Restraints and Alternatives
Using Restraint Alternatives
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Safety
- Understand that accurate patient identification before any procedure is crucial to safety.
- Safety begins with the patient's immediate surroundings - make sure the patient and family know how to use the call light and bed controls to adjust patient position.
- When the bed is stationary, keep it in the low position with the wheels locked.
- Use appropriate strategies to reduce reliance on memory.
- Communicate observations or concerns related to hazards and errors to patients, families, and the health care team.
- Utilize multifactorial interventions that match the patients’ risks and behaviors.
Equipment
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Visual or auditory stimuli, such as a calendar, radio or MP3 player and pictures
Diversional activities, such as puzzles, games, audio books, and DVDs
Wedge Cushion(s)
Gait Belt
Activity or pressure-sensitive alarm
Activity or pressure-sensitive alarm
PrintableDelegation
The skill of assessing a patient’s behaviors and orientation to the environment and determining the type of restraint-free interventions to use cannot be delegated to nursing assistive personnel (NAP). Actions for promoting a safe environment, however, can be delegated to NAP. Be sure to inform NAP of the following:
- The use of specific diversional or activity measures for making the environment safe
- How to apply appropriate alarm devices
- The need to report to you certain patient behaviors and actions, such as confusion, combativeness, and getting out of bed unassisted.
Preparation
- Assess the patient’s medical history as it relates to dementia and depression.
- Assess the patient’s behavior, such as orientation, level of consciousness, ability to understand and follow directions, combative behavior, restlessness, and agitation; balance; gait; vision; hearing; bowel/bladder routine; level of pain; electrolyte and blood count values; and the presence of orthostatic hypotension.
- Review the patient’s over the counter (OTC) and prescribed medications for interactions and any untoward effects.
- Assess the patient’s knowledge of his or her health condition and the prescribed treatments.
- If the patient wanders or is diagnosed with dementia, use the Mini‒Mental State Examination (MMSE) to assess for cognitive decline.
- Assess the patient’s degree of wandering behavior by using the Revised Algase Wandering Scale(RAWS).
- If the patient has dementia, ask the family or the patient’s friends about the patient’s usual communication style and cues to indicate pain, fatigue, hunger, and the need to urinate or defecate.
Follow-up
- Observe the patient for any injuries.
- Observe the patient’s behavior toward staff, visitors, and other patients.
- Determine the need for continuation of invasive treatments, and evaluate whether you can substitute a less invasive treatment.
Documentation
- Record in the patient’s care plan the following:
- Types of restraint alternatives attempted
- Patient behaviors that relate to cognitive status
- Interventions to mediate the patient’s behaviors
Review Questions
1. The nurse has one bed alarm available and can use it for any of the following patients, all of whom have dementia. Having an alarm is most important for which patient?
A patient who has refused most meals for the past week and whose weight has dropped by 10% in the past month - A patient who has become verbally combative with staff in recent weeks
A patient who was returned to the unit last week by staff in an adjacent assisted living facility- A patient whose abdominal feeding tube is covered with an abdominal binder
INCORRECT. The nurse will use the alarm for the patient who has recently been found wandering. Refusal of meals and associated weight loss are not addressed by placement of a bed alarm.
INCORRECT. The nurse will place the alarm on the patient who has recently been found wandering. This patient's combativeness is not necessarily associated with attempts to get out of bed without assistance, nor does it necessarily correlate with a higher risk of falling.
CORRECT. The nurse will use the alarm for the patient who has recently been found wandering.
INCORRECT. The nurse will use the alarm for the patient who has recently been found wandering. The presence of a feeding tube, disguised or not, does not increase the likelihood that the patient will try to get out of bed without assistance.
2. When caring for a patient with Alzheimer’s disease, why does the nurse cover the external urinary collection catheter?
