Transcript Restraints and Prevention of Fall

Use of
Protective Restraints
and
Prevention of Falls
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Understanding how to provide a safe
environment for the patient is
fundamental for nursing practice.
No matter what type of patient you care
for, safety is a high priority. One of the
most common risks is that of fall.
It is important that nurses be aware of the
potential for injury and promote safety at
all time.
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Risk for injury: fall RT:
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The patient will:
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Definition:
◦ A physical or mechanical device used to limit or
prevent a patient’s movement.
◦ FDA – device that limits movement to the extent
necessary for treatment, examination, or
protection of the patient
Most commonly used to:
1. Prevent the client from falling and
sustaining injury
2.
Position and protect patient during
treatments and to maintain ongoing care
3.
Protect patients who are combative and
agitated and may cause harm to self or
others
The use of restraints is
generally not
advocated and should
be used only as a last
resort
1. Mechanical/Physical
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Wrist, ankle, elbow restraints
Mitten restraints
Belts
Locked leather
**Use of vest restraints is no longer advocated
2. Chemical
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Medications used to calm an individual’s
behavior – tranquilizers and hypnotics
3. Environmental
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Side rails
Locked units
Locking devices on wheelchairs
Grab bars
 Emotional
issue on the
part of the patient,
family, and staff
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The patients response to being restrained is
rarely submissive
Many view restraints as a personal physical
assault, and are frightened, and respond by
becoming combative.
The application of restraints may subject the
nurse to allegations of false imprisonment,
battery, and lack of informed consent.
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The Joint Commission has identified misuse of
protective restraints as one of the main sentinel
events (unexpected occurrence involving death or
serious physical or psychological injury, or the risk
thereof).
Since the Joint Commission began tracking sentinel
events in 1996, the Accreditation Committee of the
Joint Commission's Board of Commissioners has
reviewed many cases related to deaths of patients
who were being physically restrained. Most of the
events occurred in psychiatric hospitals, followed
by general hospitals and long term care facilities.
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Death related to the misuse of protective
restraints were mainly due to:
◦ asphyxiation while in restraints
◦ Strangulation
◦ Cardiac arrest
◦ Fire
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Increase the monitoring frequency
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Provide a familiar environment
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Prevent the need to get out of bed unassisted
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Institute Safety Measures
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Change the treatment Plan
See Box 23-1 for details
pp. 559
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The order must clearly define:
◦ the type of restraint to be used
◦ The Purpose of the restraining device
◦ A Time limit
 What
do I do if the patient
needs a restraint and I do
not have a physician’s
order?
a.
Patient’s behavior that supported the
need for the restraint and what was used
before applying restraints
b.
Type of restraint used
c.
Explanation of purpose of using the
restraint to the patient and or family
d.
If patient or family refuses the restraint
e.
Exact time that the restraint was
applied
f.
Continued assessment of the patient
every 2 hours
g.
Care given while in the restraint
h.
Notification of the physician
The Joint Commission found that some of
the main reasons that patients died while
in restraints was that the staff had:
 insufficient training
 lack of competence
in the use of restraining devices and
monitoring of patients while restrained.
1.
Apply ONLY for the safety of the patient, NEVER for
convenience of the nurse
2.
Apply with care to avoid damaging tissue and
causing harm to the patient
3.
Recognize the physiological and psychological
effects of applying restraints
4.
Explain reason to the patient and family
5.
Review the policy and procedure manual
6.
Choose the restraint that fits the need
7.
Check on the patient every 2 hours
8.
Maintain proper body alignment
9.
Never tie to the side rails—always on the frame
10.
Be sure does not interfere with proper
functioning of tubes or equipment
11.
Must have a quick release!! Never knotted
12.
Never restrain a patient with decreased level of
consciousness on his back with limbs restrained
on either side
 Food
and Drug
Administration requires
that manufacturers label
“prescription only” to
decrease the number of
restraint- related injuries
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Increase risk of falls
Hydrostatic pneumonia
Skin abrasions, edema, pressure injuries
Ischemia and nerve damage
Contractures from immobility
Shoulder dislocation
Loss of self esteem, humiliation, fear and
anger
Death via strangulation, asphyxia,
entrapment, fire
Try alternative measures
If absolutely necessary to use –
Follow the Safety Measures and Guidelines
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See Procedure in Harkreader p. 556-558.
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Falls are a common cause of morbidity and the
leading cause of nonfatal injuries and trauma-related
hospitalizations in the United States.
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Falls occur in all types of healthcare institutions and
to all patient populations.
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In hospitals, falls consistently make up the largest
single category of reported incidents.
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Nearly half of all residents in nursing homes fall each
year, with many sustaining fractures.
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In order to increase patient safety the Joint
Commission designated a National Patient
Safety Goal on reduction of risk of harm from
falls:
Goal 9
◦ Reduce the risk of patient harm resulting from
falls.
◦ 9B ◦ Implement a fall reduction program including an
evaluation of the effectiveness of the program.
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Definition of a Fall
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A fall is defined as a sudden, uncontrolled,
unintentional, downward displacement of the body to
the ground or other object, excluding falls resulting
from violent blows or other purposeful actions.
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A near fall is a sudden loss of balance that does not
result in a fall or other injury. This can include a person
who slips, stumbles or trips but is able to
regain control prior to falling.
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An un-witnessed fall occurs when a patient is found on
the floor and neither the patient nor anyone else knows
how he or she got there.
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Patients should be assessed for their fall risk:
◦ On admission to the facility
◦ On any transfer from one unit to another within the
facility
◦ Following any change of status
◦ Following a fall
◦ On a regular interval, such as monthly, biweekly or
daily
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There are many risk assessment tools available. The
Hendrich Fall Risk Assessment is one example:
Risk Factor
Recent History of Falls
Altered Elimination
(incontinence, nocturia, frequency)
Confusion / Disorientation
Depression
Dizziness / Vertigo
Poor Mobility / Generalized Weakness
Poor Judgment (if not confused)
Scale
Score
Yes
No
Yes
7
0
3
No
Yes
0
3
No
Yes
No
Yes
No
Yes
No
Yes
No
0
4
0
3
0
2
0
3
0
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Orient to new surroundings
Keep two side rails up (depending on policy)
Keep call light, bedside table, water, glasses, etc.
within easy reach
Use a night light
Keep bed in low position
Make sure patient has non-skid footwear
Teac fall prevention techniques
Ambulate only with assistance when appropriate
Locate patient close to the nurses station