Binders, restraints, catheter and condom care Flashcards
(47 cards)
What is the definition of a restraint?
a chemical, mechanical/physical, environmental device used to restrict the behavior or actions of a person
What is the optimal goal regarding restraints?
provide a restraint-free environment
What are some methods to protect pts and to prevent accidents?
Orientation of patients (show them what is around them, keep items in reach)
Call bell in reach
Dec hazardous objects/situations
Assess risk for falls
What are some ways that restraints may be avoided?
orient pt to surroundings
communication aids (to help them tell you what they would like)
sensory aids
ROUTINE TOILETING
exercise/ambulation regimes
Consult other HCPs
Medication review
door guard
increased observation
encourage family to visit
What are some complications that come from restraint use?
Agitation, humiliation, fear, dec self-esteem
disorientation
contractures, nerve dmg, circulatory impairment
What happens to the amount of care the pt receives when they are restrained? what can this lead to?
Tend to get less care
Can result in:
- pressure ulcers
- constipation
- incontinence
- pneumonia
What are the 3 indications for restraint use?
decrease risk of injury to pt and others. (must be a significant risk)
prevent interruption of therapy
prevent confused or combative pt from removing life-support equipment
What are the 6 criteria for restraint selection?
1) least restrictive of movement
2) least obvious to others
3) noninterfering with treatments
4) readily changeable
5) safe
6) agency policy
If a restraint is put into place, what should you make sure you check?
that it is quick to remove
maintains skin integrity and circulation
ends are tied to appropriate place
knots do not tighten and when pulled
it is the correct fit
remove q2-4 hrs for ROM and skin care
Reassess need for continuation
What guidelines should be followed
ensure you know policies
assess underlying reasons for need of restraint
never apply for convenience
do not be influenced by family to take of restraints (can not legally pass on care to a family member)
try to obtain a phys. order prior to implementing
Recognize competent adults right to choose
principle of least restraint
proper fit
documentation
re-assess the need
What data should be included in your documentation if a restraint is applied?
type time of application response to treatment skin condition frequency of removal
what are the 5 type of restraints?
Soft hand mit
Freedom arm splint
Pelvic soft belt
Segufix or Pinel (this is used in acute)
Chemical
When would you use a soft hand mitt?
when scratching is a problem and needs to be prevented
When would you use a freedom arm splint?
when IVs need to be protected from being pulled out
When would you use a pelvic soft belt?
when a sitting restraint is needed (usually to prevent falls from chairs/WC)
What is the purpose of bandages and binders? (7)
Create pressure
Immobilize body part
Provide support
Dec/prevent edema
Secures splints and dressings
Applies warmth
Shapes or molds stump
What are the principles relevant to the application of bandages and bindings? (4)
microorganisms flourish in warm, damp environment
pressure upon tissues can affect circulation (esp excessive/uneven)
friction can cause trauma to skin
natural anatomical position must be maintained
When applying a bandage which direction do you work in?
distal to proximal
What do you need to have before you can apply a bandage?
a dr order
What are the 5 types of bandage turns?
Circular Spiral Spiral-reverse Figure 8 Recurrent
Describe a circular turn
each turn completely covers the last
When would a circular turn be used?
to initiate/terminate a bandage
to cover a small part; finger or toe
Describe a spiral turn
angles slightly upward overlapping 1/2 to 2/3
What is the use of a spiral turn?
used to ascend a cylindrical body part (ex wrist, arm)
