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restraints/falls
foundations exam 3
| Question | Answer |
|---|---|
| restraint | physical devices or chemical means to limit a patients freedom and movement that cannot be easily removed by the patient |
| federal guidelines regarding restraints | restraints can only be used to protect the patient, staff, and others; requires an order from a licensed healthcare provider (HCP) and face to face assessments |
| What can be considered a restraint? | if you close the door on a demented patient so they don't wander |
| alternative options for restraints | 1:1 sitters, cameras in room, involve family members, reduce stimulation; redirect w/ calming voice, use simple explanations; check environment for hazards, use electronic alarm system, allow pt to walk, use low-height beds, move closer to nurses station |
| examples of restraints | side rails (4 sides up), geri chairs with attached try, ankle, wrist, waist, mitts, leathers, chemical (medications), barricading a doorway, physical holding |
| negative effects of physical restraints | skin breakdown, contractures, incontinence, depression/anxiety, delirium, aspiration, death |
| What can cause contracture? | immobilizing joints |
| ordering restraints | need an order from MD (PA or CRNP) within one hour, unless serious risk to your patient |
| Are there restraints prn orders? | no |
| How often do you need to renew restraints? | every 24 hours |
| How many types of restraints can you use at one time? | 1 |
| What should a restraint order include? | the type of restraint, justification for the restraint, criteria for removal |
| Important notes about restraints | never spread eagle, side rails are restraints if all 4 are up, geri chairs can be a restraint |
| How many fingers do you have to fit between restraints? | 2 |
| leathers | should rarely be used- requires specific orders and assessments; seen in ER and psych |
| chemical restraint | haloperidol |
| How to protect IVs without using a restraint | wrap IV with gauze |
| What could cause patients to act out? | pain, respiratory status, vital signs, blood glucose, fluid and electrolyte issues, medications |
| What can problems with vision and hearing cause? | hospital induced delirium |
| How to reduce risk of hospital induced delirium? | ensure the use of glasses and hearing aids |
| How can you use pillows to protect the patient? | wedge against side of chair to keep patient positioned safely or to indicate edge of bed |
| leading cause of fatal and nonfatal injuries in persons 65 years and older | falls |
| In the hospital, older adults are ___more likely to have a fall than younger patients | 50% |
| What happens after a fall? | higher risk for increased hospital length of stay, decreased mobility, increased mortality, increased likelihood for discharge to a long-term care facility |
| Can you use restraints to decrease fall risk? | no, they can increase the possibility of serious injury due to a fall |
| reduce fall risk | room near nurses' station, call bell at side, personal items within reach, hourly rounding, reminders to call for assistance OOB, bed/chair alarms, non-skid footwear/slippers, alert staff to fall risk |
| What type of restraint should be the first option? | the least restrictive |
| If you have to put restraints on your patient what should you do? | notify family member or contact person |
| negative outcomes associated with restraint use | skin breakdown, contractures, incontinence, depression, delirium, anxiety, aspiration and respiratory difficulties, death |
| care of patient in restraints | routine "toileting", circulation check q2 or more, two finger check for tightness, remove and do ROM q2, food and water, proper documentation, attach to frame not side rail |
| Federal guidelines reinforce that in all settings, the primary responsibility is to... | protect and promote patient's rights |
Created by:
camrynfoster