Restraint as a Last Resort

• Assess for discomfort
• Convert IVs to saline locks or subcutaneous lines, if possible
• Try frequent and simple explanation (e.g. guided exploration of tubes)
• Try camouflaging (e.g. sleeves, gauze, pants, abdominal or foam binder, etc.)
• Put tubing out of visual field
• Use tube stabilizer
• Change IV to intermittent ASAP
• Use an elbow splint to keep arm in place
• Assess necessity of lines or tubes, discuss goals of care with patient and Circle of Support; advocate for line removal if not in alignment with patient goals of care 
• Assess for and provide pain relief, especially when person has health problems (e.g. arthritis, cancer) that are likely to result in pain or they exhibit pain in any way (e.g. facial grimace, moaning, guarded extremity)
• Increase social interactions
• Do frequent verbal explanations of procedures/treatments
• Try distraction and diversion (e.g. reading material, activity apron, photo albums)
• Use music, television
• Use a sitter/patient attendant/companion
• Try abdominal binder over PEG
• Provide written reminders of why tubes or lines are in place (e.g. "You are in the hospital.")

NOTE These are sample care plans. Please follow your local forms procedures.

• Do routine repositioning 
• Use chairs that have the right height, depth and support so the patient can be comfortable and safe
• Position hips, knees and ankles as close to 90 degrees as possible
• Avoid prolonged/continuous periods in any chair
• Reposition glide system (consult OT)
• Consult OT/PT (e.g. OT may consider custom wheelchair equipment, wedge/non-slip cushion, lower height wheelchairs, chairs without footrests so feet touch the floor, or non-slip material under feet)
• Apply “dunk” or tilt in wheelchair or chair for rest periods or to change position/relieve pressure

• Consider two upper side rails to assist with repositioning
• Keep four or full rails down unless otherwise assessed (these are typically a restraint)
• Consider low or very low bed if not mobile
• Keep bed at knee height if patient is mobile
• Consult OT re: appropriateness of crash mats
• Consult OT/PT re: improving transfers, providing equipment (e.g. transfer bar/trapeze)
• Use mattress with raised/bolstered edges
• If necessary, use ongoing monitoring of patient, using frequent contact, silent alarms or an alert system to notify if they attempt to leave a bed or chair
• Try motion-sensor light
• Try boundary reminder (e.g. body-length pillow, rolled blankets or “swimming noodles” under mattress edge)
• Reposition regularly/on a schedule 
• Consider comfort equipment (e.g. specialty mattress) 

• Refer to Nova Scotia Health Falls and Injury Reduction Policy & Procedure CL-SR-010
• Consult PT for assessment of gait and transfer abilities, as well as teaching
• Ensure transfer and mobility assist is documented and visible (e.g. above head of bed, care plan, Kardex, etc.)
• Encourage/facilitate daily exercise that promotes sit-to-stand activities, balance and walking 
• Encourage/prompt for proper use of aids (e.g. walker)
• Do medication reviews by a pharmacist to reduce falls (e.g. eliminate poor use of medications, duplicate medications, negative drug interactions and incorrect dosage levels)
• Increase social interactions
• Schedule daily naps
• Try mattress on floor/low bed
• Use non-slip strips on slippery surfaces (e.g. shower room, ramps)
• Clean glasses, hearing aids
• Position walking aids so easily available/as a cue 
• Report if walking aid is damaged 
• Communicate ‘high risk’ status to team members (e.g. cards above head of bed, Kardex)
• Instruct to call if assistance required to get out of bed 
• Instruct to call if getting up at night (e.g. if independent in the day)
• Assess for orthostatic hypotension
• Consider peak medication effects and risks when planning patient care
• If necessary, use ongoing monitoring of patient, using frequent contact, silent alarms or an alert system to notify if they attempt to leave a bed or chair
• Move closer to nursing station
• Maintain hydration 
• Use a commode at bedside or bedpan/urinal within reach, as indicated
• Put bed in locked position
• Optimize height of bed, wheelchair, other chairs and toilet 
• Consult OT/PT to consider transfer equipment, as appropriate
• Consult OT to determine if patient requires assistance/can increase their participation with daily activities, or energy conservation (may result in doing some of their own care, or recommendations for equipment or devices, such as shower bench, crash mats) 
• Increase social interactions
• Redirect with simple commands
• Assess for pain, especially when patient has health problems (e.g., arthritis, cancer) that are likely to result in pain, or they exhibit pain in any way (e.g. facial grimace, moaning or guarded extremity)
• Assess for hunger, heat, cold, thirst, loneliness

• Safely mobilize, when able, to support recovery 
• Address underlying cause of delirium 
• Be calm and reassuring
• Talk slowly and clearly
• Keep glasses, hearing aids, walking aids easily available (working/clean)
• Use simple sentences about familiar, non-threatening topics 
• Don’t argue
• Assess for pain, especially when person has health problems (e.g., arthritis, cancer) that are likely to result in pain or they exhibit pain in any way (e.g. facial grimace, moaning or guarded extremity)
• Toilet regularly
• Assess for hunger, heat, cold
• Encourage adequate fluid and nutritional intake
• Try written reminders
• If necessary, use ongoing monitoring of patient, using frequent contact, silent alarms or an alert system 
• Offer opportunities for ambulation or provide ROM
• Take care not to overstimulate the patient
• Use unit-wide noise reduction strategies
• Label environment using pictures (e.g. label bathroom door with a picture of a toilet)
• Decrease caffeine intake
• Orientate to environment (e.g. place a calendar/clock in room within view)

NOTE These are sample care plans. Please follow your local forms procedures.

