restraints: guideline for nurses and midwives in south australia

Clinical Decision Making Flowchart for occasions that may lead
to the Use of Restraints
Restraint Free Care is to be adopted first before the initiation of Minimal Restraint Care
ASSESSMENT
Assess a person’s behaviour and
environment to ensure safety
RESTRAINT FREE CARE
MINIMAL RESTRAINT CARE
IDENTIFY POTENTIAL RISK
Recognise need to initiate actions
that promote safety
ASSESSMENT OF RISK
Assess and determine person poses a risk to
themselves or others
CARE PLAN/PREVENTION
STRATEGIES
Follow and update care plan
MONITOR & EVALUATE
PREVENTION
STRATEGIES
Adequate
PREVENTION
STRATEGIES
Not Adequate
ACTION
Ensure immediate safety for all concerned
IDENTIFY CAUSES
Address the cause and provide interim solution
or alternative(s) to restraint
COMMUNICATE & CONSULT
with relevant health professionals and family
Use alternative(s) to restraint in accordance
with organisational policies
CARE PLAN
Monitor, evaluate and update as required
If not successful
COMMUNICATE & CONSULT
with relevant health professionals and family
Verbal and written documentation
IMPLEMENT restraint intervention according to
organisational policies and procedures
Ongoing Documentation and Evaluation
ENSURE SAFETY, COMFORT,
PSYCHOLOGICAL, NUTRITION, HYDRATION,
ELIMINATION NEEDS ARE MET, INCLUDING
OBSERVATION OF SEDATION LEVELS
OBSERVE & MONITOR
Review ongoing need for restraint
EVALUATE to determine the need
to continue or cease use of restraint
RESTRAINT
INTERVENTION
Not Adequate
CEASE
USE OF
RESTRAINT
RESTRAINT
INTERVENTION
Adequate