Restraints and Use of Safety Devices

by Jessica Spellman

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    00:02 Hi! I’m Jessica Spellman. This is the Ws of using restraints, the who, what, when, and how to use restraints. After taking this course, you will be able to define a restraint and be able to give examples. Understand what is needed to initiate, intervene, and discontinue restraint orders. Explain the nurses’ role and caring for a patient with a restraint.

    00:28 Recall the proper legal documentation that must be present when caring for a patient with restraints. So let’s start with the definition of a restraint. A restraint is a means of unreasonably limiting freedom of movement. And this can be done in several ways. There are four types of restraints. The first is physical, mechanical, chemical, and using seclusion. A physical restraint. A physical restraint is when you’re holding a patient in a manner in which his or her movement is restricted. An example would be a patient is confused and attempting to hit you with their hand. So you hold their hand and/or wrist to prevent being hit. This is an example of a physical restraint. A mechanical restraint. When we limit a patient’s movement but we use a device to do so. So an example of that would be applying wrist restraints to prevent a patient from extubating themselves.

    01:33 A chemical restraint. This is when we use a medication for the purpose of restraint instead of treatment. So an example would be using a medication to sedate a patient so they cannot pull out tubes or lines or if they’re combative. And then the use of seclusion is when we place the patient alone in the room so they cannot communicate or see any staff or patients. As long as the patient believes they cannot get out of the room, it is considered seclusion. It’s important that in a licensed operator or contracted department of mental health facility, that a mechanically strained patient may not be placed in seclusion. So those are two types of restraints that cannot be used together.

    02:19 Otherwise, we can combine these and do physical restraints and chemical restraints, but seclusion is not one that can be used with physical restraints. I just wanted to make an important point. So when can restraints be used? The appropriate use of restraints is to prevent harm for patients and to prevent imminent violence to others.

    02:48 Inappropriate ways that we try to avoid using restraints for, are to punish or attempt to modify patient behavior. For example, saying, “If you continue to do X, Y, and Z, I’m going to have to restrain you.” We don’t want to threaten patients with the use of restraints. We don’t want to use restraints for staff convenience. And we don’t want to use restraints on as needed or PRN basis. Restraints should be considered only after all other less restrictive alternatives have been determined to be ineffective. So once we determine that somebody needs restraints, who may order the restraints? They do require an order by a physician or another independent practitioner. However, nurses may go ahead and initiate the use of restraints if the patient is in danger of harming themselves or others. After the initiation, it is appropriate that within an hour that a physician must evaluate the patient in order to determine whether the restraints are continued to be necessary. Verbal orders cannot take the place of the physician evaluating the patient. It must be determined to be the most appropriate method of restraining the patient. It may be issued over the phone by a physician that has previously examined the patient, but that must be given directly to a registered nurse.

    04:15 So if the patient has not been seen by that physician, that physician cannot be called in or called over the phone to initiate a verbal order for restraints. Medication the physician ordered must have been given previously to the patient. We cannot initiate new medication orders over the phone. And then the treating physician must be contacted as soon as possible if he or she did not order the restraint. So just to clarify this, if there is an on-call physician on night shift that comes and sees the patient and orders the initial order for restraints, the treating physician or attending physician still needs to be contacted about the restraint order. So, how long can we use restraints? Initial restraint orders are valid for three hours. At three hours, the nurse or physician assistant or authorized physician representative may continue the order if the rationale for the use of the restraints still exists. At six hours, the physician must examine the patient and determine if the order should be renewed. The maximum amount of time restraints or seclusion may be used is eight hours and a 24-hour period. If the physician determines that they should be used longer than that, a new order must be written every 24 hours. So, why should restraints be discontinued? When the emergency no longer exists, the patient must be released from the restraints or the seclusion. Second, the patient needs to be calm. And third, the patient does not present a threat to himself or herself or the staff. So as nurses, what do you need to document when you have a patient in restraints? The first thing you want to document is the situation that initiated the use of the restraints. You also want to document who was contacted and what orders you received from that individual. You want to document the time the restraints were initiated, how the nurse is maintaining safety for the restrained patient, and any other interventions the nurse is performing to calm the patient.

    06:35 Ongoing and frequent assessments are part of the documentation that nurses need to record. What is important to include, specifically is circulation checks to the extremities. We’re looking for a pulse, the color or the pallor, the polar whether it’s cold or warm. The paresthesia whether it’s numb or have normal sensation. Paralysis, can they move their extremities, and if there’s pain. These are called the six Ps of the circulation checks- they're pulse, pallor, polar, paresthesia, paralysis, and pain. How can nurses protect patients that are in restraints? The patient must be fully clothed to maintain their dignity. And they must be offered a urinal or bedpan, or access to the bathroom. In addition, they really need to be observed continually or at least every 30 minutes in order to determine if the restraint or seclusion still needs to be used. They also need to be informed of the rationale for the restraints as well as provided interventions to assist with maintaining their emotional anxiety. Let’s review what we’ve learned about restraints.

    07:54 We’ve learned what they are. There are several types of restraints- physical, mechanical, chemical, and seclusion. Who may use restraints? Nurses may initiate the order, but the physician must evaluate the patient within an hour of initiation. How long do we use restraints for? The least amount of time possible. How do we document the use of restraints? We document the time the restraint was initiated, the physician that was contacted and orders received, how the nurse is maintaining patient safety while in restraints, and we need to perform circulation checks; the pulse, pallor, polar, paresthesia, paralysis, and pain of the extremities that are being restrained. This has been the use of using restraints, and I’m Jessica Spellman. Thanks.

    About the Lecture

    The lecture Restraints and Use of Safety Devices by Jessica Spellman is from the course Safe and Effective Care Environment. It contains the following chapters:

    • The W's of Using Restraints
    • Who may order restraints?
    • What should be documented?

    Author of lecture Restraints and Use of Safety Devices

     Jessica Spellman

    Jessica Spellman

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