• Assess patterns of behaviours (e.g. behaviour tracking) to identify precipitating factors, timing, duration, frequency and needs (e.g. pain, hunger, thirst, fatigue)
• Be mindful of communication strategies and seek additional training, as needed
• Introduce yourself by name
• Address patient by the name they prefer
• Approach patient from the front 
• Be sure to have patient’s attention before speaking to them
• Speak to patient at eye level and keep eye contact
• Speak slowly and calmly, and use short, simple words 
• Allow enough time for patient to respond (counting to five between phrases is helpful) 
• Focus on patient’s feelings, not the facts (e.g. do not argue, limit “reality checks” as reasoning may not work)
• Be patient and flexible 
• Avoid interrupting patients living with dementia, as they may lose their train of thought 
• Allow patients living with dementia to interrupt you, or they may forget what they want to say
• Limit distractions during communication (e.g. turn off the radio or move to a quiet place)
• Increase the use of gestures and other non-verbal communication techniques 
• Observe patient to recognize non-verbal communication
• If appropriate, communicate with patient using gentle touch, direct eye contact, smiles and pleasant tone of voice
• Change the topic of conversation
• Assess for pain, especially when patient has health problems (e.g., arthritis, cancer) that are likely to result in pain, or they exhibit pain in any way (e.g. facial grimace, moaning or guarded extremity)
• Tell patient what you are doing and get their permission to do it. For example, say “Is it okay if I wash your back?”
• Repeat verbal explanations frequently
• Know a patient’s story (e.g. job, family, interests, favourite foods) 
• Use past coping strategies (e.g. in care plan)
• Assess for hunger, heat, cold
• Label environment using pictures (e.g. label bathroom door with a picture of a toilet)
• Assess benefits of written cues or reminders to help patient understand tasks or schedules (e.g. one or two-word written reminders)
• Maintain social relationships
• Increase or decrease social interactions
• Distract with activities that are/were familiar (e.g. listening to familiar music, watching a movie, puzzles, crafts, cards, snacks, writing tools, reading material, comforting family photos)
• Facilitate participation in meaningful activities based on interests and abilities (e.g. indoor herb garden, seated exercise)
• Engage them in reminiscence conversation (e.g. look at their photo album, ask questions and encourage them to share a part of their life story)
• Assemble and offer items of interest (e.g. a basket of fabric swatches, activity apron, greeting cards, calendars with attractive photos) or touchable items (e.g. hats, safe tools)
• Permit pacing/wandering
• If necessary, use ongoing monitoring of the person, using frequent contact, silent alarms or an alert system to notify if person attempts to leave a bed or chair
• Hold patient’s hand/allow them to rest on your shoulder to comfort when the source of distress is unknown

NOTE These are sample care plans. Please follow your local forms procedures.

• Assess patterns of behaviours (e.g. Behaviour Tracking) to identify precipitating factors, timing, duration, frequency and needs (e.g. pain, hunger, thirst, fatigue, loneliness, security)
• Provide safe areas for patient to wander
• Try positive redirection (e.g. “Let’s have a cup of tea” as opposed to “don’t” phrases)
• Schedule visits to the bathroom at regular intervals and based on patient’s patterns or during rounding
• Assess for pain, especially when patient has health problems (e.g. arthritis, cancer) that are likely to result in pain, or they exhibit pain in any way (e.g. facial grimace, moaning or guarded extremity)
• Walk with patient when they may be unsafe
• Offer food and drinks while they are “on the go” to ensure enough intake
• Try a buddy system among staff/consistency
• Move rooms so patient is visible 
• Use past coping strategies in care plan
• Label environment using pictures (e.g. label bathroom with a picture of a toilet)
• If necessary, use ongoing monitoring of patient, using frequent contact, silent alarms or an alert system to notify if person attempts to leave a bed or chair
• Involve patient in activities/opportunities that promote friendships and have meaning, based on their abilities, choices, interests 
• Try diversional activities (e.g. pets, music, puzzles, crafts, cards, snacks)
• Engage them in reminiscence conversation (e.g. look at their photo album, ask questions and encourage them to share a part of their life story)
• Increase social interactions/activities (e.g. dining together with other patients)
• Create a wandering path or destination (e.g. busy boxes, pictures/textures on wall, path to dining room/lounge)
• Tape line or grid on floor, yellow caution tape/signage across doorways that are off limits
• Make doors less obvious so patient does not realize that leaving is possible (e.g. exit doors camouflaged with the same paint colour as wall, mural, doors painted as bookcases; examples at Sensory-scapes 2023 Catalog) 
• Try moveable/velcro screen in front of areas or doors you don’t want patient to enter
• Provide space for rocking, which can replace wandering (e.g. a safe gliding chair that has a wide base, locks when the patient attempts to get up and does not tip easily)
• Acknowledge emotions and empathize (e.g. “Tell me about your home.” versus “You can’t go home.”)

