You are caring for a patient on your unit who is now resting well but has tried to get up and fallen multiple times over the past couple of days. As you prepare to leave the patient's room, do you restrain her to prevent her from falling again?
While it may seem like the most rationale step to take in this situation would be to restrain the patient, only current behavior should determine whether a patient should be restrained. The use of restraints can have physical and psychological consequences for the patient, so it is important that nurses and other medical professionals be very careful with their use. In this situation, since the patient is resting well and not agitated, the nurse should avoid using restraints. The interviewer is asking this question to determine if the candidate understands that restraints should be used judiciously, and to effectively answer this question, the candidate should indicate they would not restrain the patient in this situation. A more successful answer this question would include an example from the candidate's nursing career where they chose not to restrain a patient based on current behavior, despite previous history of falls, violence, and/or intentional or unintentional self-harm.
"Since I have been an inpatient nurse for many years, I have dealt with these types of situations many times, and in this situation, I would not restrain the patient. Even though the patient has fallen since she has been admitted, if she is currently resting well and isn't agitated, I would not restrain her. Restraints are very difficult for patients, and I will not use them unless it is absolutely necessary. This reminds me of a patient who I was caring for recently who had been violent and restrained while in the ICU, but when he was transferred to my unit, he was much calmer. The nurse who cared for him the shift prior to mine had kept him restrained, as she was fearful of him, but the patient was now much more lucid and the restraints were stressful to him. Once I took the handoff, I immediately removed the restraints from the patient, and from then on, he was able to relax."
"Restraints should be used as a last resort, as they can be upsetting to patients and their family members, and they may increase the risk of other types of injury, such as skin tears or pressure wounds. I would work with my patient care tech and other nurses to implement other measures, such as frequently rounding on the patient to make sure her elimination needs are met. We could also place a bed or chair alarm underneath the patient to make sure staff are alerted if she tried to get up, and we could place fall alert socks on her feet so that the color indicates to all staff that the patient should not get up by herself."
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Anonymous Answer
No, I would not restrain her. You need an order to restrain someone and restraints are a last resort option for patients that need them. I would implement other methods to prevent the patient from falling.
Chad's Feedback
This is a good response! You make it clear that you would not restrain the patient in this situation. Again, sharing a story example from your nursing career of a time where you chose not to restrain a patient, despite a previous history of falls, will strengthen your response.
Anonymous Answer
Always use the least restraint to prevent additional stressors for the patient. I would not restrain this patient even tho they are a falls risk. They are resting well not agitated. I would Put on bed alarm, open curtains so visible from the nursing station, bed rails up, tuck them in with blankets, ensure they've been toileted given water and lights at the appropriate level, all necessities within reach so all basic needs have been met if possible prior to leaving the room. I would have a 1:1 sitter if possible. Restraints can be very stressful and traumatic best to try other measures prior to restraining and always have chemical restraints on Baird if physically restraining.
Cindy's Feedback
Good! So, the risk is low and outweighs the stress of restraints? I would dwell a bit longer on the reasons for your choice and make them explicit in your answer.
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