Exam 8 Restraints and application Flashcards
Restraint are used?
Temporary. For a way to assure client saftey.
What is a physical restraint?
A mechanical or physical device used to restrict freedom of movement or prevent normal access to part of the body.
The goal is?
To be restraint free.
Alternatives to restraints
Provide orientation.
Encourage family or sitter to stay with patient.
Place client in a room close to nurse’s station.
Alternatives to restraints
Put family photos or familiar items near bedside.
Provide consistent caregivers as much as possible. ( Seeing same people over and over can decrease confusion)
Response promptly to needs of toileting, relief for pain, and request for activity.
Alternatives for restraints
Provide consistency in daily routine. Alter stimulation with periods of sleep and rest.
Use wedge pillow on chair , with the thickest part toward front of chair.
Use pressure sensitive bed or chair pad with alarms or wander guard devices.
Alternatives to restraints
Use stress reduction techniques.
Use diversion activities.
Position IV Catheters, urinary catheters, tubes/drains out of view or cover with applicable items. Remember “out of sight out of mind”.
Involve in activities to provide stimulation and exercise. If patient is able.
Qualifiers for restraints
High risk for fall
Possible interruption of needed therapies
Possible removal of life support equipment.
Risk of injury to self or others.
Nursing assessment
Establish existence of qualifier present
Reason for problematic behaviors ( is it: time of day, environment, pain or other activities, or someone).
Is this behavior harmful to self or others ( does it meet one of the previous qualifiers)?
Physical restraint orders
MD order is required (may require direct M.D. observation) order will include: date and time type of behavior observed type restraint and location time limitations - durations criteria for release
Remember
No PRN orders for physical restraints
In an emergency can restrain, but must have an M.D. order within in one hour.
Types of restraints
Jacket or posy vest – comes in different sizes and straps at clients Hips.Has been banded by some facilities.
Belt may be used in chair, bed or stretcher.
Limb - must have room for two fingers between restraint and patients limb.
Types of restraints
Side rails are considered restraints if:
All four rails are in the up position. Follow the restraint policy.
Siderails limit mobility and the patient cannot remove them.
follow the restraint policy.
Chemical restraints
Also know as psychoactive drugs when overused in hospital settings.
Patients who display aggressive or agitated behavior may have PRN orders for these types of meds:
Anti-psychotics: Haldol
Anti-anxiety: Ativan
Anti-depressants: Trazadone
Sedative-hypnotic: Ambien
Steps in physical restraint application
Check order and instructions.
Pad bony prominences.
Apply correct restraint.
If in bed attach to movable part of bed frame.
If in wheelchair secure ties under arm rests and tie at back of chair.
Secure using quick release tie.
Assure call light is available.