NOTE These are sample care plans. Please follow your local forms procedures.

Resource Catalogue

Patient becomes increasingly irrational and verbally acts out (belligerent, challenging, refusing).

• Use behaviour tracking/monitoring to determine causes of agitation (e.g. fear, control issues, unmet needs, information needs, etc.)
• Kindly but firmly explain expectations, intent to support, choices and limits
• Acknowledge the underlying cause; provide empathy, active listening, reassurance and opportunity to work through negative thoughts and emotions
• Consult appropriate members of the Health Care Team 
• Recognize the difference between venting, responsive behaviours and abusive behaviour
• Invite patient to sit and talk in quiet, low-lit environment
• Help patient to remember and use coping mechanisms they identified (e.g. deep breaths, meditation, visual imagery, journal writing, bath, warm blanket, exercise)
• Assess cognitive changes from baseline
• If providing personal care, consider having a second person assist, to help provide distraction (e.g. conversation or music)
• If responsive behaviours are related to care methods, focus on unmet needs (e.g. use gentle caregiving techniques, including warnings, before touching patient or beginning care, apologize for causing distress and keep the patient covered and warm; listen to and validate their concerns, address those concerns and provide reassurance)
• Increase or decrease social interactions
• Know your patient's life story so you can talk about things that comfort them (e.g. fishing, gardening, job)
• Know abilities, try not to ask for more than what patient is capable of
• Be flexible 
• Permit pacing
• Do medication reviews by a pharmacist to reduce falls (e.g. eliminate poor use of medications, duplicate medications, negative drug interactions and incorrect dosage levels)
• Update the care plan, as needed
• Assess for pain, especially when person has health problems (e.g. arthritis, cancer) that are likely to result in pain, or they exhibit pain in any way (e.g. facial grimace, moaning, guarded extremity)

• If the situation is an emergency, respond accordingly
• Clear area of clutter or objects that could be potential projectiles
• Remove patient from a stressful situation
• Ask/assess what happened before they got upset
• Empower patient and acknowledge their ability to regain control/offer encouragement with every step towards calming themselves 
• Maintain professional boundaries 
• Invite patient to talk in a quiet room or area where there is less of an audience and less stimulation, as appropriate/safe
• If patient is not a danger to themselves or others, consider leaving them alone/walking away and come back later
• Assess for pain, especially when patient has health problems (e.g. arthritis, cancer) that are likely to result in pain, or they exhibit pain in any way (e.g. facial grimace, moaning, guarded extremity)
• Help patient remember and use coping mechanisms they identified (e.g. deep breaths, meditation, visual imagery, journal writing, bath, warm blanket, exercise)
• Find a staff member who has a good rapport/relationship with the patient; have them talk to the patient
• Use a team approach. If the patient is wearing down one staff member, have another take over (10 minutes of talking might avoid a restraint incident)
• Investigate contributing factors via Behaviour Tracking, interviewing (e.g. fear, psychosis, losses, personal issues)
• Have adequate staff available for crisis situations, and keep them up to date
• If appropriate, give a clear message of what will happen unless the patient is able to regain control: offer choices, use reasonable and enforceable consequences
• If responsive behaviours are related to care methods, focus on unmet needs (e.g. use gentle caregiving techniques, including warnings, before touching patient or beginning care; apologize for causing distress and keep the patient covered and warm; listen to and validate their concerns, address those concerns and provide reassurance)
• Consider having a second person assist, to help provide distraction during care (e.g. conversation or music)

NOTE These are sample care plans. Please follow your local forms procedures.

• Assess for pain, especially when patient has health problems (e.g. arthritis, cancer) that are likely to result in pain, or they exhibit pain in any way (e.g. facial grimace, moaning, guarded extremity)
• Pay frequent attention to patient when they are not calling out, to reinforce positive behaviours
• Use behaviour tracking/monitoring to determine causes of agitation (e.g. fear, control issues, unmet needs, information needs)
• Offer family-generated videos/DVDs/music
• Offer known calming strategies (e.g. conversation, gentle touch, warm blanket, bath)
• If patient is seeking companionship, consider a Pro-attention Plan (Fraser Health)

NOTE These are sample care plans. Please follow your local forms procedures.

• Document events or situations leading up to behaviour (e.g. viewing sexually explicit scenes on TV, flirting with staff/residents, during personal care, unclothed)
• Distract patient’s attention immediately
• State “Please stop. This is not appropriate.”
• Consider deferring care if patient’s responsive behaviour persists
• Explain who you are and your role
• Keep conversation at a minimum and directed at the task
• Have two staff assist with bathing, if necessary
• Update the care plan, as needed (e.g. successful strategies) and share with team

NOTE These are sample care plans. Please follow your local forms procedures.