Falls, restraints, and seizure safety

Strip 1 · Who falls A prior fall is the strongest single predictor. Add altered mentation, urgency or incontinence, impaired gait or weakness, and medications that sedate, lower blood pressure, or diurese.

Strip 2 · The environment fix Bed at its lowest position and locked. Call light and personal items within reach. Non-skid footwear. Adequate lighting, including at night. Scheduled rounding that offers toileting before the patient asks.

Strip 3 · Side rails Four raised rails function as a restraint. Two upper rails are a mobility aid the patient uses to reposition. The exam tests that difference, and the number is what changes the answer.

Strip 4 · The restraint ladder De-escalation first. Then diversion and companionship. Then environmental modification. Chemical or physical restraint is the last rung, always with a current provider order, never as a standing order, and never as an as-needed order.

Strip 5 · Once it is on Quick-release tie, secured to the movable bed frame and never to a side rail. Regular circulation, sensation, and skin checks. Range of motion, hydration, and toileting offered. Continuous assessment of whether the restraint can come off now.

Strip 6 · Seizure, during Stay with the patient. Turn them to the side. Protect the head. Loosen anything tight at the neck. Time the event. Put nothing in the mouth and do not restrain the limbs.

Strip 7 · Seizure, around it Suction and oxygen at the bedside before the seizure happens, and padded rails. Afterward, document duration, motor pattern, incontinence, injury, and level of consciousness on waking.

Margin noterestraint is a last rung, not a tool.

Watch outan as-needed restraint order is never acceptable.

Takeawaythe correct answer is always the least restrictive thing that actually works.

Restraint monitoring intervals by age → BOOK 04 · P9. Seizure types → BOOK 10 · P8.