited to: tucking the sheets in so tightly that the patient is unable to move using a net bed or enclosed bed to prevent the patient from freely leaving the bed exception putting a toddler in an enclosed or domed crib using freedom splints that immobilize the patients limb using the side rails to stop a patient from voluntarily getting out of the bed Geri chairs or recliners, only if the patient cannot easily take off the restraint appliance and get out of the chair without assistance

A device is not generally considered a restraint if the patient can intentionally take off the device in the same manner the staff applied the device (examples include side rails put down, not climbed over, buckles are intentionally left unbuckled, ties or knots are intentionally not tied by the staff) while considering the patients physical status and ability to accomplish an objective (examples - patient can transfer to a chair, patient can get to the bathroom on time). The following devices are not restraints: orthopedically prescribed devices surgical dressings or bandages protective helmets physical holding for the purpose of conducting routine physical examinations or tests or devices to protect the patient from falling out of the bed or allow the patient to participate in activities without risk of physical injury

The following methods and devices are not restraints: an IV arm board that is not tied down or attached to the bed to stabilize an IV line a mechanical support to attain proper body posture, balance or alignment, or to permit greater mobility such as the use of leg braces to allow a patient to walk or the use of a neck , head, or back brace to allow the patient to sit upright a medically necessary securing or positioning device that is used to maintain the position , limit mobility, or temporarily immobilize a patient who is undergoing a medical, dental, diagnostic or surgical procedure hand mitts that are not pinned, attached to a bed, that are not used in conjunction with a restraint, that are not applied so tightly that the patient is unable to move his/her fingers or hands, or that are not so bulky that the patient s ability to use his/her hands is reduced. stroller safety belts, swing safety belts, high chair lap belts and crib covers utilized to protect an infant , toddler, or pre-school child forensic and corrective restriction used for security

References

Agency for Health Care Administration: Aspen Federal Regulations Set: A 19.03 Acute Care Hospitals (03-01-10). Retrieved 07-12-11. Bernstein, K.S. & Saladino, J.P. (2007). Clinical Assessment and Management of Psychiatric Patients Violent and Aggressive Behaviors in General Hospitals, MedSurg Nursing, 16(5). Caple, C. (2011). Delirium in Acute and Post Acute Care, CINAHL Nursing Guide, Cinahl Information System. Retrieved from Nursing Reference Database 07-14-11 Caple, C. , Schub, T., & Pravikoff, D. (2011). Substance Withdrawal Syndrome, CINAHL Nursing Guide. Retrieved from Nursing Reference Database 07-14-11. Fick, D.M., Cooper, J.W., Wade, W.E., Waller, J.L., Maclean, R., & Beers, M.H. (2003). Updating the Beers Criteria for Potentially Inappropriate Medication Use in Older Adults, Archives of Internal Medicine, 163(22), pp. 2716-2724. Retrieved from Duke Clinical Research website 07-12-11.

Halm, M.A. (2009). Hourly Rounds: What does the Evidence Indicate, American Journal of Critical Care, 18(6), p581-584. Kratz, A. (2008). Use of the Acute Confusion Protocol A Research Utilization Project, Journal of Nursing Care Quality, 23(4), p 331-337. Minnick, A. F., Mion, L.C. , Johnson, M,E. , Catrambone, C., & Leipzig, R. (2007). Prevalence and Variation of Physical Restraint Use in Acute Care Settings in the US, Journal of Nursing Scholarship, 39(1), p.30-37. Park, M. & Tang, J.H. (2007). Evidence-Based Guideline Changing the Practice of Physical Restraint Use in Acute Care, Journal of Gerontological Nursing, p. 9-16.
Rutledge

D; Schub T; Pravikoff D; Cinahl Information Systems, 2011 Feb 11 (2p) Fall Prevention in Hospitalized Patients(evidence-based care sheet) CINAHL AN: 5000000248 Retrieved 06-21-11. Schofield, I. (2008). Delirium: challenges for clinical governance, Journal of Nursing Management, 16, 127-133. Schub, T., Cabrera, G., & Pravikoff, D. (2011). Alcohol Withdrawal Syndrome, CINAHL Nursing Guide. Retrieved from Nursing Reference Database 07-14-11.

UHS Corporate Policy Number 9.13

Restraints and Seclusion effective 07-27-09.