Lawful Requirements & Nursing Actions for Using Restraints

According to (JCAHO) Joint Commission on ACCREDIATATION OF

HEALTHCARE ORGANIZATIONS

according to the agencies policies.

Restraints should not interfere with any treatments or affect the client’s health problems.
Document the following:

Reason for the restraints

Method of restraints

Date and time of application

Duration of use and clients response

Release from the restraints (every 30 minutes) with periodic exercise and

Circulatory, neurovascular and skin assessment

Evaluation of client’s response

6. DON’T ASK PERMISSION IF THE PATIENT HAS AN ALTERED LEVEL
OF CONSCIOUSNESS!!!

7. If the client is unable to give consent to a restraint procedure, then consent of proxy

must be obtained AFTER FULL DISCLOSURE OF ALL RISK AND BENEFITS.

8. Use a clove hitch knot so that restraint can be changed and release easily and ensure

that there is enough slack on the straps to allow some movement o the body part.

9. Never secure restraints to bed rails or mattress. Secure restraints to parts of the bed or

chair that will move with client & not constrict movement.

ALTERNATIVES TO RESTRAINTS

Before restraints offer explanations, ask someone to stay with the client, use clocks, calendars, TV & radio ( to decrease disorientation) or any relaxation techniques.
Use LESS restrictive methods first. RESTRAINTS should always be the last.
Assign confuse and disoriented clients to rooms near the nurse’s station.
Maintain toileting routines & institute exercise and ambulation schedules as the client

condition allows.

QUESTION: Can I put restraints on a patient who is combative I there is no order for this?

Only in an EMERGENCY, for a limited time (no longer than 24 hours)

For the limited purpose of protecting the patient from injury – NOT FOR

CONVENIENCE OF Personnel. Notify the attending MD immediately, consult

with another staff member, obtain patients consent if possible, and get a co-

worker to witness the record. RESTRAINTS OF ANY DEGREE MAY CONSTI-

TUTE FALSE IMPRISONEMENT. Freedom from any UNLAWFUL restraint is a

Basic human right protected by law. In July 1992 the FDA (Food and Drug Admi-

nistration) issued a warning that the use of restraints is – NO LONGER

REPRESENTS RESPONSIBLE PRIMARY MANAGEMENT of a client’s

behavioral problem.

Nurse Care Plan