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NCM 106 SKILS

APPLICATION OF RESTRAINTS

RESTRAINTS - are protective devices used to limit the physical activity of the client or a
part of the body. They can be classified as physical or chemical.
The forcible confinement or control of a subject, as of a confused, disoriented, psychotic,
or irrational person; it may be either physical or chemical.
Restraint of any kind is used only when the patient's behavior presents a danger to himself
or herself or another person. It is never used for the convenience of staff or as a substitute
for conscientious nursing care.

TYPES OF RESTRAINTS:

PHYSICAL RESTRAINTS - are any manual method or physical or mechanical device,


material, or equipment attached to the clients body; they cannot be removed easily and
they restrict the clients movement.
CHEMICAL RESTRAINTS - are medications such as neuroleptics, anxiolytics,
sedatives, and psychotropic agents used to control socially disrupted behaviour. The
purpose of the restraints is to prevent the client from injuring self or others.

SELECTING A RESTRAINT

Before selecting a restraint, nurses need to understand its purpose clearly and measure it
against the following five criteria:
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02. NCM 106 SKILLS - APPLICATION OF RESTRAINTS

1. It restricts the clients movement as little as possible. If a client needs to have one arm
restrained, do not restrain the entire body.
2. It does not interfere with the clients treatment or health problem. If a client has poor blood
circulation to the hands, apply a restraint that will not aggravate the circulatory problem.
3. It is readily changeable. Restraints need to be changed frequently, especially if they become
soiled. Keeping other guidelines in mind, choose a restraint that can be changed with minimal
disturbance to the client.

SELECTING A RESTRAINT

4. It is safe for the particular client. Choose a restraint with which the client cannot self
inflict injury. For example, a physically restrained person could be injured trying to climb
out of bed if one wrist is tied to the bed frame. A jacket restraint would restrain the person
more safely.
5. This is the least obvious to others. Both clients and visitors are often embarrassed by a
restraint, even though they understand why it is being used. The less obvious the restraint,
the more comfortable they feel.
APPLICATION OF RESTRAINTS

Guidelines in Application of Restraints

Allow the patient as much freedom to move as possible and at the same time serve the
purpose of restraint.
The patients circulation must not be occluded by the restraint.

Pad bony prominences under a restraint in order to avoid skin abrasions. Preferably, use
soft restraints.
The restraint needs to permit the body to assume its normal position, for example, slight
flexion of the rams. Attach restraint to the bedframe, not to the side rails to prevent trauma.
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02. NCM 106 SKILLS - APPLICATION OF RESTRAINTS

Guidelines in Application of Restraints

Use at least conspicuous type of restraint possible. Even if the patient is not aware of the
restraint , visitors often find them disturbing.
At the first indication of occluded peripheral circulation (pallor, blueness, cold, tingling, or
pain) the restraint needs to be loosened and the limb exercised.
Remove restraints at least every 2 hours for 30 minutes. Exercise the limb and provide skin
care to prevent skin abrasions.
Restraints application requires doctors order.

Secure doctors order for each episode of restraint application. A PRN order for restraints
application is unacceptable.
Ideally, application of restraints require consent from relatives or significant others.
APPLICATION OF RESTRAINTS

KINDS OF RESTRAINTS

There are several kinds of restraints. Among the most common for adults are jacket
restraints, belt restraints, mitt or hand restraints, and limb restraints.
Geri chairs, wheel chairs with lap trays, bed rails can also be considered restraints.

Restraints for infants and children include mummy restraints, elbow restraints, and crib
nets.

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02. NCM 106 SKILLS - APPLICATION OF RESTRAINTS

KINDS OF RESTRAINTS

BELT OR SAFETY STRAP BODY RESTRAINTS are used to ensure the safety of all
clients who are being moved on stretchers or in wheelchairs. Some wheelchairs have a soft,
padded safety bar that attaches to side brackets that are installed under the arm rests. To
prevent the person from slumping forward, the nurse when attaches a shoulder Y strap to
the bar and over the clients shoulders to the rear handles.

KINDS OF PHYSICAL RESTRAINTS

A MITT or HAND RESTRAINT is used to prevent confused clients from using their
hands or fingers to scratch and injure themselves. For example, a confused client may need
to be prevented from pulling at intravenous tubing or a head bandage following brain
surgery.
Hand or mitt restraints allow the client to be ambulatory and/ or to move the arm freely
rather than confined to a bed or a chair. Mittens need to wash and exercise the hands. The
nurse also needs to take off the mitten to check the circulation to the hand.

KINDS OF PHYSICAL RESTRAINTS

LIMB RESTRAINTS, which are generally made of cloth, may be used to immobilize a
limb, primarily for therapeutic reasons (e.g. to maintain an intravenous infusion)

APPLICATION OF RESTRAINTS

PURPOSES:
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02. NCM 106 SKILLS - APPLICATION OF RESTRAINTS

Enable the client to receive treatment

To allow the treatment to proceed without client interference (e.g. to prevent movements
that would disrupt therapy to a limb connected to tubes or appliance)

ASSESSMENT

Assess

The behaviour indicating the possible need for a restraint.


Underlying cause for assessed behaviour
What other protective measures may be implemented before applying a restraint
Status of skin to which restraint is to be applied.
Circulatory status distal to restraints and of extremities
Effectiveness of other available safety precautions.
APPLICATION OF RESTRAINTS

PLANNING

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02. NCM 106 SKILLS - APPLICATION OF RESTRAINTS

Review institutional policy for restraints and seek consultation as appropriate before
independently deciding to apply a restraint. All other possible interventions that are less
restrictive must have been tried. The physician must be notified prior to using a restraint,
unless there is an emergency.

APPLICATION OF RESTRAINTS
EQUIPMENT

Appropriate type and size of restraint.

