Restraints in Healthcare
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Adults may need to be restrained for some
diagnostic procedures, therapeutic procedures or
during the physical examination and sometimes
to protect from an injury
An appropriate safe and comfortable restraint
should be selected. The restraint may be
provided manually with help of some device
INTRODUCTION
Restraints
are protective devices
used to limit the physical activity of a
client or to immobilize a client or
extremity. Restraints are used to
protect the client, allow for treatment
in a safe environment, and reduce the
risk of injury to others.
Definition
Physical restraints
reduce the client’s
movement through the application of a device.
Most states require a physician’s order for the
application of physical restraints.
Chemical restraints
are medications used to
control the client’s behavior. Commonly used
chemical restraints are anxiolytics and
sedatives.
Seclusion
is defined as the involuntary
confinement of a person in a room or an area
where he or she is physically prevented from
leaving.
Types Of Restraints
To carry out the physical examination
To provide the safety to patient
To protect the patient from injury
To complete the diagnostic and therapeutic
procedures
To maintain the patient in prescribed position
To reduce the discomfort of patient during some
tests and procedures like specimen collection
Use of Restraints
Restraints are used only when necessary and not
as a substitutes for punishment.
Improperly applied can cause skin irritation and
impaired circulation.
Restraints should not be too tight not too loose.
Careful observation and periodic checking is
essential to prevent complication (every 15 mins).
Proper explanation is essential before the
application of restraints.
Principles
Behavioral Restraint
(Almost exclusively in ER)
Used for the control of aggressive/violent
behavior or behavior that is dangerous to self or
others.
Medical/Surgical Restraint
(Most common on
units)
Used for care management for a patient who is
exhibiting behavior that is interfering with
treatment (e.g. pulling on IV, Foley, or
dressings).
Two major types of restraints
1. Medical surgical restraints
Mummy restraint
Elbow restraint
Arm boards
Jacket restraint
Orthopedic appliances
Helmets
2. Behavioral restraints
Elbow restraint
Jacket restraint
seclusion
Types of restraints
Equipment needed
Baby Blanket
Clove hitch knot rope
Cotton pads
Restraint cloths with pocket
and spatulas
Jacket for jacket restraint
Adhesive tape to fix the bandage
Purposes
To immobilze the arms and legs of an infant.
When the child’s head and neck to be examined.
When the jugular puncture is to be done
When the scalp vein needle is to be inserted
When a gastric lavage is to be done
While bathing to provide warmth of the body.
While passing Ryle’s Tube.
Checking weight.
Mummy Restraint
Mummy Restraint
Procedure
Take the blanket or draw sheet and spread it over the
bed or table.
Place the baby on backside
Keep the one hand of baby near the body and wrap the
baby’s body by holding the corner of the sheet and tuck
it under the body in opposite side.
Now place another hand near the body and wrap the
child’s body by holding another corner of sheet and
tuck it.
Now take the rounded sheet at bottom near the leg and
fold it towards the chest and tuck it at upper level of
sheet or we can pin it at lower level of sheet.
Mummy Restraint
Purpose
To examine the chest and
abdomen
Modified Mummy Restraint
This is used to hold the elbow in an extended
position so that the patient cannot reach the
face.
Purposes
When the patient has had surgery on face or
head
When the patient has eczema or other skin
disorders on face and head
When the scalp vein needle is in place.
Elbow Restraint
Elbow Restraint
Procedure
The elbow restraint is made up of double piece
of clothe or other strong material, with pockets
sewn into which tongue blades are inserted.
The tongue blades should be strong enough to
reach from the axilla to the wrist, so that the
elbow cannot be bent when the restraint is
applied around the arm.
Elbow Restraint
Purpose
To prevent the patient falling from
a highchair and wheel chair
Jacket Restraint
Jacket Restraint
Procedure
The jacket is put on with the strings in the back so
that the patient cannot reach them.
Secure ties of jacket to a non movable part of the
bed frame or wheelchair.
Use the knot that cannot be quickly released.
Reposition the patient release immmobilizing
restraints and perform range of motion every 1-2
hours.
