Restraints & Seizure Precautions

Question 1

Physical Restraint

Answer 1

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

Question 2

Chemical Restraint

Answer 2

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

Question 3

Seclusion

Answer 3

involuntary confinement to a room where pt is prevented from leaving

require continual monitoring

Question 4

When should you use a restraint?

Answer 4

only if you have to

LAST RESORT

Question 5

Non-violent / Non Self-destructive Behavior / Medical/Surgical

Answer 5

needed to directly support medical care and prevent injury

Question 6

Examples of medical/surgical reasons for restraint

Answer 6

pt repeatedly trying to remove IV, foley catheter, intubation, etc.

Question 7

Violent / Self-destructive Behavior / Behavioral

Answer 7

immediate threat to self or others

require a higher level of monitoring than medical-surgical

Question 8

Places you may bring a pt who is showing violent behaviors

Answer 8

ICU, psych, etc. (depends on facility)

Question 9

Does long term care use restraints?

Answer 9

no because it is their home

Question 10

Using Restraints Process (4)

Answer 10

document the need
document alternatives
use the least restrictive device
must have an order

Question 11

Alternatives of Restraint

Answer 11

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

Question 12

What does the order for restraint require?

Answer 12

from physician for med-surg restraints
reason for restraint
type of restraint
time limits (no longer than 24 hrs)

Question 13

In an emergency, when can an order be obtained?

Answer 13

immediately after applying the restraints

Question 14

Within what time frame does the LIP need to see the violent/self-destructive pt after restraint?

Answer 14

within 1 hour of restraint initiation

Question 15

Order renewal for non-violent behavior

Answer 15

new order each calendar day
LIP must evaluate pt prior to renewing order

Question 16

Order renewal for violent behavior

Answer 16

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

Question 17

Why are restraint standards driven by accrediting agencies?

Answer 17

due to high risk to patient safety

Question 18

Monitoring for a pt with a non-violent behavior

Answer 18

at least every 2 hours

Question 19

Monitoring for a pt with a violent behavior

Answer 19

every 15 minutes

Question 20

What do you need to monitor the pt with restraints for? (7)

Answer 20

need for restraint
alternatives
application/skin/circulation
toileting/hydration
ROM/positioning
behavior (calm, agitated, etc)
vital signs (every 4 hours)

Question 21

Mitt - restraint device

Answer 21

snug, not too tight, 2 fingers fit

NOT restraint unless tied to bed

Question 22

Belt - restraint device

Answer 22

goes over lap, criss cross in back to tie to bed

Question 23

Vest/Jacket - restraint device

Answer 23

color identifies size, right to right side of bed (same w/ left) unless in chair

Question 24

Wrist/Ankle - restraint device

Answer 24

secure, 2 fingers, tie to MOVEABLE area of bed (not bed rail)

Question 25

Leathers/Key - restraint device

Answer 25

vinyl restraint, more secure than cloth

blue = wrist (sky)
green = ankle (grass)

MAKE SURE KEY IS ACCESSIBLE TO RELEASE IN EMERGENCY

Question 26

How many people do you need to restrain someone?

Answer 26

5 people minimum

1 to fasten restraints, 4 to hold down limbs

Question 27

4 point restraint

Answer 27

all 4 extremities restrained

Question 28

Should you put anything in a patient’s mouth who is seizing?

Answer 28

NO

Question 29

During Seizure Procedure (8)

Answer 29

turn pt on side if possible, assist to floor (prevent aspiration)
protect the head
adjust environment to protect from injury
don’t put anything in pt’s mouth
note time of seizure
oxygen if needed
suction if needed after seizure
document

Question 30

How can you oxygenate a pt during a seizure?

Answer 30

can hold non-rebreather to pt’s face

Question 31

If a pt is unconscious after seizure, what do you need to do?

Answer 31

put oral airway in

Question 32

What should you reassess after a pt has a seizure?

Answer 32

vitals
neuro
skin
respiratory
A and O x4
cranial nerves

update physician after reassessments

Question 33

Seizure Precautions (4)

Answer 33

padded side rails or blanket side rails
oral airway in room
suction equipment available
oxygen available