Restraints & Seizure Precautions Flashcards
Physical Restraint
any device that limits movement of the body parts, used to prevent injury to self or others
may use for safety of pt or others
Chemical Restraint
using medication to control behavior or restrict freedom of movement and is not a standard treatment for the patient’s condition
may put them to sleep/relax them
ex: haldol
Seclusion
involuntary confinement to a room where pt is prevented from leaving
require continual monitoring
When should you use a restraint?
only if you have to
LAST RESORT
Non-violent / Non Self-destructive Behavior / Medical/Surgical
needed to directly support medical care and prevent injury
Examples of medical/surgical reasons for restraint
pt repeatedly trying to remove IV, foley catheter, intubation, etc.
Violent / Self-destructive Behavior / Behavioral
immediate threat to self or others
require a higher level of monitoring than medical-surgical
Places you may bring a pt who is showing violent behaviors
ICU, psych, etc. (depends on facility)
Does long term care use restraints?
no because it is their home
Using Restraints Process (4)
document the need
document alternatives
use the least restrictive device
must have an order
Alternatives of Restraint
redirection and explain why what they are doing is wrong
distraction
remember pt’s needs (drink, pee, etc.)
pt may be stressed/anxious
may have someone sit w/ pt
What does the order for restraint require?
from physician for med-surg restraints
reason for restraint
type of restraint
time limits (no longer than 24 hrs)
In an emergency, when can an order be obtained?
immediately after applying the restraints
Within what time frame does the LIP need to see the violent/self-destructive pt after restraint?
within 1 hour of restraint initiation
Order renewal for non-violent behavior
new order each calendar day
LIP must evaluate pt prior to renewing order
Order renewal for violent behavior
new order every 2 hours if pt is 9 years of age and older
new order every 1 hour if pt is 8 years of age and younger
Why are restraint standards driven by accrediting agencies?
due to high risk to patient safety
Monitoring for a pt with a non-violent behavior
at least every 2 hours
Monitoring for a pt with a violent behavior
every 15 minutes
What do you need to monitor the pt with restraints for? (7)
need for restraint
alternatives
application/skin/circulation
toileting/hydration
ROM/positioning
behavior (calm, agitated, etc)
vital signs (every 4 hours)
Mitt - restraint device
snug, not too tight, 2 fingers fit
NOT restraint unless tied to bed
Belt - restraint device
goes over lap, criss cross in back to tie to bed
Vest/Jacket - restraint device
color identifies size, right to right side of bed (same w/ left) unless in chair
Wrist/Ankle - restraint device
secure, 2 fingers, tie to MOVEABLE area of bed (not bed rail)
