Tie One On (Safely!)
What is Mechanical Restraint
True or False, Essentia policy allows patients on suicide precautions to walk in the hall.
What is True. Pt's on suicide precautions can go for walks in the hallway with their SCO unless it is documented in their chart by a provider why they can't.
If it isn't this, it didn't happen.
What is charted/documented
When a patient is restrained, safety checks must be done at least this often.
What is every 15 minutes (for violent/self-destructive)?
This communication style is often most effective in calming an agitated patient.
What is calm, clear, and respectful tone?
A type of restraint that uses medications not required for medical treatment.
What is a chemical restraint
Within this amount of time, a provider must conduct a face-to-face evaluation for violent restraints.
What is one hour
This type of staff can document the 15 min checks of a violent restraint.
What is RNs, BHTs, and trained CNAs
Circulation checks should include these 3 things.
What are color, warmth, and pulse?
Modifications to the surrounding room made to prevent falls, lessen confusion, or enhance patient comfort.
What is an environmental modification? Modifying the pt's surroundings is a great technique to utilize that can prevent the use of restraints.
True or False: You need a provider order before initiating any type of restraint.
What is False. Restraints can be initiated by a nurse in the moment, however, the provider must place the order and complete a face to face with the pt.
Restraint orders cannot be written this way.
What is PRN
How often are nurses required to document on non-violent restraints?
What is every 2 hours
Name one major complication of improperly applied restraints.
What is impaired circulation, skin breakdown, asphyxiation, or psychological trauma?
Name one therapeutic activity that may prevent escalation.
What is listening, distraction, relaxation techniques, or offering comfort items?
Name two less restrictive measures that can be tried before resorting to restraints.
Verbal de-escalation, distraction/redirection, PRN medication, trying a different staff member, giving space and reapproaching, decreasing stimuli
True or False, It does not matter what state a patient is from when initiating a hold.
What is time restraints were initiated, what was tried prior to restraints, injuries to staff or patient, time order was obtained, time MD face to face completed, time of discontinuation, time of guardian notification
This ethical principle is most challenged when restraints are used.
What is autonomy?
True or False: Offering a PRN medication before applying restraints is considered an alternative intervention.
What is true?
How long is an adult violent/self-destructive restraint order good for.
What is 4 hours.
This governing body accredits hospitals and has specific restraint standards.
What is The Joint Commission
After restraints are removed, the nurse must always document this type of evaluation.
What is the patient's physical and psychological response. (Skin integrity, circulation, pt's affect and mood, response to education)
The nurse must offer these needs regularly while a patient is restrained (name 3).
What are fluids, toileting, nutrition, repositioning, and range of motion?
T or F, Restraints are the best way to prevent falls.
False. Restraints can increase delirium, lengthen hospital stays, and cause injury to staff. Focus on the least restrictive alternative first (Telesitters, BCOs, Distraction activities, etc).