Documentation of Restraint Use (Nursing)

by Samantha Rhea, MSN, RN

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    00:04 So, we just talked about a lot of important points before you even consider applying restraints.

    00:10 Now, it's really important to thoroughly document anytime restraint use is in place.

    00:16 So here's about 11 points, okay, yeah I said 11, that we've got to consider when we're using restraint application.

    00:24 So we're going to talk through these and why they're "Oh so important".

    00:28 So, first of all, one of a very important piece, when you document someone using restraints, is assessing the continued need.

    00:36 What do I mean by this, just because someone's in restraints, doesn't mean that they continually need them, for two days, six hours, three weeks, for example.

    00:47 Obviously that last one's a little excessive.

    00:49 But we always want to continually assess if those restraints can safely be removed.

    00:56 Now, obviously your patient condition can improve or it can decline.

    01:00 So, it's important for you to assess the continued actual need for those restraints.

    01:07 Mental status is next, this is really important because, sometimes a very ill patient's in restrains, it can really make their confusion worse, their frustration worse, they're scared sometimes, when they're in restraints.

    01:19 So, please make sure you're assessing this, because this is really important.

    01:23 It's also important, to document the type of restraints used and where.

    01:27 When I say location, I'm talking about did we restrain their arms, did we restrain their legs, is it all of them, what type of restraint are we using, such as wrist, maybe mittens, a restraint bed for example.

    01:40 Also because something is usually applied to someone's limbs, such as a wrist restraint.

    01:46 Circulation and sensation is really important.

    01:49 Now, you can imagine, something wrapped around your wrist and your pulse points, really important that the patient has continued circulation and they can feel and also make sure that they have great blood flow to their limbs, because again we've got something restrictive on them.

    02:04 And next, almost about halfway through.

    02:06 Range of motion exercises.

    02:09 Obviously when someone's in restraint, they can't be walking around, most of the time they're going to be restrained to the bed.

    02:15 So it's important with someone lying there, as you all know, bedridden patients, it's bad for their lungs, it's not great for their circulation.

    02:23 We want to make sure, when applicable, that we can do range of motion exercises to promote circulation.

    02:30 Okay, so that's about halfway through, let's talk about this last half shortly.

    02:35 So, next is skin integrity.

    02:37 As you can imagine, you've got something around your wrist, we definitely don't want to impair their skin.

    02:43 Also, think about making sure their nutrition for their skin as well is also up-kept.

    02:48 Also, you can imagine if you're restrained, eating and drinking is pretty difficult, so is toileting.

    02:55 So, it's really important as a nurse, that you're meeting that patient's basic needs while they're restrained.

    03:00 So, making sure we're offering fluids really often, making sure they're assisted with eating and making sure they're getting toileted is applicable.

    03:09 Now, restraints are really scary, so we're almost done here.

    03:12 But restraints are a really scary situation for not only the patient, but if my care, my loved one is being restrained and I walk into the room, I may not know what's going on.

    03:22 So, it's really important as a nurse to communicate with the patient and the family, of why we're doing the restraints and why it's necessary.

    03:30 So, please make sure you provide thorough education.

    03:33 Now, for continuation of care, restraints is a biggie that needs to be continually assessed.

    03:38 So, make sure you include this in your plan of care and also document the frequency, per the agency protocol and it's really important to make sure you're up to date, with your facility guidelines.

    About the Lecture

    The lecture Documentation of Restraint Use (Nursing) by Samantha Rhea, MSN, RN is from the course Restraint Management and Application (Nursing).

    Included Quiz Questions

    1. “Restraint removed from the left wrist, but the client immediately attempted to pull out their IV. Restraint returned to the left wrist.”
    2. “Restraint applied to client’s left wrist. Radial pulse palpable, capillary refill under two seconds. Client able to wiggle their fingers, and denies wrist pain.”
    3. “Client was attempting to remove their IV, restraint applied.”
    4. “Client is calm and cooperative and is no longer grabbing at their IV line. Left wrist restraint will remain on until the end of shift.”
    1. The student nurse does not tell the client’s family why the client is in restraints, as the student nurse does not want to upset the family.
    2. The student nurse assists the client in performing range of motion exercises.
    3. The student nurse offers the client sips of water frequently.
    4. The student nurse documents every hour that the client is in restraints, as per hospital policy.

    Author of lecture Documentation of Restraint Use (Nursing)

     Samantha Rhea, MSN, RN

    Samantha Rhea, MSN, RN

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