Fundamentals - Practice & Skills, part 11: Fall Prevention and Restraints

August 02, 2021 Updated: August 03, 2021 7 min read

Full Transcript

Hi, I'm Meris. And in this video, we're going to be talking about fall prevention, both within the hospital and at home, and the use of restraints. I will be following along using our Fundamentals of Nursing flashcards. These are available on our website, leveluprn.com. And if you're following along with your own, I'm starting on card number 75. All right. Let's get started. Okay. So first up, let's talk about fall prevention in the acute care setting, so this is within your facility. As you can see, we've got a lot of bold red text here and key points for you to pay attention to. So let's talk about this, rounding hourly on your patient. It just means poking your head in and making sure that they're doing okay, that they don't need anything, that they are still in their bed. That's going to help to prevent falls. If your patient is confused or can't follow instructions, we want to move their room closer to the nurse's station. That's a really good noninvasive way for us to be able to keep a close eye on them. We of course, want to make sure the floors are clean, dry, and uncluttered. But also, we can set a bed alarm. So your bed for the patient should always be locked and in the lowest position for all patients all the time. But we can also set bed alarms for patients who are at high risk for falls, and that way, if they get out of bed, we can hear it and come running immediately. So we also want to make sure that anything the patient needs, like their water, their glasses, dentures, all of those things, are within reach of their bed on the overbed table. If it's far away, your patient's going to try and get out of bed to get the things that they need, so keep them close to the bed. Another thing is to make sure that the patients are wearing nonslip, well-fitting footwear. This is why all of the socks in the hospital have those grippy things on the bottom. Those are nonslip socks. And then we also want to encourage our patients to sit up and dangle their legs on the edge of the bed before standing up so that we don't have that orthostatic hypotension, which could lead to falls.

Now, let's talk about what to do at home to prevent falls. You'll see here we have some big, bold red things here as well. Very important to know, this is highly testable content for nursing school and for NCLEX because it has to do with patient safety, right? And patient safety is always number one. So first up, we have remove scatter rugs. Scatter rugs make your house look really cute and cozy, but they are a fall risk because you can slip and fall or trip on them. We also want to have good lighting, especially over stairs. We want to mark the edges of our steps with colored tape or reflective tape. We want to tape down electrical cords, so actually tape them down. Don't put them under a rug or just leave them free, right? If we tape them down, it makes them less of a tripping hazard. And we want them to be behind furniture or against a wall, if possible. We want to have grab bars in the shower and bathtub so that we don't slip and fall there, a nonslip mat on the shower floor. And then also, just like we talked about in the last video, we need to make sure that our patients know how to use their assistive devices correctly. So that overs fall prevention measures within the acute care setting and also at home.

Next up, we are talking about restraints. Restraints are very important to understand for nursing school because there is a lot to know about them, when to use them, nursing care, when to stop them, all of those sorts of things. So let's get into it because there is a lot to go over. First and foremost, we have two types, physical restraints and chemical restraints. Physical restraints are anything you physically put on your patient, right? A vest or hand mitts, those are physical. But chemical restraints are things that are going to keep your patient sedated or calm, things like benzodiazepines or anti-psychotics. So don't forget, medication can be a restraint. Order requirements, this is what we need to have an order for restraints. We need the provider to do an in-person assessment of the patient within 24 hours of the order. The order only lasts for 24 hours, which means that after it is up, if the patient continues to need restraints, we need a new order. PRN orders are not allowed, which means I can't have an order that says to restrain the patient PRN or as needed. That's not how it works. We restrain them until restraints are no longer needed, and we immediately discontinue them. And like I said, a new restraint order every 24 hours.

The documentation portion is very important. We're going to be documenting the rationale. Why is the person in restraints? The time they have been in restraints. The patient assessment findings. What is their general well-being? Are they calm? Are they breathing? Are they doing okay, or do they still seem agitated? We're going to document that and then what care we offered and provided to the patient. So I offered toileting, fluids, range of motion exercises. "The patient received range of motion exercises and fluids, declined toileting." Right? Now, this card right here, this is card number 78. I want you to really, really focus on this card and make sure you understand everything that's being said here because this covers the nursing care, which is always what we are focused on, right? What's my job as the nurse? So there's a lot here, and most of it is bold and red, meaning very important. So alternatives first, right? We go least to most restrictive. So that means if my patient is pulling out their lines, tubes, and drains, I don't just put them in full leather restraints, right? We're going to start by trying to distract them. We're going to move them closer to the nurse's station. We're going to try and use a technique of giving them something to do. "Hey, can you fold these washcloths for me?" We're not going to jump to restraining them. If we have to, we can, but we're going to move incrementally up that ladder.

The restraint needs to be tied-- okay, this is so important, and I'm going to use my hands to show you. And I'm sorry, but very important. The restraint needs to be tied in a slipknot fashion, quick-release fashion, meaning when I pull on the long tail, it's immediately untied. So that's for emergency purposes, right? The other thing is that it needs to be tied to a part of the bed frame. The bed frame moves with the bed, meaning it goes up and down as the bed is raised or lowered, right? So bed frame goes up and down, but the frame itself is unmovable, meaning does not move by itself. So for instance, the side rail, that is going to move by itself, right? I can put it down. I can bring it up independent of the bed moving. That's not where I want to tie it because if I put the bed frame-- put the side rail down, now it's really, really tight, right? And then I put the side rail up, and now it's really slack or loose. So I want to tie it on an unmovable part of the bed frame, but it is moving, meaning that it's going up and down, but not moving independently. I hope that makes sense. That really trips a lot of students up. It can be confusing. So just remember, bed frame, not side rail, not head of the bed that goes up and down, bed frame.

Okay. I'm going to assess my patient's status and behaviors every 15 minutes. That is very fast for assessments, right? That's very frequent, I should say, for assessments. Most of the times, we don't assess things every 15 minutes if you're in general med-surg or something. Every 15 minutes, you need to be checking in on that patient. And the big reason here being something called positional asphyxia. Your patients could fight against these restraints, right, and get themselves all twisted and turned in a position where they cannot breathe adequately. And if they cannot breathe adequately, they can asphyxiate, or suffocate, and die, even while they are restrained. So we check on them every 15 minutes. I really want to hammer that point home. We take vital signs, provide range of motion, and offer fluids and toileting every two hours. That's more consistent with what you're used to. And then as soon as the patient is no longer a risk to themselves or others, we discontinue the restraints. We never restrain a patient because it's convenient for us, because we like having them in restraints, absolutely not. As soon as they no longer meet the requirements for the order, we discontinue, okay? If we need to check skin integrity, we can take off one restraint at a time, do range of motion, check the skin, place that restraint, then come over and remove the other restraint, okay? So that's an important distinction between removing restraints one at a time in order to provide care and removing restraints entirely.

Restraints are very big in nursing school. There's a lot of questions about it because it really is important to protect your patient's legal rights to not have false imprisonment, right, to not have things done to them against their will, unless it is medically necessary because they are a threat to themselves or others. So be sure you're familiar with this. This is going to come up for you in Funds, in med-surg, in mental health. It's going to be very, very common nursing test-taking knowledge for school and for NCLEX, so be familiar with it.

Okay. So that is our review here for fall prevention and restraints. I hope it was helpful. If it was, please like this video and let me know. If you have a really great way to remember something, I super want to hear it, so please leave it in the comments so that I can see. And then be sure to subscribe to our channel so that you are the first to know when our next video drops, which is going to be talking about skin integrity, specifically pressure ulcers, pressure injuries. Very, very, very important stuff for nursing school, so you don't want to miss it. Thanks so much, and happy studying.


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