Restraints

A

100

A drug or medication that is used as a restriction 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

Chemical Restraint

200

Allows medical treatments to continue without interruption.  Prevent pulling out necessary tubes or drains

Non-violent/Non-self-destructive Restraints

300

What are some contraindications for extremity restraints?  Name 2.  

AV fistula/ AV graft

Vascular reconstructive surgery

Active seizures

Prone positioning

400

Comfort measure include?

Nutrition/hydration

Hygiene and elimination 

Restraint release and ROM to extremities

B

100

The use of a manual or physical method to restrict a person's freedom of movement or normal access to their body.  

Manual Hold Restraint

200

Restraints standards implemented to protect the individual again injury to self or others.  

Violent/Self-destructive Restraints

300

How often are restraint medical orders renewed?  

Renewed every calendar day

PRN and standing orders are NOT acceptable for use of restraints

400

How quickly should a change in a patient's condition be reported to the Primary Team?  

STAT!  Immediately!

C

100

In order to prevent positional asphyxia, patients must not be restrained in the prone position, or have weight placed on the _______ or ________ at any time.  

Chest, Abdomen

200

Alternatives to restraints.  Name 3.

Frequent monitoring

Family participation

Therapeutic communication

Therapeutic distraction

Diversionary activities

Decreased stimulation

Exercise

300

How often are patient's assessed when on restraints?

Every 2 hours

D

100

An apparatus which restricts a patient's movement of head, limbs, or body, and which the patient is unable to remove.  

Mechanical Restraint

200

4 side rails are considered restraints when they have the effect of restricting a patient's movement and cannot be easily removed by the patient.  True or False?

True

300

What should the nurse assess when a patient is restrained?

Every 2 hours the nurse assesses:  

- Level of orientation and respiratory status

- Correct application of restraint

- Signs of injury due to restraint

- Circulation in the extremities

E

100

The term "Mechanical Restraint" may also apply to an apparatus not normally used for this purpose, such as a ________ or ________, if the patient is not able to release the mechanism.  

bed rail, bed sheet

200

Geri-chairs or lounge chairs with fixed tray tables are considered restraints when they are utilized to restrict a patient's movement.  True or False?

True

300

How often are restraints released and comfort measures offered?  

At least every 2 hours, or more frequently according to the patient's needs