Restraints

What are Restraints? Restraints are

physical, chemical or environmental measures used to control the physical or behavioural activity of a person or a portion of his/her body.

LawsPolicies of the Ministry of Health and Long-Term

Care that are binding on long-term-care facilitiesStatutes and regulations of Ontario that govern

the use of restraints in facilities (the Charitable Institutions Act, the Nursing Home Act, the Homes for the Aged and Rest Homes Act)

The common law, which includes among various civil wrongs the torts of battery, assault and false imprisonment

The Criminal Code of Canada, which includes criminal offences.

The Canadian Constitution, which includes the Canadian Charter of Rights and Freedoms.

Risks of Restraints Falls Strangulation Loss of Muscle tone Pressure sores Decreased mobility Agitation Reduced bone mass Stiffness Frustration Loss of Dignity Incontinence Constipation

Risk without Restraints Falls Safety of self and others

Kensington Gardens Policy

The Home practices a philosophy of Least Restraint.

Who? What? Why? How? When?

Least restraint means all possible alternative interventions are exhausted before deciding to use a restraint.

This requires assessment and analysis of what is causing the behaviour. All behaviour has meaning. When the reason for the behaviour is identified, interventions can be planned to resolve whatever difficulty the resident is having that contributes to the consideration of restraint use.

Kensington Gardens Policy

Restraint Assessment Form must be completed prior to initial application of the restraint.

Assessment Tools

 

Behavioural Map Aggressive Behaviour

Risk Assessment   Cohen-Mansfield

Agitation Inventory   Continence Assessment TENA incontinence

product evaluation   

Environmental Improved or altered lighting     Path cleared in resident's

room/on unit     Cloth barrier across

doorway     Comfortable room

temperature     Privacy and dignity     Environment personalized     Wanderguard applied    Moved to secure unit     Night light    

Safety

Positioning of pillows     Bed height lowered     Call bell within easy

reach Bed, Chair or Seatbelt

Alarm   Side rails     Floor pad beside bed   

Toileting and Continence

o Individualized toileting routine    

o Product change    o Identify bathroom using

signs/symbols    o Commode at bedside    o Urinal at bedside    

Direct Care

One to one supervision/support     Medical conditions, i.e. infections     Individualized daily routine     Move resident closer to RHA

Infomation Centre     Facilitate rest periods     Limit time spent in bed     

Direct Care Continued Apply glasses and/or

hearing aides     Use ambulatory aides as

per Care Plan     Evaluate medical

interventions i.e. catheter, feeding tube    

Provide cues during care/activities

Physiological Interventions

Treatment of the underlying pathology, i.e. medication ordered    Pain management    Medication review    

Psychological• Companionship   • Active listening     • Increase family/friends visiting    • Consistent staffing    • Encourage staff one to one activities    • Familiarization with the environment    • Behaviour management intervention    • Alter sensory stimulation     • Remove to a quiet area    • Relaxation techniques     

Life Enhancement & Programs

Teach safe transfer techniques to resident/family/responsible party    

Walking and exercise programs     Incorporate exercise into daily

plan of care     Meaningful individual and/or

group activities     Music therapy     PT/OT consult    

Nutritional Care

Provide adequate fluid/nutritional intake    Adapt provision of nutrition to resident's condition, i.e. finger food, frequent small meals, etc.    Dietitian Consult    

Referrals

Attending Physician  Social Worker    Psycho-Geriatric

Team     Gerontologist     External Therapeutic

Assessment Program i.e. Toronto Rehab  

Seating and Positioning High back or

supportive chair   Individualized

seating   

Chair tilt mechanism    

Positioning in a Wheelchair

Hips Level and positioned at the back of the seat

Upper LegsSupported on the cushion to three (3) inches

behind the knee Feet

Resting on the footrests Back

Against the back of the cushion

Positioning in a Wheelchair Headrest

Must be on wheelchair and positioned when chair is tilted

Use of tiltChange tilt position many times

throughout the day Padded Leg Slings

Loose to allow legs to rest back when in tilt

Things that Interfere with Good Positioning

Cushion Check- air amount, gel quality, wrong way, upside down, pommel

Medical- hip flexion restriction, back pain back kyphosis, scoliosis

Pads and transfer slings on top of cushion

Improper Positioning

Falls to the side or forward Slides out of the wheelchair Redness on pressure areas Discomfort Unable to self propel with hands or

feet Unable to engage in functional

activity

Pressure Areas

Seating Cushion Materials

Foams- Pommel at the front of the cushion

Fluid Gels- Must be kneaded properly after each use

Roho Cushion- Ensure right amount of air

Roho Cushion Correct amount: the

cushion looks ¾ full When pressure is

placed on the cushion, then released, the cushion regains its shape

Too Much Air: All cells are visible, the cushion is hard, unstable and looks too large for the wheelchair

Restraint Deemed Necessary

The Least Restrictive is Used

Consent The decision to

apply a restraint involves the resident and/or his family/substitute decision-maker.

Documentation shows thorough assessment of the need for a restraint, including ALL alternate measures attempted

Doctor’s Order Restraint is

applied on written order (or a telephone order which is cosigned) of a Physician who has attended the resident and approved the type of restraint.

Approved Restraints Wheelchair tray Rear facing seatbelts Lap restraint Mitt restraint Self limiting seat belt

(resident cannot undo without assistance)

How Often do I check?

The resident is checked at a minimum of hourly and repositioned at a minimum of every two hours while restrained.

Documentation

Document on the Restraint Monitoring Record.

Proper Application of Seatbelts ONLY FASTEN THE

SEAT BELT IF & WHEN REQUIRED

MAKE SURE THE SEAT BELT IS IN GOOD CONDITION

Compare to a Car Seatbelt CHECK THAT THE

SEAT BELT IS TIGHTENED APPROPRIATELY

Place one flat hand between belt and resident

Too Loose is Dangerous

Position at the hips not the abdomen

NO Twisting Ensure the belt is not

twisted Do not tie belt

around arm of chair If seatbelt is too long

inform Shopper’s Home Health

Reassessment The need for continuing use

of the restraint is reassessed within 12 hours and the Restraint Monitoring record signed at the bottom by the Registered staff to indicate the continued need past twelve hours

Registered staff are also required to reassess restraint quarterly

Questions?

The End!!!

Thank-you for Coming