Registered Nurse Care of the

Restrained Patient




Registered Nurse Care of the Acute
Medical Surgical Restrained Patient

Non Violent, Non Self-Destructive
Patients
Restraint Course Objectives
Provide Examples of Low Level Interventions &
Restraint Products
Identify Patient Care & Monitoring for the
restrained patient
Describe the RN role for the use of restraints in
the med/surg patient population
Describe the RN role in the use of restraints for
the patient behavior population
Review changes in hospital policy
Background
Patient restraint use is highly regulated by the
State of Colorado, The Joint Commission,
and Centers for Medicaid and Medicare
(CMS)
Why such tight regulation?
Patients die from restraint use; small # annually
but impact severe
Ethical issue: patient rights compromised
Adverse events w/restraint use: skin tears in
elderly, injury, emotional distress
UCH Philosophy on Restraints
Avoid use whenever possible
UCH goal: a restraint-free environment
Team working together essential to avoid
restraint use
Respect and dignity drive our care: Patients
and families first.
Sometimes, despite our best efforts..
Reality in Acute Care Settings

Restraints may be needed to protect patient
lives, continue medical treatment.

Regulations must be followed for patient
safety!
Different policies and
Order Sets
Medical/ Surgical
Management
-Used for the medical/surgical and
ICU non-violent, non self-
destructive patients
-This includes patients that are
pulling at essential lines,
confused, and cannot follow
directions needed for safe
medical/ surgical care.
Behavior/ Violent
Management
-Used for a patient who is
attempting to harm himself or
others who cannot be calmed by
other methods.
- This includes patients that have
violent behavior, aggression,
combative, and unanticipated or
known danger to self (suicidal), or
others.


Differences between med/surg
and behavioral policies
Med/ Surg restraints
expire every 3 days
Restraint use does not
require the use of
security personnel
A restraint must be
assessed every 15
minutes
Chart restraint
assessment every 2
hours
-Behavioral restraints must be
evaluated and renewed every 4
hours
-Seclusion can be used for the
confinement of a patient to
prevent imminent injury to self or
others
-There must be continuous 1:1
face to face monitoring to ensure
patient safety.
-The constant observer must
keep a log of patient behavior
every 15 minutes

Medical/ Surgical Restraint Behavioral Restraints
Low Level Interventions
Communicate with all team members including the pharmacist, RN, MD to
adjust/change dosages and types of medications
Diagnostic labs to detect potential infections
Work w/patient family to plan how to manage dementia, disorientation,
confusion
Determine if a family member can help to watch their loved one Move the
patient closer to the care team station
Create a diversion such as an activity apron or folding washcloths
Move the patient closer to the care team station
Frequently reorient the patient to their surroundings
Low Level Equipment
These items are not restraints and do not
require a restraint order
One freedom splint Untied mitt(s)
(Fingers can be covered, 2 mitts ok)
Document use in narrative; monitor outcomes
Low Level Equipment
Distraction: Posey
Apron
Skin sleeves to
hide IV line(s)
IN PERSON ASSESSMENT

MD or RN in person patient assessment must be
done prior to applying restraint and/or a restraint
order
Confirm the correct restraint order-set used
Regardless of type of restraint, the RN or MD
must evaluate patient within one hour of the
initiation of the restraint to assure the
restrained patient is safe and restraint is
necessary
Types of Restraint Orders
Acute Medical Surgical Restraint Orders
MD must do a face to face assessment no later
than 24 hours, preferably sooner
This type of restraint order is in effect for 3 days
In person assessment must be done to renew
order: is restraint still needed?
Goal: to eliminate restraint as soon as possible
4
th
Side Rail

4
th
side rail up does not require a restraint order if it
is used in the following ways:
Specialty bed surfaces elevating patient
ICU and med/surg units may require 4
th
side rail
as protective device so patient does not fall out
of bed
ED and Procedure Areas
Restraint Orders
The only restraint order an RN can initiate is an
emergent telephone order when the MD is
driving or in a procedure
The RN applies the restraint, then pages MD
MD: must co-sign order within 24 hours
PRN ORDERS ARE NEVER ACCEPTABLE
RN/MD cannot write anytime or as necessary
or continuous
Attending Notification



CMS: requires Intern or Resident MD/LIP to inform
Attending MD of restraint ASAP but no later than 24 hours
for a medical surgical restraint
TYPES OF RESTRAINTS

UCH uses Posey brand restraints:
The least restrictive type restraint should be used based on
assessment of patient condition
Types of restraints for acute medical surgical restraint use
are: limb restraints, tied mitts, vest restraint, two freedom
splints, or a canopy bed. Review order sheet.
Types of Restraints
Order Required!
Enclosed Bed
If the 4
th
Side Rail
is used as a restraint
instead of a fall prevention
Types of Restraints
Order Required!
Posey Vest Posey Limb Holder
Types of Restraints
Restraint order required!
TWO freedom splints TIED mitt(s)
ANY Tied Mitt
Safe Restraint Application
Restraints are a regulated medical device; report
any problems to risk management 4-RISK
Select correct size and type: least invasive
Restraints must be tied to the bed frame
Use quick release tie; never apply when pt. face down. Two
persons must apply an acute med surg/ICU restraint
Restrained Patient Care
RN and MD are safety net and security for patient in restraint
Special restraint care:
Head of bed elevated; feed upright
Watch for any patient distress: airway clear
Circulation unimpaired (one finger between skin and restraint)
Skin integrity maintained- must remove restraint to assess skin
Body aligned properly and safely
Range of motion exercises q 2 hours
Nutrition, fluids, toileting needs met
Assess pain, discomfort
Maintain privacy and dignity
Vital signs, other cares as ordered or required
Assess for restraint removal; Use procedure sheet attached to the order
forms.
Rules to Remember
If a restraint is discontinued, but later reapplied, a
new order must be initiated.
There are no dangling restraints permitted;
restraints on or off
If restraint removed, and later needs to be reapplied,
a new MD order is required!
An MD,LIP, or RN can discontinue a restraint
order This is a requirement of regulations and the
EPIC computer system
PATIENT AND FAMILY ROLE

UCH practices patient and family centered care. Patient &
family need explanation of restraint, criteria for release.
RN or MD must notify family ASAP but no later than end of shift

Patient and family education must be documented
Document Care Accurately
Medical/ Surgical Restraints
RN is responsible for the monitoring and care of the
restrained patient
Restraints must be assessed every 15 minutes
You must document ongoing care monitoring
every 2 hours
You may delegate monitoring, but must assure it
happens safely and is documented
Care of the restrained patient is regulated and audits
review care by computer and regulatory visits.
Document Care Accurately
Behavioral/ Seclusion Restraints
Require the RN or delegated trained provider to
conduct continuous 1:1 face to face monitoring
Monitoring requires the constant observer to
keep a log of patient behavior every 15 minutes,
ensuring documentation of the observation is
maintained
RN must monitor restraint/seclusion use and
supervise the 1:1 face to face monitoring of the
trained observer, at a minimum of every one
hour time period
Changes this year in restraints include:
a. Two policies
- University of Colorado Health System
- University of Colorado Hospital
b. RNs can also discontinue all restraints orders.
c. Family must be educated at least once regarding
the use of restraints.
d. Acute Med/Surg restraints are active for 3 days.
e. The 4th side rail is not a restraint if it is used to
prevent a patient from falling out of bed.
Conclusion
Thank you for reviewing this module.
You will take an assessment of what
you have learned. You must pass the
post test with a score of 100%.

Please close this module by pressing
the exit tab in the
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