1. The Safe Use of Patient Restraints
Mandatory Annual Review Course

2. Click each button for details
Definitions
Any method of physically restricting a person’s freedom of movement, physical activity or normal access to his or her body.
Patient immobilization that is a normal component of a procedure is not considered restraint.
Restraint is:
Medical
(Non-behavioral)
Restraint:
A manual method, physical or mechanical device, material, or equipment that immobilizes or reduces the ability of a patient to move his or her arms, legs, body or head freely.
A drug used solely as a restrictions to manage the patient’s behavior or restrict freedom of movement.
Behavioral Health
Restraint:
The restriction of patient movement in response to severely aggressive, destructive, violent or suicidal behaviors that place the patient or others in imminent danger.
Click each button for further details
Restraint is not:
Forensic restriction used by law enforcement for security purposes.

3. Side Rails – Restraint or Not?
Click the answer
The use of side rails may pose risk to patient’s safety. Clinical judgment determines whether or not the use of side rails is considered restraints.
Raising all four side rails to prevent the patient from exiting the bed
Not
Restraint
Restraint
Four or full side rails to prevent the patient from rolling our of bed
Patient actively seizing
Post-op patient recovering from anesthesia
Patient on a gurney
Not
Restraint
Restraint
Click the photo for examples
Not
Restraint
Raising fewer than four side rails (when bed has more than two)
Restraint

4. Alternatives to Restraints
Restraints must never be used as a substitute for good nursing care or staff convenience. Restrained patients require MORE CARE and INCREASED DOCUMENTATION.
PHYSICAL MEASURES
SPIRITUAL NEEDS
Relaxation techniques
Promote normal sleep patterns
Use of lap belt in chair as a reminder
Provide glasses, hearing aid, dentures
Tape foley to abdomen of male patient
Use Activity Apron
Exercise and activities
Anticipate and provide for basic needs
PSYCHOLOGICAL MEASURES
Provide for companionship: family, friends
Orient to reality
Explain all procedures
Use TV, radio, music
Collaborate w/other healthcare members
Provide pain medication, eliminate itch
Contact patient’s pastor, minister, priest, rabbi
Offer sacrament of Communion, Reconciliation, Anointing of the Sick
Use sitter or volunteer to read to patient
Use audio tapes, CDs
ENVIRONMENTAL NEEDS
1:1 communication
Use of cushions to maintain safety
Locate patient next to Nurse’s station
Use appropriate lighting
Use Geri chair, position commode, walker, near bedside
Decrease noise, control activity level
Place Call light within reach
Position tubes/drains out of site
Initiate frequent bathroom rounds
Review medications for side effects & interactions
PHYSIOLOGICAL MEASURES

5. To Determine the NEED for RESTRAINT USE:
Patient Assessment
To Determine the NEED for RESTRAINT USE:
Attempt Alternatives
Use safe, effective and least restrictive method of restraint
Clinical Justification based on observed patient actions or behaviors
Interference with therapy or patient care
Pulling tubes
Picking at wounds
Removing dressings
Activity or thoughts with a reasonable probability of harm to self
Wandering
Unsteady gait (high risk for falls)
Suicidal
Activity or thoughts with a reasonable probability of harm to others
Confused patient striking out at others
Homicidal attempt or talks about killing/harming someone
Violent patient in alcohol or drug withdrawal

6. Reason for the restraint. Be time specific Include type of restraint.
Restraint Orders
Restraints will be initiated or continued on the order of a treating physician. The order must meet the following criteria:
Reason for the restraint.
Be time specific
Include type of restraint.
Reflect least restrictive manner.
Be in accordance with safe and appropriate restraining techniques.
Be discontinued at the earliest point in time.
Never be written as a standing order or PRN.

7. Medical vs. Behavior Health Orders
Behavioral Health
Time Limitations
24 hours
4 hours 18yrs or older
2 hours 9-17yrs
1 hour 8yrs and under
RN Assessment
Every 2 hours or sooner
Continuously document every 15 mins
MD Assessment
Every 24 hours prior to writing new order
Every 8 hours 18yrs or older
Every 4 hours 17yrs and younger
Emergency Application by RN
Notify MD ASAP, within 1 hour MD must provide telephone or written order. MD must assess patient ASAP, within 24 hours.
Notify MD ASAP, within 1 hour MD must assess patient and write order.
Restraint Reapplication
Requires new order, and MD assessment. -Even if original order has not exceeded its “time limit.” This does not include the temporary release that occurs for patient assessment.

