Restraints Flashcards
Bill 90
- Clinical decision to use restraints: shared responsibility among multidisciplinary team - OT, PT, MD and nursing -No MD order will be needed to initiate or discontinue emergency restraint use provided the nurse has the required competencies and training.
- However, after an emergency there must be team consultation to plan preventive measures and obtain informed consent for future planned interventions.
Goal of bill 118.1
Prevent the use of physical restraints as much as possible and ensure that the rights of the patients and families are respected
Emphasizes the need for a pro-active approach based on collaboration between patients, family, and the multidisciplinary team
Planned intervention
A “Planned” Intervention must be justified by recent evidence of disorganized or dangerous behavior and be written in the “Nursing Therapeutic Plan”
Garde preventive
Emergency Situation -Any concerned member: (health care worker, family, friend, neighbour) can call the peace officers to bring the person to a hospital centre
- Decided by any M.D.
- Without person’s consent for confinement
- No psychiatric assessment
- Mental state presents immediate and grave danger to self or others
- No form -Duration: 72 hours or more if judge not available (e.g. weekends).
Garde Provisoire
- Court order at the request of any MD
- Without person’s consent for confinement
- To submit to psychiatric assessment in the appropriate facilities
- Mental health state presents danger to self or others
- All refused requests can only be re-submitted with different facts
- Request form for Psych assessment
Restraints contraindication
- 4-point restraints are not recommended for elderly patients or patients diagnosed with delirium or dementia
- Bed-restraint (particularly 4-point restraint) is not recommended for people who have experienced forms of physical or sexual abuse/torture
- Caution and consideration with pregnant women
Seclusion
Involuntary confinement of a patient alone in a room, or area from which the patient is physically prevented from leaving.
Contraindications to seclusion and restraint
- Extremely unstable medical & psychiatric conditions*
- Delirium or dementia leading to inability to tolerate decreased stimulation*
- Severe suicidal tendencies*
- Severe drug reactions or overdoses or need for close monitorin g of drug dosages*
- Desire for punishment of patient or convenience of staff
Indications for restraints
- To protect the patient from self-harm
- To prevent the patient from assaulting others (Threat to others)
- Prevent falls provided a FALLS RISK ASSESSMENT has been documented
- Prevent the disruption of medical treatment (removal of drains, tubes, etc)
- Prevent the disruption of medical treatment (removal of drains, tubes, etc)
Restraints and seclusion are legal when
- Behavior is physically harmful to patient or others
- Disruptive behavior presents a danger to facility (e.g. starting fires)
- Alternative measures fail
- Low stimulation (seclusion) is needed
- Patient requests controlled environment
- Patient legally detained for involuntary treatment & AWOL risk.
- Multidisciplinary involvement
- Patient advocate/relative notification
- Requires free & informed consent, except in emergencies
Use restraints when the following measures fail
- Provision of a therapeutic environment
- Verbal intervention (support & limit setting)
- Team approach Medication
Effects of the use restraints and seclusion
- Urinary incontinence
- Increased agitation
- Circulation problems
- Pressure ulcers (bed sores) -Constipation
Alternative interventions
- De-escalation techniques
- Behavioral care plan
- Medication
- Decrease in sensory stimulation
- Milieu management/ Promote therapeutic environment (e.g. Removal of problematic stimulus)
- Presence of significant other
- Frequent observation -Use of sitter
Management of psychiatric emergency
- Identify crisis leader
- Assemble crisis team – show of force
- Notify security officers if necessary
- Remove all other patients from area
- Obtain restraints
- Devise a plan to manage crisis and inform team
- Assign securing of patient limbs to crisis team members
- Explain necessity of intervention to patient and attempt -to enlist cooperation
- Restrain patient as directed by crisis leader
- Administer medication if ordered
Guidelines for mechanical restraints or seclusion
- Indications are present
- Legal requirements have been met
- Documentation
- Plan of care for restraint use or seclusion implementation
- Clinical assessments
- Observation and ongoing assessments
- Release procedures
Documentation
- Every 15 minutes while patient is restrained
- Events leading to use of restraints
- Patient’s consent
- Type of restraint
- Purpose of restraints
- Alternative measures which failed
- Duration of application
- Patient’s response to use of restraints
- Patient’s physical condition
- Nursing care provided throughout
- Rationale for terminating the intervention
- Time that restraints were discontinued
Monitor and document
- Vital signs BP, pulse, respirations q 15 min, before all medications and prn
- Nurse observes patient q 15 min
- Mental status assessment is made q 1 h
- Restraints should be as brief as possible and followed by psychological assessment of the patient
Nursing interventions
- Remove restraints before bedtime if possible, if not raise bed 20°
- During restraint period only nurses or doctors may enter room
- Family may visit if assessment has been made that both family and patient will benefit from visit and family has been informed of patient’s need for restraints
Discontinuation
- Absence of verbal threats
- Stabilization of mood
- Improvement of reality testing
4 Point restraint “Close Montoring”
- Face to face observations
- Q15 mins: presence of breathing, LOC, behavior
- Q30 mins: circulation and skin at restraint sides
- Q60 mins: physical needs
- Q2hours: position and motion
- VS includes O2 sat
