00:02
Hi! I’m Jessica Spellman. This is the Ws
of using restraints, the who, what, when,
and how to use restraints. After taking this
course, you will be able to define a restraint
and be able to give examples. Understand what is
needed to initiate, intervene, and discontinue
restraint orders. Explain the nurses’ role
and caring for a patient with a restraint.
00:28
Recall the proper legal documentation that
must be present when caring for a patient
with restraints. So let’s start with the
definition of a restraint. A restraint is
a means of unreasonably limiting freedom of
movement. And this can be done in several
ways. There are four types of restraints.
The first is physical, mechanical, chemical,
and using seclusion. A physical restraint.
A physical restraint is when you’re holding
a patient in a manner in which his or her
movement is restricted. An example would be
a patient is confused and attempting to hit
you with their hand. So you hold their hand
and/or wrist to prevent being hit. This is an
example of a physical restraint. A mechanical
restraint. When we limit a patient’s movement
but we use a device to do so. So an example
of that would be applying wrist restraints to
prevent a patient from extubating themselves.
01:33
A chemical restraint. This is when we use
a medication for the purpose of restraint
instead of treatment. So an example would
be using a medication to sedate a patient
so they cannot pull out tubes or lines or
if they’re combative. And then the use of
seclusion is when we place the patient alone
in the room so they cannot communicate or
see any staff or patients. As long as the
patient believes they cannot get out of the
room, it is considered seclusion. It’s important
that in a licensed operator or contracted
department of mental health facility, that
a mechanically strained patient may not be
placed in seclusion. So those are two types
of restraints that cannot be used together.
02:19
Otherwise, we can combine these and do physical
restraints and chemical restraints, but seclusion
is not one that can be used with physical
restraints. I just wanted to make an
important point. So when can restraints be
used? The appropriate use of restraints is
to prevent harm for patients and to prevent
imminent violence to others.
02:48
Inappropriate ways that we try to avoid using restraints
for, are to punish or attempt to modify patient
behavior. For example, saying, “If you continue
to do X, Y, and Z, I’m going to have to
restrain you.” We don’t want to threaten
patients with the use of restraints. We don’t
want to use restraints for staff convenience.
And we don’t want to use restraints on as
needed or PRN basis. Restraints should be
considered only after all other less restrictive
alternatives have been determined to be ineffective.
So once we determine that somebody needs restraints,
who may order the restraints? They do require
an order by a physician or another independent
practitioner. However, nurses may go ahead
and initiate the use of restraints if the
patient is in danger of harming themselves or
others. After the initiation, it is appropriate
that within an hour that a physician must
evaluate the patient in order to determine
whether the restraints are continued to be
necessary. Verbal orders cannot take the place
of the physician evaluating the patient. It
must be determined to be the most appropriate
method of restraining the patient. It may
be issued over the phone by a physician that
has previously examined the patient, but that
must be given directly to a registered nurse.
04:15
So if the patient has not been seen by that
physician, that physician cannot be called
in or called over the phone to initiate a
verbal order for restraints. Medication
the physician ordered must have been given
previously to the patient. We cannot initiate
new medication orders over the phone. And
then the treating physician must be contacted
as soon as possible if he or she did not order
the restraint. So just to clarify this, if
there is an on-call physician on night shift
that comes and sees the patient and orders
the initial order for restraints, the treating
physician or attending physician still needs
to be contacted about the restraint order.
So, how long can we use restraints? Initial
restraint orders are valid for three hours. At
three hours, the nurse or physician assistant
or authorized physician representative may
continue the order if the rationale for the
use of the restraints still exists. At six
hours, the physician must examine the patient
and determine if the order should be renewed.
The maximum amount of time restraints or seclusion
may be used is eight hours and a 24-hour period.
If the physician determines that they should
be used longer than that, a new order must
be written every 24 hours. So, why should
restraints be discontinued? When the emergency
no longer exists, the patient must be released
from the restraints or the seclusion. Second,
the patient needs to be calm. And third, the
patient does not present a threat to himself
or herself or the staff. So as nurses, what
do you need to document when you have a patient
in restraints? The first thing you want to
document is the situation that initiated the use
of the restraints. You also want to document
who was contacted and what orders you received
from that individual. You want to document
the time the restraints were initiated, how the
nurse is maintaining safety for the restrained
patient, and any other interventions the nurse
is performing to calm the patient.
06:35
Ongoing and frequent assessments are part of the documentation
that nurses need to record. What is important
to include, specifically is circulation checks
to the extremities. We’re looking for a
pulse, the color or the pallor, the polar
whether it’s cold or warm. The paresthesia
whether it’s numb or have normal sensation.
Paralysis, can they move their extremities,
and if there’s pain. These are called the
six Ps of the circulation checks- they're pulse,
pallor, polar, paresthesia, paralysis, and
pain. How can nurses protect patients that
are in restraints? The patient must be fully
clothed to maintain their dignity. And they
must be offered a urinal or bedpan, or access
to the bathroom. In addition, they really
need to be observed continually or at least
every 30 minutes in order to determine if
the restraint or seclusion still needs to
be used. They also need to be informed of
the rationale for the restraints as well as
provided interventions to assist with maintaining
their emotional anxiety. Let’s review what
we’ve learned about restraints.
07:54
We’ve learned what they are. There are several types
of restraints- physical, mechanical, chemical,
and seclusion. Who may use restraints? Nurses
may initiate the order, but the physician
must evaluate the patient within an hour of
initiation. How long do we use restraints
for? The least amount of time possible. How
do we document the use of restraints? We document
the time the restraint was initiated, the physician
that was contacted and orders received,
how the nurse is maintaining patient safety
while in restraints, and we need to perform
circulation checks; the pulse, pallor, polar,
paresthesia, paralysis, and pain of the extremities
that are being restrained. This has been the use
of using restraints, and I’m Jessica Spellman. Thanks.