Physical restraint.pptx

Physical restraint

1. PATIENT RESTRAINT POLICY PREPARED BY SDU- 2019

2. OBJECTIVES At the end of the class you will be able to: Define the term ‘Restraint’ Discuss the purposes of restraints List down the types of restraints Enlist the indications & contraindications of restraint application Demonstrate the application of physical restraints

3. INTRODUCTION Restraints in a medical setting are items that limit a patient’s movement. Restraints can help keep a person from getting hurt or doing harm to others, including their care givers. Restraints are used as last resort.

4. DEFINITION INCOMPETENT PATIENT : An incompetent patient may be defined as one whose mind is unsound or impaired function such as deterioration, illness or psychosis. RESTRAINT: Restrict freedom of movement, physical activity or normal access to one’s body.

5. PURPOSES To promote patient safety by respecting their rights and dignity through proper and appropriate application of restraint. To aid in the performance of procedures and treatments (intubation, removing of tubing and catheters). To emphasize the use of restraints requires appropriate clinical judgement and justification.

6. POLICY STATEMENTS 1) Restraints shall be used only for incompetent patients in order to maintain physical safety and prevent injury of harming oneself, staff or others or interference with medical / surgical treatment. 2) Restraints shall be used only upon written order of physician except in emergency situation. 3) Patient dignity should be maintained during restraint. It should not be used as a means of coercion, discipline or convenience by the staff or as means to control behavior without clinical justification. 4) Physical restraint should be terminated immediately when the patient no longer possess a serious risk of harming themselves or others.

7. TYPES OF RESTRAINTS: PHYSICAL : Any manual method physical/mechanical device material or equipment that immobilizes or reduce the ability of a patient to move his/her arms, legs, body or head freely or prevent the patient from voluntarily exiting the bed. CHEMICAL : A drug/ medication when it is used as a restriction to manage the patient’s behavior or restrict the patient’s freedom of movement and is not a standard treatment or dosage for the patient’s condition. (benzodiazepines, sedatives & antipsychotics etc.). Note: Medications which are part of the patient’s regular medical regime are not considered as chemical restraint.

8. CATEGORIES OF RESTRAINTS ACCORDING TO PURPOSE: Non violent or Non self destructive (Medical/ surgical restraints): Used to promote healing and improve the patients well being (e.g.: removing NGT, foley’s catheter, IV cannula, Tracheal tubes etc.). Violent or self destructive behavior (Behavioral restraint) Emergency measures Violent / self destructive behavior that jeopardizes the immediate physical safety of the patient, staff or others. ( suicidal ideas)

9. TYPES OF PHYSICAL RESTRAINTS Safety Belt : It is intended to use either for extremely restless or, if not, combative patients those who are being transported in a wheelchair, at serious risk of falling. Soft limb holder (Wrist & Ankle): The wrist /ankle holders allows the patient’s wrist/ ankle to be immobilized: When the patient is on bed or when transferring in a chair who are restless or require one or both arms to be firmly held by Velcro fastening. It can also be used to prevent removing tubes or bandages.

10. It may use 2,3,or 4 point restraints as ordered and appropriate. Two Point Extremity Restraints : Usually refers to application of restraints on one arm and one leg on the opposite side of the body or two arms. Three Point Extremity Restraints : One arm and both legs or both arm and one leg. Four Point Extremity Restraints : All four limbs. In case limb holders aren’t available in area, can apply limb restraints with soft bandages or elastic stockinette.

11. INDICATIONS AND CONTRAINDICATIONS INDICATIONS Patient pulling tubes, lines or dressings. Confused patient hindering nursing care. Agitation, hostility or aggression towards others in the form of overt actions of biting, kicking, hitting etc. Unpredictably and suddenly a patient awakes and harms him / herself. E.g.: propofol weaning in intubated patient or self extubation. CONTRAINDICATIONS Fractured limbs / history of fracture Pelvic fractures & multiple rib fracture Severely ill patients eg : COPD Open wounds Pregnancy Head or spinal cord injury Cardiac disorders Seizure disorder Bone deformities, trauma or bone disease Premature babies Chorea /involuntary movements of hands

12. EQUIPMENTS Alternative to restraint Restraint Monitoring Sheet Limb holders Safety Belt

13. PROCEDURE Alternatives to restraint use: The staff must attempt alternative and non-physical interventions before applying physical restraints. The staff may use physical restraint, if alternatives & non-physical interventions are determined to be ineffective to protect the patient and or others safety. 2) Assessment to prior restraint application : A doctor or registered nurse should assess a patient before applying restraints to determine whether the restraint is justified and type of restraint to be used. Physician must notify the patient’s family prior to physical restraint except in emergency situation.

