Chapter 14

1. Chapter 14 Restraint Alternatives and Safe Restraint Use

2. Some persons need extra protection. • Every attempt is made to protect the person without using restraints. • Restraints are used only as a last resort to protect persons from harming themselves or others.

3. History of Restraint Use • Until the late 1980s, restraints were thought to prevent falls. • Research shows that restraints cause falls. • Injuries are more serious from falls in restrained persons. • Older persons were restrained more often than younger persons were. • Their purpose was to protect a person. • They can cause serious harm, even death.

4. OBRA, the Centers for Medicare & Medicaid Services (CMS), the U.S. Food and Drug Administration (FDA), The Joint Commission (TJC), state laws, and accrediting agencies have guidelines about restraint use. • They do not forbid the use of restraints. • They require trying all other appropriate alternatives first. • Every center has policies and procedures about restraint use.

5. Centers for Medicare and Medicaid Services (CMS) • Terminology • Physical Restraint • Chemical Restraint • Freedom of Movement • Remove easily • CMS rules protect the person’s rights and safety. • Restraints may only be used: • To treat a medical symptoms or for the immediate physical safety of the person or others • When less restrictive measures fail to protect the person or others • Restraints must be discontinued at the earliest possible time.

6. Restraint Alternatives • Often there are causes and reasons for harmful behaviors. • Knowing and treating the cause can prevent restraint use. • Restraint alternatives for the person are identified. • Restraint alternatives become part of the care plan. • It restraint alternatives do not protect the person, the doctor may need to order restraints.

7. Safe Restraint Use • Restraints can cause serious injury and even death. • Centers must follow: • OBRA guidelines • CMS guidelines • FDA guidelines • Accrediting agency guidelines • State laws • Restraints are not used to discipline a person or for staff convenience.

8. According to OBRA, restraints are used only when necessary to treat a person’s medical symptoms. • Sometimes restraints are needed to protect the person or others. • Physical restraint: • May be any manual method, physical or mechanical device, material, or equipment • Is attached to or next to the person’s body • Restricts freedom of movement or access to one’s body • Cannot be easily removed by the person

9. Drugs are restraints if they: • Control behavior or restrict movement • Are not standard treatment for the person’s condition • Complications of restraint use • Injuries occur as the person tries to get free of the restraint. • Injuries occur from using the wrong restraint, applying it wrong, or keeping it on too long. • The most serious risk is death from strangulation. • There are also mental effects.

10. Restraints are medical devices. • The Safe Medical Device Act applies if a restraint causes illness, injury, or death. • CMS requires the reporting of any death that occurs while a person is in restraints. • Legal aspects • Restraints must protect the person. • A written doctor’s order is required. • The least restrictive method is used. • Restraints are used only after other measures fail to protect the person. • Unnecessary restraint is false imprisonment. • Informed consent is required.

11. The least restrictive method is used. • Allows the greatest amount of movement or body access possible. • Some restraints attach to the person’s body and to a fixed (non-movable) object. • Restricts freedom of movement or body access. Vest, jacket, ankle, wrist, hand, and some belt restraints are examples. • Other restraints are near but not directly attached to the person’s body (bed rails or wedge cushions). • Partially restrict freedom of movement. They allow access to certain body parts and are the least restrictive.

12. Safety guidelines • Observe for increased confusion and agitation. • Protect the person’s quality of life. • Follow the manufacturer’s instructions. • Apply restraints with enough help to protect the person and staff from injury. • Observe the person at least every 15 minutes or more often as required by the care plan. • Remove the restraint, reposition the person, and meet basic needs at least every 2 hours. • Follow the care plan.

13. Report and record: • The type of restraint applied • The body part or parts restrained • The reason for the application • Safety measures taken • The time you applied the restraint • The time you removed the restraint • The person’s vital signs • The care given when the restraint was removed • Skin color and condition • Condition of the limbs • The pulse felt in the restrained part • Changes in the person’s behavior • Complaints of a tight restraint; difficulty breathing; and pain, numbness, or tingling in the restrained part (report these complaints to the nurse at once)

14. Applying restraints • Restraints are made of cloth or leather. • Restraints may increase confusion and agitation in persons with dementia. • Never use force to apply a restraint. • Ask a co-worker to help apply the restraint if needed. • Report problems to the nurse at once. • Wrist restraints (limb holders) limit arm movement. • Hands are placed in mitt restraints. • Belt restraints are used when injuries from falls are risks or for positioning during a medical treatment.

15. Cloth restraints (soft restraints) • Mitts, belts, straps, jackets, and vests. • Applied to the wrists, ankles, hands, waist, and chest. • Leather restraints • Applied to the wrists and ankles. • Wrist restraints • Used when a person continually tries to pull out tubes used for life-saving treatment. (intravenous infusion [IV], feeding tube) • Mitt restraints • Prevent finger use. • Allow hand, wrist, and arm movements. • Belt restraints • Prevent person from getting out of bed or out of a chair. • A roll belt allows the person to turn from side to side or sit up in bed. • The belt is applied around the waist and secured to the bed or chair (lap belt). It is applied over a garment.

16. Vest restraints and jacket restraints are applied to the chest. • A jacket restraint is applied with the opening in the back. • For a vest restraint, the vest crosses in front. • The straps of vest and jacket restraints: • Always cross in the front • Never cross in the back • Are always applied over a garment • Have life-threatening risks • You are advised to only assist the nurse in applying vest and jacket restraints. • Death can occur from strangulation. • Never use force to apply a restraint. If a person is confused or agitated, ask a co-worker to help apply the restraint. Report problems to the nurse at once.

17. Quality of Life • Restraints lessen the person’s dignity. • The restrained person depends on others for basic needs. • Try to understand the person’s situation to better understand how the person with restraints feels. • Treat the person with kindness, caring, respect, and dignity.