Fall Prevention and Use of Restraints in Nursing

Introduction

• Topic: Fall prevention in hospital and home settings, and the use of restraints.
• Based on Fundamentals of Nursing flashcards from leveluprn.com.
• Starting from card number 75.

Fall Prevention in Acute Care Setting (Hospital)

• Rounding Hourly:
  • Check on patients regularly to ensure safety.
• Room Proximity:
  • Move confused patients closer to the nurse's station.
• Environment:
  • Ensure floors are clean, dry, and uncluttered.
• Bed Position and Alarms:
  • Bed should be locked and in the lowest position.
  • Use bed alarms for patients at high risk for falls.
• Accessibility:
  • Keep essential items within reach (water, glasses, dentures, etc.).
• Footwear:
  • Patients should wear nonslip, well-fitting footwear.
• Orthostatic Hypotension:
  • Encourage patients to sit up and dangle legs before standing.

Fall Prevention at Home

• Remove Scatter Rugs:
  • They pose a tripping hazard.
• Good Lighting:
  • Ensure proper lighting, especially over stairs.
• Mark Steps:
  • Use colored or reflective tape on step edges.
• Tape Down Cords:
  • Secure electrical cords to avoid tripping.
• Grab Bars in Bathrooms:
  • Install grab bars in showers and bathtubs.
• Nonslip Mats:
  • Use in showers to prevent slipping.

Restraints

Types of Restraints

• Physical Restraints:
  • Items like vests or hand mitts.
• Chemical Restraints:
  • Medications like benzodiazepines or antipsychotics.
• Order Requirements:
  • In-person provider assessment within 24 hours.
  • Restraint orders last only 24 hours; no PRN orders allowed.

Documentation Requirements

• Rationale:
  • Reason for restraint use.
• Time:
  • Duration of restraint use.
• Patient Assessment:
  • Including well-being and behaviors.
• Care Provided:
  • Document offered care such as toileting, fluids, and ROM exercises.

Nursing Care for Restraints

• Alternatives First:
  • Use least restrictive methods first (distraction, moving closer to nurse's station).
• Tying Restraints:
  • Use slipknot for quick release.
  • Tie to bed frame, not side rails.
• Frequent Assessment:
  • Check patient status and behavior every 15 minutes.
  • Watch for positional asphyxia.
• Care Every 2 Hours:
  • Vital signs, ROM, fluids, and toileting.
• Discontinue ASAP:
  • Stop restraints as soon as they are not needed.
  • Ensure legal rights are protected to avoid false imprisonment.

Conclusion

• Importance of understanding restraint use in nursing school and exams (NCLEX).
• Upcoming video on skin integrity and pressure ulcers/injuries.
• Encouragement to like, comment, and subscribe for more nursing tips and videos.