Client Safety: Restraints, Seizure Precautions, and Fall Prevention – Structured Study Notes

Client Safety and Use of Restraints

Definition and Types of Restraints

Restraints are methods or devices used to restrict a person's movement, physical activity, or normal access to their body. They are implemented to ensure safety but must be used judiciously due to ethical, legal, and medical considerations.

• Physical Restraints: Devices such as belts, mittens, bed rails, or chairs that limit movement.

• Chemical Restraints: Psychoactive medications used to inhibit behavior or movement (e.g., sedatives, antipsychotics, antidepressants, anti-anxiety drugs, alcohol).

• Environmental Restraints: Modifications to surroundings to restrict mobility (e.g., secure units, seclusion rooms).

Purpose for Restraints

Restraints are used for two main reasons:

• Behavioural Restraint: Used to control aggressive or violent behavior that poses danger to self or others, typically in emergency settings.

• Medical/Surgical Restraint: Used to prevent interference with medical treatment (e.g., pulling out IVs, catheters) or to protect confused or combative clients.

Objectives and Indications for Physical Restraints

• Reduce risk of client injury (does not prevent falls).

• Prevent interruption of therapy (e.g., IV infusion, NG tube feeding).

• Prevent removal of life-support equipment by confused or combative clients.

• Reduce risk of injury to others by the client.

Types of Physical Restraints and Indications

Type	Indications
Mitten Restraints	Patient who scratch themselves or pull out tubes
Lap or Belt	Patients at risk of sliding or falling from the chair
Bed Rail or Side Rail	Patient at risk of falling
Wrist Restraints	Patient at risk of pulling out tubes or hitting others
Elbow Restraints	Patient at risk of pulling out tubes
Mummy Restraints	Restrict movement of limb in small children during procedures

Chemical Restraints

Chemical restraints involve the use of psychoactive medications to intentionally inhibit behavior or movement, not for treatment of illness but for safety purposes.

• Examples: sedatives, antipsychotics, antidepressants, anti-anxiety medications, alcohol.

Environmental Restraints

Environmental restraints restrict or control mobility by changing surroundings.

• Examples: secure units, seclusion rooms.

Assessment and Alternative Interventions

Assessment is the first step in determining the safest, least restrictive way to care for the patient.

• Discover the cause of the problem (e.g., wandering, unsteadiness, medication side effects).

• Learn about the patient’s interests and routines.

• Give the patient a say in their care.

• Involve family members for additional information and support.

Alternative interventions should be attempted before restraints:

• Move patient closer to nurses’ station

• Keep patient door open

• Bed in low position

• Call bell within reach

• Reorient patient to environment

• Conceal IV site and tubing

• Decrease noise/minimize stimulation

• Bed/exit alarms with sensor pads

• Encourage family involvement

Use of Restraints as a Last Resort

Restraints should only be used when all alternative interventions have been exhausted and there is a clear and present danger.

• Protect patient’s rights and dignity

• Choose the least restrictive method

• Document each occurrence

• Properly trained staff must apply/remove restraints

• Choose correct restraint size

Physician’s Order Criteria for Restraints

Physician must be informed and conduct a face-to-face assessment within one hour. Orders must include:

• Start and stop time

• Date

• Reason for restraint

• Type of restraint

• Signature of physician

Face-to-face re-evaluation and orders must be renewed every 8 hours for adults, every 4 hours for children 17 and younger.

Nursing Procedure and Responsibilities

• Check physician order and identify patients

• Explain procedure to patient and family

• Allow patient to ask questions and participate

• Ensure privacy and hand hygiene

• Arrange articles near patient’s bedside

• Monitor for injury, circulation, range of motion, comfort, and readiness for discontinuation

• Apply least restrictive to most restrictive devices

• Review restraint regularly and consider earliest discontinuation

Hazards and Problems with Long-term Use of Restraints

• Immobilization, restriction of freedom, risk of tangling, pressure ulcers, constipation, pneumonia, incontinence, retention, contracture, nerve damage, circulatory impairment, asphyxia

• Emotional effects: humiliation, fear, anger, loss of self-esteem

• Long-term: self-esteem issues, incontinence, immobility, pressure ulcers, infections, falls, serious injuries, untimely death

Legal and Ethical Considerations

• Least-restraint approach is recommended for highest quality care

• Alternatives must be attempted first

• Thorough assessment by nursing and physician; family consent may be required

Seizure Precautions

Definition and Types of Seizures

A seizure is a neurologic condition characterized by abnormal electrical brain activity. Epilepsy is a chronic disorder with recurrent and/or random seizure activity. Seizures are classified as:

• Generalized seizures

• Focal seizures

Signs and Phases of Seizures

Phase	Signs
Pre-ictal (Aura)	Abnormal sensations (smell, taste), vertigo, nausea, anxiety, déjà vu, visual/auditory phenomena
Post-ictal	Confusion, lethargy, upset, no recall of seizure, abnormal/combative behavior, postictal coughing, spitting, hypersalivation, nose-wiping, psychosis, mania

Complications of Seizures

• Aspiration pneumonia (from breathing in food/saliva)

• Injury from falls, bumps, bites

• Permanent brain damage (stroke, other damage)

• Medication side effects (drowsiness, toxicity)

• Long-term medication effects (osteoporosis)

Seizure Precautions and Management

• Consider padded side rails, head board

• Safety equipment: oral airways, suction equipment, disposable gloves

• During seizure: position client, clear area, provide privacy, loosen tight clothing, do not put anything in mouth, stay with client and observe

• Following seizure: explain event, answer questions, recovery position, comfort, call bell within reach, quiet environment

Client Injury and Falls

Factors Contributing to Falls

• Age, previous falls, gait disturbance, balance, mobility problems, medications, postural hypotension, sensory impairment, urinary/bladder issues

Falls are the most reported incident of client injury.

Assessing Fall Risk

Hendricks II Fall Risk Model

• Confusion/disorientation

• Depression

• Altered elimination

• Dizziness/vertigo

• Gender (male)

• Medications (antiepileptics, benzodiazepines)

• Get-Up-and-Go test

Risk Factor	Risk Points
Confusion/Disorientation	4
Depression	2
Altered Elimination	1
Dizziness/Vertigo	1
Male Gender	1
Medications	2
Get-Up-and-Go Test	0-4

Morse Fall Scale

• History of falls

• Secondary diagnosis

• Ambulatory aid

• IV or monitoring equipment

• Gait (weak vs. impaired)

• Mental status

Variable	Score
History of Falling	25
Secondary Diagnosis	15
Ambulatory Aid	0-30
IV/Heparin Lock	20
Gait/Transferring	0-20
Mental Status	15

Fall Prevention Activities

• Manage underlying health conditions (osteoporosis, delirium, infections)

• Exercise programs

• Promote continence, use of aids (glasses, walkers)

• Monitor medications, reduce polypharmacy

• Bed-exit alarms

• Appropriate footwear

• Minimize environment clutter

• Minimize effects of orthostatic hypotension

Purposeful Rounding for Fall Prevention

Rounding focuses on the "4 Ps":

• Pain

• Position

• Possessions (placement of personal items)

• Potty (toileting needs)

Additional info: These notes expand on the original content by providing definitions, structured explanations, and context for the use of restraints, seizure precautions, and fall prevention in clinical settings, relevant to psychological and behavioral safety in healthcare.