14. Application of Restraints: Initiation of physical restraint : 1. Restraint should only be initiated on a physician’s order. 2. Physician orders for either physical or chemical restraints which shall be documented in patient medical record with the following information: Physical restraint: Date, time, duration & type of restraint to be applied & its justification. Whether initial or recurrent order. Any instructions based on the patient’s medical condition.

15. Chemical restraints: Medication name, dose, route and frequency. Describe the specific behavior necessitated chemical restraints Chemical Restraint: Continuation If a patient requires additional medication, will be evaluated by a doctor and has a treatment plan that addresses the behavior no longer considered as a chemical restraint.

16. Points to remember : Physical restraint should be applied correctly and appropriately according to the manufacture’s recommendation. A minimum of 2 staff nurses should be present when applying restraints. Restraints straps should be secured to the bed frame (not to side rails). Physical restraints should be removed every two hours for no less than 10 min for range of motion and skin care.

17. Recurrent use of restraint : If physical restraint is continued after 24 hours, a physician and registered nurse will document the justification for recurrent restraints use in the patient’s record The patient’s physical and behavioral status also to be documented. If a patient has been released from physical restraint and there is new precipitating event, the patient will be re-assessed by the physician and a new order generated if application of restraints is required.

18. Monitoring & Documentation of patient on Physical restraint 1. The application of patient restraint must be documented in the nurse’s notes. This shall include: Date & time of application Reason for restraint Patient/ relative education Skin condition in affected areas Patient reaction after restraint application

19. A registered nurse should check the patient who is on restraint at least 2 hourly or sooner if necessary and document it in the restraint monitoring sheet. Monitor the following : Skin integrity / circulation ( To ensure optimal circulation adjust restraint cuff two finger width) Range of motion of restrained limbs Restraint status Fluid/ Nutrition or Toileting Position (To reduce the risk of bed sore offer back care every 2 nd hourly) Vital signs (according to the patient condition) Termination of restraint

20. CHEMICAL RESTRAINT: Describe the specific behavior that necessitates chemical restraint. Medication name, dose, route & frequency to be written in treatment sheet. If a patient needs additional medication, (assessed by a physician and the behavior has been addressed on the care plan) it is no longer chemical restraint.

21. If the ordering physician is not the treating physician, the treating physician must be informed within 24hrs. PRN orders (if necessary), verbal or telephone orders for restraints are not permitted under any circumstances. In emergency situation (violent/destructive behavior) where the nurse has initiated the restraint, the physician must be notified within 1 hour to perform a face to face evaluation and immediately refer to psychiatrist for further evaluation.

22. To prevent the risk of aspiration during restraint, the head end of the bed should be elevated and keep the patient in supine position. The validity of the order expires after 24 hours. A written order must be obtained from the physician for extended restraint. Staff nurse should educate the patient and family on the rationale for the use of restraints.

23. MONITORING PATIENT ON CHEMICAL RESTRAINT Registered nurse must check vital signs before administration of chemical restraint. After administration of chemical restraint, monitor the patient every half hourly for first 2 hours and document in the nurses notes as following : - Vital signs - Level of consciousness - Behavioral status

24. 4) Termination of Restraints : Physical restraints will be terminated immediately when the patient no longer presents as a risk of serious injury to self or others. In the event of emergency, restraints may be cut off with hand scissors. Termination will occur at the earliest possible time, this may occur before the order expires. If the termination of physical restraint does not occur before the end of a medical order, the restraint will be discontinued unless the order is renewed.

25. Justification for terminating physical restraint, time of termination and the name of the person who terminated restraint will be documented in the patient's clinical record by the physician and registered nurse.