8. Observation & Monitoring
Assessment will include:
The patient’s physical and emotional well-being .
Comfort and care needs, including hygiene, elimination, hydration, nutrition
The appropriateness of restraint application, removal, and reapplication
Assessment of the need for continuing or discontinuing restraint
Patient death associated with restraint use:
RN will immediately notify Nurse Manager or House Supervisor
Complete a UOR (unusual occurrence report)
Hospitals AR&L Director or designee will notify CMS

9. Application of Restraint
Must have quick-release application
Use the correct size
Note “front” and “back” of device
Secure to bed springs or frame, not mattress or bed rails
Do not apply one-sided restraints
Do not restrain feet while their hands are free
Place call light and necessary items within reach
Do not position pregnant patients 20 weeks or greater on their back, nor should chest or waist restraints be used
Restraints should be discontinued as soon as it is no longer indicated by the patient’s actions.

10. Patient basic needs must be attended to, including:
Documentation
Patient basic needs must be attended to, including:
Nutrition
Circulation
Range of motion
Hygiene
Elimination
Hydration
Document the following in Patient’s record in KP Health Connect:
Physician’s order
Initial assessment by the RN and 1 hour in-person evaluation by MD
Patient’s actions or condition that indicated the initial and continued use of restraint
Less restrictive alternatives considered
Patient monitoring and response to interventions used
Significant changes in the patient’s condition
Reassessment/observations, discontinuation of restraints
Education and information about restraints provided to the patient and family

11. Post Test

12. Quiz Answer True or False
Application of restraints should be the initial nursing intervention when caring for the confused or disoriented patient.
True False
Restraints are utilized to prevent disruption of treatment or significant harm to persons.
True False
The care of a patient in restraints requires more nursing time.
True False
Once restraints are applied, they are not to be removed by anyone without a physician’s order.
True False

13. Quiz Answer True or False
Bed rails can either be restraints or a protective device, depending on the intent of use.
True False
Use of restraints can be harmful to patients and can result in such outcomes as impaired skin integrity, incontinence, increased falls, etc.
True False
When appropriate, the use of alternatives is attempted in an effort to use restraints as a last resort.
True False
Reassessment is ongoing and occurs at a minimum of q 4 hours for patients in medical restraints in an effort to discontinue the restraints early whenever possible.
True False

14. Quiz Answer True or False
Four-point soft restraints for an actively suicidal patient requires the same 15-minute observation checks as leather or hard restraints.
True False
A physician’s order for a behavioral health restraint must be time specific with a maximum limit of 4 hours for the adult, 2 hours for children ages 9-17, and 1 hour for children 8 and under.
True False
RNs may discontinue restraints before the ordered time frame, but must obtain a new order if the patient again meets indications that justify restraint.
True False
RNs can apply a restraint without a physician order, but must obtain a verbal phone order within 1 hour of the initiation of the medical restraint.
True False

15. Select the Correct Answer
Quiz
Answer True or False
Bed rails should be used on all patient at all times to keep them from falling or getting out of bed.
True False
Select the Correct Answer
Which of the following observations intervals is incorrect?
Every 30 minutes for a patient in four-point restraints to prevent combative behavior.
Every 15 minutes for a patient in leather restraints for violent behavior to prevent injury.
Every 2 hours for a patient with soft wrist ties to prevent dislodgment of NG tube.
Every 2 hours for bed rails up on a patient to prevent them from continued wandering.

16. Select the Correct Answer
Quiz
Select the Correct Answer
Which of the following are types of protective devices and not considered restraints?
Portable table top chair to prevent the patient from slipping out of the chair.
Safety belt on a gurney.
Knee immobilizer.
All of the above.
The nurse should assess and address which of the following at least every two hours for patients who are restrained:
Hydration and nutrition
Hygiene and elimination
Continuance or termination of restraint
Circulation and ROM
All of the above.

17. Select the Correct Answer
Quiz
Select the Correct Answer
Which of the following is not a clinically justified use of restraints?
Patient continues to pull at the NG tube after reorientation and explanation.
Combative patient in DTs.
Patient is 75 years old and is weak and confused.
Patient removes abdominal dressing despite use of abdominal binder.
Which of the following is not an example of an alternative to restraint use?
Medicate patient to induce sleeping.
Tape foley to abdomen of male patient.
Provide adequate pain medication.
Use TV, radio, or music as diversion.

18. Select the Correct Answer
Quiz
Select the Correct Answer
A 9-year-old requires transport via gurney to radiology for a MRI. The gurney rails are placed in the up position. This is not considered restraint because:
Children are allowed to sit up in gurneys.
The child can see through side rails.
Side rails are to be up during patient transports of all types regardless of age and are a protective/safety device.
The child will be transferred to an exam table upon arrival so it doesn’t matter.
Which of the following employees would need documented competency for restraints?
A transportation aide that unties and reties wrist restraints for transport to radiology.
A physical therapist that releases and reties a patient restraint in order to exercise a patient.
A RN that monitors the patient in restraints.
An unlicensed assistant that removes and reapplies restraints to bathe a patient.
All of the above.