Restraint Alternatives and Safe Restraint Use



Restraint Alternatives and Safe Restraint Use





Chapters 9 and 10 have many safety measures. However, some persons need extra protection. They may present dangers to themselves or others (including staff).


The Centers for Medicare & Medicaid Services (CMS) has rules for using restraints. Like the Omnibus Budget Reconciliation Act of 1987 (OBRA), CMS rules protect the person’s rights and safety. This includes the right to be free from restraint. Restraints may be used only to treat a medical symptom or for the immediate physical safety of the person or others. Restraints may be used only when less restrictive measures fail to protect the person or others. They must be discontinued as soon as possible.


The CMS uses these terms.



• Physical restraint—any manual method or physical or mechanical device, material, or equipment attached to or near the person’s body that he or she cannot remove easily and that restricts freedom of movement or normal access to one’s body.


• Chemical restraint—any drug used for discipline or convenience and not required to treat medical symptoms. The drug or dosage is not a standard treatment for the person’s condition.


• Freedom of movement—any change in place or position of the body or any part of the body that the person is able to control.


• Remove easily—the manual method, device, material, or equipment used to restrain the person that can be removed intentionally by the person in the same manner it was applied by the staff. For example, the person can put bed rails down, untie a knot, or unclasp a buckle.



History of Restraint Use


Restraints were once used to prevent falls. Research shows that restraints cause falls. Falls occur when persons try to get free of the restraints. Injuries are more serious from falls in restrained persons than in those not restrained.


Restraints also were used to prevent wandering or interfering with treatment. They were often used for confusion, poor judgment, or behavior problems. Older persons were restrained more often than younger persons were. Restraints were viewed as necessary devices to protect a person. However, they can cause serious harm, even death. See “Risks From Restraint Use” on p. 127.


Besides the CMS, the Food and Drug Administration (FDA), state agencies, and The Joint Commission (TJC—an accrediting agency) have guidelines for restraint use. They do not forbid restraint use. They require considering or trying all other appropriate alternatives first.


Every agency has policies and procedures about restraints. They include identifying persons at risk for harm, harmful behaviors, restraint alternatives, and proper restraint use. Staff training is required.



Restraint Alternatives


Often there are causes and reasons for harmful behaviors. Knowing and treating the cause can prevent restraint use. The nurse tries to find out what the behavior means.



Restraint alternatives for the person are identified (Box 11-1). They become part of the care plan. The care plan is changed as needed. Restraint alternatives may not protect the person. The doctor may need to order restraints.



Box 11-1   Alternatives to Restraint Use



Physical Needs




• Life-long habits and routines are in the care plan. For example, showers before breakfast; reads in the bathroom; walks outside before lunch; watches TV after lunch.


• Pillows, wedge cushions, and posture and positioning devices are used.


• Food, fluid, hygiene, and elimination needs are met.


• The bedpan, urinal, or commode is within the person’s reach.


• Back massages are given.


• A calm, quiet setting is provided.


• Exercise programs are provided.


• Outdoor time is planned for nice weather.


• Furniture meets the person’s needs (lower bed, reclining chair, rocking chair).


• Observations and visits are made at least every 15 minutes. Or as often as noted in the care plan.


• The person is moved to a room close to the nurses’ station.


• Light is adjusted to meet the person’s needs and preferences.


• Staff assignments are consistent.


• Sleep is not interrupted.


• Noise levels are reduced.



Safety and Security Needs




• The call light is within reach.


• Call lights are answered promptly.


• The person wanders in safe areas.


• All staff are aware of persons who tend to wander. This includes staff in housekeeping, maintenance, the business office, dietary, and so on.


• Knob guards are used on doors.


• Falls and injuries from falls are prevented (Chapter 10).



• Warning devices are used on beds, chairs, and doors.


• Walls and furniture corners are padded.


• Procedures and care measures are explained.


• Frequent explanations are given about equipment or devices.


• Confused persons are oriented to person, time, and place. Calendars and clocks are provided.






