RESIDENT_____________________________________

DATE

PROBLEM

GOAL

TO DATE

INTERVENTIONS

RESP

DISC

Restraint

Potential for discomfort, injury, and loss of autonomy related to use of Physical Restraint

Reason used:

Alternative measures attempted:

Bed rail

Full/half/one side

Bed placed against wall and the other side blocked by one or more rails

Veil screen

Enclosed bed system

Trunk restraint    

Vest or waist restraint, belts used in wheelchairs

Limb restraint - Hand, arm, foot, or leg restraint, Mittens

Other

Chair prevents rising    

Chair with locked lap board

Chair that places resident in a recumbent position that restricts rising

Chair that is soft and low to the floor that restricts rising

Enclosed framed wheeled walker, Merry Walker

Used less than daily

Used daily

Used in Bed

Used in Chair or Out of Bed  

Resident will be free from discomfort and injury, and autonomy will be maintained at highest possible level

Make sure restraint is applied properly and in comfortable position, check every 30 minutes, release every two hours for ten minutes, and document

Check with resident frequently to ascertain needs

Toilet resident per schedule and request

Provide adequate fluid intake and nourishment

Make sure resident attends activities, and is provided with adequate stimulation

Exercises to maintain range of motion as per Restorative care plan

Provide verbal reminders to resident to call when needing assistance

Keep call light and most frequently used personal items within reach

Explain procedure to resident and family and discuss with them possible alternatives

Attempt reduction or removal of restraint weekly and prn, and document

See Falls Care Plan

Monitor for potential negative outcomes:

Declines in the resident's physical functioning (e.g., ability to ambulate) and muscle condition

Contractures

Increased incidence of infections and pneumonia

UTI

Compromised circulation

Skin Breakdown

Bruising

Abrasions

Withdrawal from social activities

Agitation

Depression

Sensory deprivation

Delirium

Decreased appetite

Sleeping pattern disturbance

Incontinence

Constipation