- To protect the bed from being soiled
- To avoid offending visitors who would otherwise see the device
- To reduce the patient’s access to the device
- To keep the patient from trying to get out of bed alone
INCORRECT. When caring for a patient with Alzheimer’s disease, the nurse may camouflage the external urinary collection catheter to reduce the patient’s access to the device. Covering the device does not protect the bed from being soiled.
INCORRECT. When caring for a patient with Alzheimer’s disease the nurse may camouflage the external urinary collection catheter to reduce the patient’s access to the device. Visitors' sensibilities are not relevant.
CORRECT. When caring for a patient with Alzheimer’s disease, the nurse may camouflage the external urinary collection catheter to reduce the patient’s access to the device.
INCORRECT. When caring for a patient with Alzheimer’s disease, the nurse may camouflage the external urinary collection catheter to reduce the patient’s access to the device. Unassisted ambulation attempts are an unrelated problem.
3. Which nursing action is the most therapeutic in response to a cognitively impaired patient who demands to know when his daughter is coming to visit?
- Marking the date of the visit on the patient’s wall calendar
- Evaluating the patient’s understanding of the concept of time and date
- Telling the patient when his daughter will be visiting and ensuring that he verbalizes his understanding
- Calling the daughter to suggest that she visit sooner than she had planned
CORRECT. Marking the date of the visit on the patient’s wall calendar is the most therapeutic option, because it will serve as a permanent visual cue to remind the patient of the date each time he becomes anxious about his daughter's visit.
INCORRECT. This is not the correct option, because the patient’s deficiencies have already been determined.
INCORRECT. Discussing the date of the visit with the patient is not the correct option because, even if the patient momentarily understands and can be reassured, it is likely that his anxiety or disorientation will return.
INCORRECT. Persuading the patient's daughter to hasten her visit is not the correct option, because it does not address the patient’s anxiety regarding the date of her visit.
4. The nurse wants to offer some diversional activity to a patient with dementia. The patient's family has told the nurse that he is a bit of a loner who enjoyed a 40-year career as an aircraft mechanic. The patient seems frustrated and bored. What is the best activity for the nurse to offer him?
- Weekly pet therapy with a golden retriever
- A jigsaw puzzle of an appropriate level of difficulty
- A crossword puzzle book of an appropriate level of difficulty
- Frequent card games with other patients
INCORRECT. Pet therapy would offer this patient tactile stimulation, but the activity would not be frequent enough to relieve his boredom.
CORRECT. A jigsaw puzzle is a good choice, because it is a solitary activity that offers tactile stimulation and engages the patient's mental faculties, attributes that are likely to be familiar and pleasurable to him.
INCORRECT. Doing crossword puzzles is an appropriately solitary activity for this patient, but it offers little tactile stimulation; in addition, a word puzzle is unlikely to appeal to this mechanically inclined patient.
INCORRECT. The family has told the nurse that the patient prefers to keep to himself, so social interaction is unlikely to provide meaningful, welcome stimulation that will relieve his boredom and frustration.
5. Which statement made by nursing assistive personnel (NAP) assigned to care for a patient with dementia requires the nurse to follow up?
- "I encouraged his son and daughter-in-law to stay with him during visiting hours, if possible, even if they run out of things to talk about."
- "He can't see his Foley because it's covered by his boxer shorts."
- "I'll ask the patient every hour or so whether he needs to use the bathroom."
- "He doesn't understand much of what anyone says to him today, so I didn't put in his hearing aids."
INCORRECT. This statement is appropriate, because having familiar visitors for extended periods helps orient the patient to his environment and decrease anxiety and restlessness.
INCORRECT. This statement is appropriate, because positioning catheters, tubes, and drains out of sight reduces the patient's access to them, allowing medical treatment to be administered without interruption.
INCORRECT. This statement is appropriate, because being offered an opportunity to void regularly reduces the likelihood that the patient will try to reach the bathroom alone.
CORRECT. This statement requires the nurse to follow up, because the patient will become all the more disoriented if he cannot hear what is going on around him.
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