Physical Restraints Flashcards
Explain direct vs. indirect injury caused by physical restraints and give an example of each.
direct injury: actual physical damage as a result of external force or pressure from restraint devices e.g. nerve compression, asphyxiation, and death from entrapment between mattress and side rail
indirect injury: adverse outcomes that may be linked to the use of physical restraints e.g. pressure sores, contractures, or immobility, bladder and bowel incontinence, nosocomial infections, cognitive decline, increased mortality rate
What are the principles behind least restraint?
1) restraints should only be used as a last resort (not in replacement of nursing care)
2) benefits of restraint must outweigh the potential risks
3) the minimal restraint to be effective should always be used
What 2 areas in the hospital/facility would have policies on physical restraints?
institutional policy and procedures: online and printed hard copy
restraint documentation record - user guide
What are 3 safety measures that need to be considered when using restraints?
1) quick release knot only when securing the restraint
2) frequent/continuous observation of client who is physically restrained
3) restraints in bed should be secured to the bed frame, not side rail
How frequently should you document about restraints?
qshift and prn
What are the main components that need to be documented regarding restraints?
1) type of restraint
2) assessment: behavior, CWMS, respirations, etc.
3) interventions: skin check, repositioning/turning, HOB 30 degrees, intake/output, toileting, communication
4) restraint use: continue, discontinue, or trial off
Explain the difference between chemical and physical restraints
physical: device used to restrict, restrain, or prevent a person’s movement
chemical: any drug used for discipline or convenience and is not required to treat medical symptoms
Explain the difference between behavioural and non-behavioural classifications of client restraints
behavioural: use of restraints in clients who have anticipated violent outburst that places the client, other patients, and/or staff at risk for harm
non-behavioural: use of restraints to prevent clients from interfering with medical treatment and/or to maintain client safety (e.g. risk for falls)
What are some examples of psychological adverse effects from physical restraint use?
anger fear denial demoralization loss of dignity humiliation depression agitation regressive behaviours
What type of knot is required to secure a physical restraint?
quick release
What must be included on the physician’s order regarding physical restraint?
a time limit
What considerations must be made for patients who must be restrained in the supine position?
ensure their head is free to rotate to the side
HOB must be elevated to minimize aspiration risk
What considerations must be made for patients who must be restrained in the prone position?
ensure unobstructed airway at all times
never cover the client’s face
ensure lung expansion is not restricted by excessive pressure on the client’s back
T/F: You must never restrain a client in bed with unprotected split siderails
True
How frequently must you assess patients with physical restraint?
q15 until stable, then q30 x 2 (for 1 hour), then q60 until restraints are discontinued
constant monitoring is the standard of care during and after a code white while the patient’s behaviour is unstable