PERFORMANCE
1. Explain to the client and family what you are going to do, why it is necessary, and how they
can cooperate. Discuss how the results will be used in planning further care or treatments.
Allow time for the client to express feelings about being restrained. Provide needed emotional
reassurance that the restraints will be used when absolutely necessary and that there will be
close contact with the client in case assistance is required.
2. Wash hands and observe appropriate infection control procedures.
3. Provide for client privacy if indicated

4. Apply the selected restraint.

Determine that the safety belt is in good order. If a Velcro safety belt is to be used, make
sure that both pieces of Velcro are intact.
If the belt has long portion of the belt behind (under) the bedridden client and secure it to
the movable part of the bed frame.
Rationale: The long attached portion will then move up when the head of bed is elevated
and will not tighten around the client. Place the shorter portion of the belt around the
clients waist, over the gown. There should be a fingers width between the belt and the
client.
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02. NCM 106 SKILLS - APPLICATION OF RESTRAINTS

4. Apply the selected restraint.

Apply the appropriate sized restraint, using appropriate knotting techniques.

Use a quick release knot such as half bow, when trying restraints to the bed frame or
wheelchair. Do not tie restraints to the side rails.
R: A quick release knot is used to prevent patient injury and for ease of caring for the
patient. Tie the knot on an immovable part of the bed to prevent injuring the patient if the
side rails or head of bed are lowered. A half bow knot will not tighten or slip when the
patient moves about, but unties quickly when you pull on the loose end.

APPLICATION OF RESTRAINTS
BELT RESTRAINT

BELT RESTRAINT:

- is used mainly to prevent a patient from falling when getting up from a chair or
wheelchair and may be used to remind a patient not to get out of bed unassisted.

Place belt restraint at the patients waist, removing any wrinkles.


Make sure that the belt is snug but does not constrict the patients waist.
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02. NCM 106 SKILLS - APPLICATION OF RESTRAINTS

Some belts have a key locked buckle to prevent slipping.


APPLICATION OF RESTRAINTS
VEST RESTRAINT

VEST OR JACKET RESTRAINT

-is used mainly to prevent a patient from falling out of chair or wheelchair and may be used
to prevent a patient from getting out of bed unassisted.

Place the patient in a jacket restraint in the vest restraint. A zipper style vest is preferred.

R: A vest restraint with a real zipper is less likely to accidentally strangle the patient.

Attach the vest straps to the bed or wheelchair.


APPLICATION OF RESTRAINTS
WRIST RESTRAINT

WRIST OR ANKLE RESTRAINT

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02. NCM 106 SKILLS - APPLICATION OF RESTRAINTS

is used mainly to prevent a patient from pulling at tubes such as IV sites and nasogastric
tubes. Wrist and ankle restraints are used with an extremely agitated patient. Ankle
restraints are used in very limited situations.

Apply the padded portion of the wrist or ankle restraint around the patients wrist or ankle.
Make the restraint snug enough to prevent the patient from being able to slip it off, but not
tight enough to impair circulation. Generally, you should be able to slide two fingers under
the restraint.

Attach the restraint strap to the bed frame. Do not attach to bed rails.
APPLICATION OF RESTRAINTS
MITT RESTRAINT

MITT RESTRAINT:

is used mainly to prevent a patient from pulling at tubes, such as IV sites and nasogastric
tubes.

Place patients hand in mitt restraint, ensuring that fingers are slightly flexed in the mitt.
Attach restraint strap to the bed frame.

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02. NCM 106 SKILLS - APPLICATION OF RESTRAINTS

5.Adjust the restraint to maintain good body alignment, comfort and safety.

6. Release restraints and provide skin care, passive and active range of motion, ambulation,
toileting, hydration, and nutrition at least every 2 hours.

R: Prevents impaired circulation and injury.

7. Assess the restraint every 30 minutes.

R: Ensures that it is still functioning as intended.

8. Place the patient on fall risk precautions according to agency policy.

R: Helps prevent injury.

EVALUATION

Assess the initial restraint placement, circulation and skin integrity. Observe for pallor,
cyanosis, and coolness of extremities when extremities are restrained.

Assess the need for continuing the use of the restraint every 2 hours, and remove it when it
is no longer needed.

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02. NCM 106 SKILLS - APPLICATION OF RESTRAINTS

PATIENT TEACHING

Explain to the patient and family the need for the restraints.
Explain that the restraints will be removed as soon as possible.

DOCUMENTATION

Document the initial restraint placement, circulation and skin integrity. Document reasons
for placing the restraint (e.g., patient behaviors)

Document on fall risk assessment sheet, restraint flow sheet, and nurses notes according to
agency policy.

LIFESPAN CONSIDERATIONS RESTRAINTS

INFANTS

Elbow restraints are used to prevent infants or small children from flexing their elbows to
touch or reach their face or head, especially after surgery. Ready made elbow restraints
are available commercially.

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02. NCM 106 SKILLS - APPLICATION OF RESTRAINTS

A mummy restraint is a special folding of a blanket or sheet around the infant to prevent
movement during a procedure such as gastric washing eye irrigation, or collection of a
blood specimen.

LIFESPAN CONSIDERATIONS RESTRAINTS

CHILDREN

A crib is simply a device placed over the top of a crib to prevent active young children
from climbing out of the crib. At the same time, it allows them freedom to move about in
the crib.
The crib net or dome is not attached to the movable parts of the crib so that the caregiver
can have access to the child without removing the dome or net.

Place the net over the sides and ends of the crib.

Secure the ties to the springs or frame of the crib. The crib sides can then be freely lowered
without removing the net.
Test with your hand that the net will stretch if the child stands against it in the crib.

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02. NCM 106 SKILLS - APPLICATION OF RESTRAINTS

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