Safe Restraint Use


Restraints can cause serious injury and even death. CMS, OBRA, FDA, and TJC guidelines are followed. So are state laws. They are part of the agency’s policies and procedures for restraint use.


Restraints are not used to discipline a person. They are not used for staff convenience. Discipline is any action that punishes or penalizes a person. Convenience is any action that:



Restraints are used only when necessary to treat medical symptoms. A medical symptom is an indication or characteristic of a physical or psychological condition. Symptoms may relate to physical, emotional, or behavioral problems. Sometimes restraints are needed to protect the person or others. That is, a person may have violent or aggressive behaviors that are harmful to self or others.


See Focus on Surveys: Safe Restraint Use.




Physical and Chemical Restraints


According to the CMS, physical restraints include these points.



Physical restraints are applied to the chest, waist, elbows, wrists, hands, or ankles. They confine the person to a bed or chair. Or they prevent movement of a body part. Some furniture or barriers also prevent freedom of movement.



Drugs or drug dosages are chemical restraints if they:



Drugs cannot be used for discipline or staff convenience. They cannot be used if they affect physical or mental function.


Sometimes drugs can help persons who are confused or disoriented. They may be anxious, agitated, or aggressive. The doctor may order drugs to control these behaviors. The drugs should not make the person sleepy and unable to function at his or her highest level.




Risks From Restraint Use


Box 11-2 lists the risks from restraints. Injuries can occur as the person tries to get free of the restraint. Injuries also can occur from using the wrong restraint, applying it wrong, or keeping it on too long. Cuts, bruises, and fractures are common. The most serious risk is death from strangulation.



Restraints are medical devices. The Safe Medical Devices Act applies if a restraint causes illness, injury, or death. Also, the CMS requires the reporting of any death that occurs:




Legal Aspects


Laws applying to restraint use are followed. Remember:



• Restraints must protect the person. They are not used for staff convenience or to discipline a person. Using restraints is not easier than properly supervising and observing the person. A restrained person requires more staff time for care, supervision, and observation.


• A doctor’s order is required. The doctor gives the reason for the restraint, what body part to restrain, what to use, and how long to use it. This information is on the care plan and your assignment sheet. In an emergency, the nurse can decide to apply restraints before getting a doctor’s order.


• The least restrictive method is used. It 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. They restrict 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). They do not totally restrict freedom of movement and are less restrictive.


• Restraints are used only after other measures fail to protect the person (see Box 11-1). Some people can harm themselves or others. The care plan must include measures to protect the person and prevent harm to others. Many fall prevention measures are restraint alternatives (Chapter 10).


• Unnecessary restraint is false imprisonment (Chapter 3). You must clearly understand the reason for the restraint and its risks. If not, politely ask about its use. If you apply an unneeded restraint, you could face false imprisonment charges.


• Informed consent is required. The person must understand the reason for the restraint. The person is told how the restraint will help the planned medical treatment. The person is told about the risks of restraint use. If the person cannot give consent, his or her legal representative is given the information. Consent must be given before a restraint can be used. The doctor or nurse provides needed information and obtains the consent.


See Focus on Communication: Legal Aspects.




Safety Guidelines


The restrained person must be kept safe. Follow the safety measures in Box 11-3. Also remember these key points.



Box 11-3   Safety Measures for Using Restraints



Before Applying Restraints




• Do not use sheets, towels, tape, rope, straps, bandages, Velcro, or other items to restrain a person.


• Apply a restraint only after being instructed about its proper use.


• Demonstrate proper application of the restraint before applying it.


• Use the restraint noted in the care plan. Use the correct size. Small restraints are tight. They cause discomfort and agitation. They also restrict breathing and circulation. Strangulation is a risk from big or loose restraints.


• Use only restraints that have manufacturer instructions and warning labels.



• Use intact restraints.



• Test zippers, buckles, locks, hooks, loops, and other fasteners. The device must fasten securely.


• Do not use a restraint near a fire, a flame, or smoking materials.

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Nov 5, 2016 | Posted by in MEDICAL ASSISSTANT | Comments Off on Restraint Alternatives and Safe Restraint Use

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