NON-BEHAVIORAL RESTRAINT REMINDERS

Physician order must have a telephone or verbal order completed by the nurse if physician not present at the time of restraint initiation.

Physician not present at the time of initiation must sign, time and date the restraint order sheet within 24 hours of initiation.

DATES and TIMES MUST BE COMPLETE ON ALL ORDER AND DOCUMENTATION FORMS.

Nursing documentation must be done every 2 hours. MAKE SURE DATE AND TIME ARE CHARTED ON NURSING DOCUMENTATION.

COMPLETE REMOVAL OF RESTRAINTS FOR ANYTHING OTHER THAN PERSONAL CARE AND RANGE OF MOTION REQUIRES A NEW RESTRAINT ORDER IF THE PATIENT IS PLACED BACK INTO RESTRAINTS.

Assessment and initiation of the appropriate type restraint is critical:

MedicalBehavioral

To limit mobility related to To limit mobility for any patient

medical/surgical patients with aggressive or violent

to prevent interruption of carebehavior; danger to self or

others

Prior to placing patient in restraints, make sure that all alternatives have been considered and attempted. Documentation of alternatives, even those not listed in the documentation tool, is required.

Alternatives

Attempts should be made to evaluate and use interventions/ alternatives when possible prior to application of restraints. Please see back of this page for a list of possible interventions/alternatives.

Alternatives/Interventions

Monitoring

Companionship, staff or family to stay with the patient

  • Place patient in a room visible to nursing staff
  • Close, frequent observation, one-to-one when necessary
Environmental Measures
  • Decrease stimulation; quiet surroundings, appropriate lighting, relaxing music
  • Call bell accessible at all times
  • Orientation/reorientation of patient surroundings
  • Bed in low position with brakes locked
  • Rooms/halls clear of obstacles and excess equipment
  • Use of bed alarm system
  • Availability of bedside commode
  • Familiar possessions/photographs
  • Briefs over Foley
Comfort Measures
  • Address pain management or other source of discomfort
  • Comfortable positioning and clothing, keeping patient clean and dry
  • Reduce noise, avoid waking up patient during sleep, if possible
  • Gentle touch, soothing voice
Interpersonal Skills
  • Pleasant, consistent interaction with patient and family
  • Actively listening to patient; calm reassurance
Staffing
  • Consider assessed patient needs/behavior as well as patient/staff safety when making assignments
  • Flexibility to allow for assignment changes as per patient needs/behavior
  • Consistency in staffing (i.e. assigning staff familiar to patient as often as possible)
Regular Toileting
  • Establish consistent toileting schedule; every two hours while awake, one to two times at night
  • Encourage patient to ask for assistance at first feeling of toileting need; respond to patient’s need promptly and positively
  • Check for constipation/full bladder as indicated
Education
  • Educate patient/family/significant other to patient’s deficits and have a consistent plan of approach; re-educate/remind them of goals/potentials on an ongoing basis
  • Solicit patient/family/significant other for alternative measures
  • Provide patient/family/significant other with opportunities for control; other choices
Diversion Activities
  • Distract patient with videos, TV, reading materials, engage in conversation
  • Purposeful activities such as puzzles
  • Provide alternative activity for hands (i.e. rubber ball, squeezing devices, fold linen)
  • Sensory aids
  • Be sure patient has and is using eyeglasses, hearing aids, as appropriate
  • Provide alternative system for sensory deficits if needed
Medication/Nutrition
  • Assist in adjustment of treatment to stabilize physiological changes by notifying physician
  • Discontinue all lines that may be no longer medically necessary and initiate oral as appropriate from IV or NG
Reality Orientation and Psychological Intervention
  • Involve the patient in conversation. Do not talk over him/her
  • Explain procedures to reduce fear and convey a sense of calm
  • Provide reality links when appropriate (calendar, clock, etc.)
  • Use relaxation techniques (warm bath, warm drink, etc.)
  • Attempt to verbally redirect behavior
Interdepartmental Communication/Consultation
  • Occupation/Physical/Activities therapy may be consulted by staff to assist with activities planning to redirect behavior
  • Pharmacy may be consulted to review medication regimen
  • Respiratory Therapist may be consulted to review oxygenation
  • Psych Department may serve as a resource for behavioral interventions