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Where restraint is clinically necessary to prevent harm, the health service organisation has systems that:
Harm relating to the use of restraint is minimised. Reflective questionsWhat strategies does the health service organisation have in place to minimise the use of restraint? Are members of the workforce competent to implement restraint safely? How does the health service organisation ensure that the workforce is aware of safety implications of different forms of physical and mechanical restraint with different patient populations? What processes (for example, benchmarking, routine review) are used to review the use of restraints in the health service organisation? Key tasks
Strategies for improvement
In this section of the NCLEX-RN examination, you will be expected to demonstrate your knowledge and skills of use of restraints and safety devices in order to:
The most common reasons for restraints in health care agencies are to prevent falls, to prevent injury to self and/or others and to protect medically necessary tubes and catheters such as an intravenous line and a tracheostomy tube, for example. All health care environments adopt the philosophy and goal of a restraint free environment; however, it is not often possible to prevent the use of restraints and seclusion. There are rare occasions when the use of restraints is not preventable because the restraints have become the last resort to protect the client and others from severe injuries. Commonly Used Terms Associated With Restraints and Restraint Use
For example, a vest restraint to prevent a patient fall is an example of a physical restraint and a sedating medication to control disruptive behavior is considered a chemical restraint. Both restrict the person's ability to move about freely. Other examples of physical restraints are soft padded wrist restraints, a sheet tied around a person to keep them from falling out of a chair, side rails that are used to stop a person from getting out of bed, a mitten to stop a person from pulling on their intravenous line, arm and leg restraints, shackles, and leather restraints.
Nurses assess and determine the need for a client to be restrained or secluded and they also assess the appropriateness of the type of restraint/safety device that is used in context with the client's current condition and behaviors; they assess and reassess the client in a regular and ongoing basis to insure that the client is safe and that their needs have been met when the use of restraints or seclusion cannot be avoided. These assessments also explore the client's condition within the context of the appropriateness of the restraint in terms of its being the least restrictive alternative and being used for the shortest possible period of time. Following the Requirements For the Use of Restraints and Safety DevicesAccording to the Joint Commission on the Accreditation of Health care Organizations and the Centers for Medicare and Medicaid Services, there are many regulations and requirements that address restraints and restraint use including:
Alternative Preventive MeasuresSome of the preventive, alternative measures that can decrease the need for restraints to prevent a fall include:
Some of the preventive, alternative measures that can decrease the need for restraints in order to prevent the dislodgment of medical tubes, lines and catheters include:
Some of the preventive, alternative measures that can decrease the need for restraints in order to prevent violent behaviors that place self and/or others at risk for imminent harm include:
Restraint OrdersA complete doctor's order is needed to initiate the use of restraints except under extreme emergency situations when a registered nurse can initiate the emergency use of restraints using an established protocol until the doctor's order is obtained and/or the dangerous behaviors no longer exist. Restraints without a valid and complete order are considered false imprisonment. The minimal components of orders for restraint include the reason for and rationale for the use of the restraint, the type of restraint to be used, how long the restraint can be used, the client behaviors that necessitated the use of the restraints, and any special instructions beyond and above those required by the facility's policies and procedures. The Least Restrictive RestraintThe least restrictive restraint to correct the problem like falls and the dislodgment of tubes, lines and catheters is used when restraints are necessary. Restraints, from the least restrictive to the most restrictive, are:
Restraints should NEVER be used for staff convenience or client punishment. Monitoring the Client During RestraintWhen you monitor the patient or resident who is restrained, you must observe and monitor the patient's physical condition, the patient's emotional state, and the patient's responses to the restraint or seclusion. Is the patient safe? Are the restraints still in place and safely applied? Are the patient's vital signs normal? Are the skin color, intactness of the skin, and circulation good? Is the restraint too tight? Is the patient comfortable and without any physical needs that you can attend to like toileting, food and/or fluids? Is the person confused? Is the patient or resident angry, upset or agitated? Is the person afraid or fearful? After the restraint is applied, initial monitoring is done whenever necessary but at least every 15 minutes for the first hour by a licensed independent practitioner (LIP) or the qualified registered nurse (RN). When the patient or resident is stable and without significant changes, the monitoring and correlate documentation is then done at least every 4 hours for adults, every 2 hours for children from 9 to 17 years of age, and at least every hour for those less than 9 years of age. The scope of monitoring must include an evaluation or reassessment of the patient's:
The Provision of Care to Restrained ClientsThe following aspects of care must be provided as needed to a restrained patient or resident and documented at least every two (2) hours when the person is restrained for non behavioral reasons, and at least every four (4) hours when the person is restrained for behavioral reasons and more often for children (every two (2) hours for those 9 to 17 years of age, and at least every hour for those less than 9 years of age, unless the person needs more frequent care. The components of this care are based on the client's needs and it typically includes:
Some facilities use restraint flow sheets to document and record the use of restraints, the monitoring of the client, the care provided and the responses of the patient who is restrained or in seclusion. When these flow sheets are not used, the nurse must document all monitoring and care elements in the progress notes. Monitoring and Evaluating Client Response to Restraints and Safety DevicesWhen the registered nurse monitors and evaluates the client's responses to the restraints or safety device, the nurse will assess and evaluate the client and their:
Trial releases from restraints and attempts to control the behavior with appropriate alternatives to restraint provides the registered nurse and/or licensed independent practitioner (LIP) with reassessment data that guides the decision-making process in terms of the:
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