POLICY BASICS
This is the primary purpose of the Restraints and Seclusion policy: to comply with regulations while preserving these four things for the patient.
What are safety, rights, dignity, and well-being?
Restraint and seclusion orders cannot be written this way.
What is neither as a standing order nor PRN?
After a chemical restraint is administered, respiratory status and sedation/agitation level are assessed this often until the patient is stable.
What is every 5 minutes?
At initiation, nursing documentation must include the patient's behavior and these interventions that were attempted before restraint.
What are alternatives/less restrictive interventions and their effectiveness?
A 29-year-old patient arrives under an Emergency Custody Order after using methamphetamine. Despite multiple verbal de-escalation attempts, the patient begins throwing equipment, charges at security, and attempts to assault staff. The provider orders IM ketamine for immediate behavioral control.
What is a chemical restraint?
Before restraints or seclusion can be used, these should be attempted or considered first.
What are patient-specific alternatives and less restrictive measures?
Medications used for procedural sedation or for intubated patients are considered this under the policy.
What is NOT a chemical restraint?
Name two things that must be monitored for a patient in restraints.
What are circulation/skin integrity, body alignment, physical or mental status, and respiratory status?
This scale is recommended in the ED to assess sedation and agitation after a chemical restraint.
What is the mRASS?
A patient becomes difficult to arouse with an mRASS of -4. According to the education, this should occur immediately.
What is notifying the provider immediately, closely monitoring the airway, and activating the Rapid Response team if needed?
This type of restraint may be indicated when cognitive impairment creates an imminent threat that a patient will remove an invasive device necessary for medical management.
What is non-violent restraint?
In this rare circumstance, a medication or dosage is considered a chemical restraint.
What is when a medication is used to control behavior or restrict movement and is not part of the patient's standard treatment or dosage?
If an additional chemical restraint medication is administered, this process must begin again.
What is restarting the monitoring and assessment timeline from the beginning?
During ongoing monitoring, the documentation must demonstrate that the restraint is safely applied, patient needs are attended to, and this is continually reassessed.
What is the continued need for restraints?
An mRASS of +4 after medication should prompt this action.
What is notifying the provider and assessing the need for additional intervention?
A patient is aggressively attempting to harm staff and themselves. This type of restraint is indicated when behavior jeopardizes immediate physical safety.
What is violent and/or self-destructive restraint?
Name the three things that must be included in a restraint order.
What are clinical justification, the specific time period the order is valid, and the type of restraint?
Stability after a chemical restraint is defined by these two criteria.
What are stable respiratory status and a RASS/mRASS score between -2 and +2?
A patient is transferred to another acute-care facility while still restrained. The documentation must identify these three things.
What are the number, type, and location of restraints?
A patient is placed in restraints. Thirty minutes later, the patient calms down and meets criteria for release. The nurse removes the restraints. Two hours later, the same behavior returns and the nurse reapplies the restraints using the original order because there is still time remaining. What is wrong?
What is a new Licensed Practitioner order is required before reinitiating restraint after discontinuation, even if time remains on the previous order?
This is the principle that determines both whether restraint is appropriate and what type of restraint should be used.
What is a comprehensive individualized assessment of the patient's current condition and specific situation?
A 22-year-old patient is placed in violent/self-destructive restraints. The practitioner writes an order for 6 hours. Is this order compliant with the policy?
What is no? An adult violent/self-destructive restraint order cannot exceed 4 hours.
Once respiratory status and sedation are stable, monitoring changes to this schedule.
What is q15 x2 (per order)?
The provider must complete this within one hour after a chemical restraint is used.
What is a face-to-face assessment?
An adult patient arrives in the ED intoxicated and becomes violent. The patient attempts to hit a staff member.
The RN immediately applies violent restraints.
The physician writes a PRN restraint order for 8 hours.
The nurse documents, "Patient violent—restraints applied," but does not document alternatives attempted.
The patient remains restrained for 3 hours even though they have been calm and cooperative for the last hour.
No face-to-face evaluation occurs.
At 4 hours, the nurse continues the restraints because "the patient still has an order."
Identify at least FOUR policy violations.