Restraint alternatives

 

Restraint alternatives

Some persons need extra protection. They may present dangers to themselves or others. For example:

·      Ms. Perez needs help with getting up and with walking. She forgets to call for help. Falling is a risk.

·      Ms. Wilson tries to pull out her feeding tube. The tube is part of her treatment.

·      Ms. Walsh scratches and picks at a wound. This can damage the skin or the wound.

·      Mr. Ross wanders. He may wander into traffic or get lost in neighborhoods, parks, forests, or other areas. Exposure to hot or cold weather presents other dangers.

·      Mr. Winters tries to hit, pinch, and bite the staff. They are at risk for harm.

The RN uses the nursing process to decide how to best meet the person's safety needs. In nursing centers, a resident care conference is held. The health team reviews and updates the person's care plan. Every attempt is made to protect the person without using restraints. Sometimes they are needed.

A restraint is any item, object, device, garment, material, or drug that limits or restricts a person's freedom of movement or access to one's body. Restraints are used only as a last resort to protect persons from harming themselves or others.

HISTORY OF RESTRAINT USE

Until the late 1980s, restraints were thought to prevent falls. Research shows that restraints cause falls. Falls occur when persons try to get free of the restraints.

 

Injuries are more serious from falls in restrained persons than in those not restrained.

Restraints also were used to prevent wandering or interfering with treatment. They were often used for persons who showed confusion, poor judgment, or behavior problems. Older persons were restrained more often than younger persons were. Restraints were viewed as necessary protective devices. Their purpose was to protect a person. However, they can cause serious harm. They can even cause death.

OBRA, the Centers for Medicare & Medicaid Services (CMS), and the federal Food and Drug Administration (FDA) have guidelines about restraint use in hospitals and nursing centers. So do states and accrediting agencies. They do not forbid restraint use. However, all other appropriate alternatives must be tried first.

Every agency has policies and procedures for restraint use. They include identifying persons at risk for harm, harmful behaviors, restraint alternatives, and proper restraint use. Staff training is required.

RISKS OF RESTRAINT USE

·      Agitation

·      Anger

·      Bruises

·      Constipation

·      Cuts

·      Dehydration

·      Depression

·      Embarrassment

·      Fecal incontinence

·      Fractures

·      Humiliation

·      Mistrust

·      Nerve injuries

·      Nosocomial infection

·      Pneumonia

·      Pressure ulcers

·      Strangulation

·      Urinary incontinence

·      Urinary tract infection

 

RESTRAINT ALTERNATIVES

Often there are causes and reasons for harmful behaviors. Knowing and treating the cause can prevent restraint use. The RN tries to find out what the behavior means. This is very important for persons who have speech or cognitive problems. The focus is on these questions:

·      Is the person in pain?

·      Is the person ill or injured?

·      Is the person short of breath? Are cells getting enough oxygen?

·      Is the person afraid in a new setting?

·      Does the person need to urinate or have a bowel movement?

·      Is a dressing, bandage, or binder tight or causing other discomfort?

·      Is clothing tight or causing other discomfort?

·      Is the person's position uncomfortable?

·      Is the person too hot or too cold?

·      Is the person hungry?

·      Is the person thirsty?

·      Are body fluids, secretions, or excretions causing skin irritation?

·      Is the person seeing, hearing, or feeling things that are not real?

·      Is the person confused or disoriented?

·      Are drugs causing the behaviors?

Restraint alternatives for the person are identified. They become part of the care plan. The health team follows the care plan. Care plan changes are made as needed. Restraint alternatives may not protect the person. Then the doctor may need to order restraints.

Alternatives:

·      Diversion is provided. This includes TV, videos, music, games, books, relaxation tapes, and so on.

·      Lifelong habits and routines are in the care plan. For ex-ample, showers before breakfast; reads in the bathroom; walks outside before lunch; watches TV after lunch; and so on.

·      Family and friends make videos of themselves for the person to watch.

·      Videos are made of visits with family and friends for the person to watch.

·      Time is spent in supervised areas (dining room, lounge, near nurses' station).

·      Pillows, wedge cushions, posture, and positioning aids are used.

·      The signal light is within reach.

·      Signal lights are answered promptly.

·      Food, fluid, and elimination needs are met.

·      The bedpan, urinal, or commode is within the person's reach.

·      Back massages are given.

·      Family, friends, and volunteers visit.

·      The person has companions and sitters.

·      Time is spent with the person.

·      Extra time is spent with a person who is restless.

·      Reminiscing is done with the person.

·      A calm, quiet setting is provided.

·      The person wanders in safe areas.

·      The entire staff is aware of persons who tend to wander. This includes staff in housekeeping, maintenance, business office, dietary, and so on.

·      Exercise programs are provided.

·      Outdoor time is planned during nice weather.

·      The person does jobs or tasks he or she consents to.

·      Warning devices are used on beds, chairs, and doors.

·      Knob guards are used on doors.

·      Padded hip protectors are worn under clothing.

·      Floor cushions are placed next to beds.

·      Roll guards are attached to the bed frame.

·      Falls are prevented.

·      The person's furniture meets his or her needs (lower bed, reclining chair, rocking chair).

·      Walls and furniture corners are padded.

·      Observations and visits are made at least every 15 minutes.

·      The person is moved closer to the nurses' station.

·      Procedures and care measures are explained.

·      Frequent explanations are given about required equipment or devices.

·      Persons who are confused are oriented to person, time, and place. Calendars and clocks are provided.

·      Light is adjusted to meet the person's needs and preferences.

·      Staff assignments are consistent.

·      Uninterrupted sleep is promoted.

·      Noise levels are reduced.