week 10: Restraints Flashcards
What are the conditions for restraining a patient?
-use as a last resort
-reduce risk of injury
-prevent interruptions of therapy: NGT tubes, IV, ventilators
-reduce risk of injury to others
what are two types of restraints?
physical & chemical
what is a chemical restraint? example
medications used to manage a patient’s behavior and are not a standard treatment or dosage for the patient’s condition
EX: sedative
what is a physical restraint?
any manual method, physical or mechanical device, or material, or equipment that immobilizes or reduces the ability of the patient to move freely
when is the use of restraint indicated?
-review facility policy and procedure and laws regarding restraint implementation, care of patient in restraints, documentation
-physician’s order is required
-based on a face-to-face assessment of pt
-order only good for 24 hrs
-renewed every 24 hrs after reassessment by MD
what are types of physical restraints? & what its used for?
-mitten (tethered) = trying to take out lines/tubes
-belt = prevent rolling over
-posey vest = make sure nice & smooth & tie to bed frame
-extremity (ankle or wrist) = most restrictive
-four side rails = needs order
-enclosed bed
what must be done before a restraint is applied?
-follow agency-specific policy and procedures for appropriate use and monitoring of restraints
-physician’s order (or ordering provider) is required
-application of restraints in violation of state and federal regulations constitutes abuse
where do we safely tie restraints?
-always tie restraints to the bed frame
-use a slip knot or quick release restraint
restraint order details
-reason for restraint use
-type of restraint
-duration
-when to discontinue
-restraint alternative(s) tried
-when order expires
give examples of restraint alternatives
-bed alarms
-enclosed bed
what are the nursing interventions/assessments that must be done while our patients are in restraints?
-assess and reassess indication for restraint (remove when behavior ceases)
-ensure active physician order
-frequent monitoring
-ABC, comfort, patient safety
restraints: ethical aspects
use of restraints must be clinically justified and part of the prescribed medical treatment and plan of care
how often should assessments occur?
the assessments need to be done every 2 hours
what specifically should we assess?
-we need to assess circulation, skin breakdown
-release the restraint for mobility and ROM
-we must offer food, fluid, and use the bathroom
what do we document while our patients are in restraints?
-indications
-type of restraints used
-assessments
-interventions
