Bandages And Binders and restraints Flashcards
What is the optimal goal reguarding restraints?
restraint free environment
What is the definition of restraint?
a chemical mechanical pr phyrical environmental device used to restrict behavior or actions of a person
What are ways to protect individuals and prevent actions?
orientation of patient to unit - physical design and people they will be seeing
Call bell is accessible
decrease in hazardous objects/situations - clutter free
assess risk for falls - why are they falling?
What are alternate interventions to rstraints?
orientate pt to surroundings locate confused pts close to nrs station encourage fam/friends to stay visual/auditory stimuli implement relaxation techinques ROUTINE TOILETING excercise/ambulation regimes Consult other HCP med review
What are complications for restraint use?
Increased agitation/ humiliation/fear/ decreased self esteem increase disorientation contractures, nerve damage, circulatory impairment pressure ulcers constipation urinary and fecal incontinence pneumonia urinary retention
Why would a restraint be indicated?
for decreased risk of injury to pt and others
prevent interruption of therapy
prevent confused or combative pt from removing life support equipment
What criteria should you use for selection of restraint?
least restriction of movement least obvs noninterference with tx readily changeable safe agency policy
What are some safety and legal issues’ regarding restraint use?
follow agencies policies for use ensure quick removal allow movement maintan skin integrity and circulation ends tied to appropriate place knots dont tighten removed every 2-4 hrs for ROM/skin care Reassess need for continuance follow agencies policies apply only when needed for health and saftey physicians orders least restriction recognize competent adult's rights correct fit documentation periodic re evaluation of need
Posey Soft Hand Mitt/
one finger between wrist and device
for scratching, so someone doesnt remove IV
freedom arm spint?
so people cant remove IV/life saving devices
Pelvic Soft Belt?
who shouldnt you use it on?
to keep person from sliding
do not use on combative, ,suicidal or aggressive pt
Segufix/Pinel?
Approved only in acute care
between hips and head
clothing between device and skin
When applying a restraint what should be charted?
type time response skin condition removal frequency LOC notification of physician
What do assess about baseline prior to application?
CWMS Swelling/tingling pulses numbness pain wound, dressing status ADL abilities Pt understands?
What to assess ongoing with the restraint, bandage, or binder?
CWMS Pain/swelling drainage effectiveness status of bandage
Purpose of bandages/binders?
pressure immobilization support decreases chance of edema by increasing BF to legs secures splints and dressings applies warmth shapes or moulds stump
Principles of bandaging?
Mo love warm damp areas - may need guaze
Pressure upon tissue can affect circulation (even pressure, dis–>prox)
Friction can cause skion trauma
Natural anatomical position
excessive, uneven pressure can interfere with circulation
Circular bandage?
What is it used for?
each turn goes completely over the last
initiates or terminates bandage
covers small part- toe
Spiral Bandage?
what is it used for?
characteristics?
angles slightly upward
ascends body part
overlaps .5-.75
covers cyindrical body part (arm)
Spiral Reverse use?
cyndrical parts with varying circumferences.. lower leg.
guaze with little stretch
twist of bandage half way through each turn
assess after 15 mins and twice after in 8 hours
When is a figure 8 bandage used?
over joints or full extremities
most common
overlapping turn alt between ascending and descending over bandaged area
A recurrent bandage?
uneven bodyparts (head, toe, stump finger)
anchored with circular turn, turned center of tip then alt right and elft followed by circular to secure
what are binders used for?
reduce pain
What should you do when applying binders?
assess underlying skin, and document assessments
