Skill 65

Restraint-Free Environment

Patients at risk for falls or wandering present special safety challenges when trying to create a restraint-free environment. Wandering is the meandering, aimless, or repetitive locomotion that exposes a patient to harm and is often in conflict with boundaries, limits, or obstacles (NANDA International, 2012). This is a common problem in patients who are confused or disoriented. Interrupting a wandering patient can increase distress. The Department of Veterans Affairs has suggestions for managing wandering, most of which are environmental adaptations. Some of these include hobbies, social interaction, regular exercise, and circular design of a care unit (VA NCPS, 2010). Environmental modifications are effective alternatives to restraints. More frequent observation of patients, involvement of family during visitation, and frequent reorientation are also helpful measures. There are many alternatives to the use of restraints. Use these alternatives before applying restraints.

Delegation Considerations

The skills of assessing patient behaviors and orientation to the environment and determining the type of restraint-free interventions to use cannot be delegated to nursing assistive personnel (NAP). However, actions for promoting a safe environment can be delegated to NAP. The nurse instructs the NAP about:

▪ Using specific diversional or activity measures for making the environment safe.

▪ Applying appropriate alarm devices.

▪ Reporting patient behaviors and actions (e.g., confusion, getting out of bed unassisted, combativeness) to the nurse.

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