Examples of Restraints
Soft Limb
Required in-person reassessment by the physician within one hour of restraint initiation.
One Hour Face-to-Face Evaluation
Documented q15min x 1 hour after administering a chemical restraint.
Vital Signs and RASS score
Timeframe a Least Restrictive restraint order is valid for.
24hrs
Required incident reporting for tracking purposes when a patient expires in restraints or within 24hrs of restraint removal.
STARs Report
Used when soft limb restraints are ineffective for the management of violent behaviors.
Rigid Restraints
PCS
This must be documented once a restraint is initiated and discontinued/expired.
Time of START and DISCONTINUE in flowsheet
Frequency of nurse assessment and documentation on the least restrictive flowsheet.
Q2hrs
Types of Non-violent behaviors.
Pulling at lines/tubes/drains, impulsiveness, confusion, disorientation, removing dressing, medical equipment.
Device used for impulsive, confused patients that is applied around the waist of the patient.
Lap Belt/Roll Belt
Timeframe a Most Restrictive Restraint order is valid for.
4 Hours
What is initiated once a restraint order is placed and must be documented daily?
Restraint care plan
At what point do least restrictive restraints become "prolonged restraints" and leadership must be notified?
>3days
What type of restraint order would be needed if 3 or more extremities are being restrained?
Most Restrictive restraint order
Used for pulling at lines/tubes, risk for injury to self or others, and resembles boxing gloves.
Mittens
This additional safety intervention is required for ALL Most Restrictive restraints.
1:1 monitoring/Sitter
Where does the sitter document their q15min checks?
Visual Checks Flowsheet
What behaviors would make an enclosed bed an inappropriate choice for a patient?
Multiple lines, violent/aggressive patients, C.diff patients, suicidal patients.
Types of violent behavior.
Hitting, kicking, scratching, biting, throwing objects, uncontrolled expressions/anger/hostility, verbal threats/gestures/menacing behaviors.
Restriction to manage patient behavior or restrain freedom of movement.
Physical Hold
Administered to manage the patient's behavior or restrict the patient's freedom of movement and is NOT a standard treatment or dosage for the patient's condition.
Medication (Chemical Restraint)
What must be documented in the flowsheet or note that demonstrates interventions were trialed, but unsuccessful?
Less Restrictive Alternatives
This is considered a restraint unless patient is being transported, sedated, paraplegic or quadraplegic, involuntary movements (i.e. seizures), specialty beds, or are comatose.
4 side rails up
Involuntary confinement of a person alone in a room or an area from which the person is physically prevented from leaving; this can only be used for the management of violent or self-destructive behavior.
Seclusion