Jacket Restraint
Danger of jacket restraint
Jacket restraint is that of
strangulation through pressure of
the restraint that has slipped out of
place and encircled a patient’s neck.
Jacket Restraint
This restraint is used to hold the
patient
in
a supine position on the bed.
Abdominal restraint should not be too
tight, so that it cannot interfere with
respiration and bowel movement.
For this restraint, use wide size wooden
strips.
Place the cotton pad approximately to
provide the proper comfort.
Abdominal Restraint
It is used to immobilize the extremities
Extremity restraint (Ankle or Wrist)
The material for clove hitch can be soft cloth, crepe bandage
and 2 inch wide gauze bandage.
First apply the cotton pad over the wrist, ankle to prevent
discomfort.
Prepare figure of eight by the bandage and place it in the
wrist or in the ankle.
Tie the bandage by knot. Knot should not be too tight or too
loose.
Patient can remove the knot if it is too loose. Too tight knot
can interfere in blood circulation.
The fingers and toes should be checked for discoloration or
any skin rash etc.
Clove hitch knot restraint
Finger Restraint
It can be completed by making mitten.
The mitten covers all the fingers of a hand and restrict
the movements of the fingers.
The hand can be wrapped by gauze or hand can be put
in a bag like pouch and tie it properly at the wrist of
the
patient
.
Finger restraints are used in case of facial surgeries,
burns, IV infusions, any eczema of face and body
parts.
Keep the mittens soft and it should not interfere with
the circulation.
Finger Restraint
Crib-net Restraint
In this a net is used to cover the patient’s cot. Net is
attached to the cot frame.
This net restraint is used to prevent the patients
climbing over the side rails of cot.
In this net when side rails are up, the patient can
stand but cannot climb over the side rails of cot.
Inside the crib net, the patient is totally free to
move, no movement is restricted.
It mainly prevents the patient to climb and fall from
the side rails of cot.
Crib-net Restraint
Safety belts
These are made up of electrically
nonconductive materials.
These belts are used on stretcher and
operation tables to prevent the patient
from falling.
These belts go around the patient’s waist
and tied to the frame of bed under the
mattress.
Safety belts
Side rails
These are available especially in patients cot.
The rails are made up of iron or steel.
These can be raised when ever need arises
and can be decreased as per convenience.
The main purpose of side rails are to prevent
from fall.
These are used for patients with convulsive
disorder also.
Side rails
39
RESTRAINTS MONITORING
Observe
every
15 minutes
for
behaviors and physical conditions
and document on
BehavioralRestraint/Seclusion
Flowsheet
Offer
liquid, nutrition, comfort,
and bathroom every
2
hours
Remove
restraints every 2 hour for
no less than 5 minutes for range of
motion and skin care.
BEHAVIORAL
MEDICAL/SURGICAL
•
Observe
every
2
hours for
behaviors and physical conditions
and document
•
Offer
liquid, nutrition, comfort,
and bathroom every
2
hours
•
Remove
restraints every
2
hours for no less than 10 minutes
for range of motion and skin care
.
Use Prevention Management of Aggressive Behavior (PMAB) interventions for
escalating behaviors in all clinical settings.
Why has the practice of
using physical restraints
become so regulated and
monitored?
• Due to enforced immobilization:
Physical
– Increased weakness & falls
– New pressure ulcers
– New onset incontinence
– Joint contractures
Adverse Consequences of
Physical Restraint
• Psychological/Mental Impact
– Independent predictor of delirium
– Increased agitation
– Depression
– Demoralization
Adverse Consequences (cont.)
• Indirect: death
• Direct effects
– Death
– Anoxic encephalopathy
– Brachial nerve damage
– Wrist fractures
Adverse Consequences (cont.)
Reason for the restraint.
Method of restraint.
Application: Date, time, and client’s response
Duration.
Frequency of observation and client’s response.
Safety: Release from restraints with periodic, routine
exercise and assessment for circulation and skin
integrity.
Assessment of the continued need for restraint.
Client outcome.
Key elements of restraint
documentation
Free all restraints at least every 2 to 4 hours, and
provide range-of-motion exercise and skin care
Instantly report to the nurse in charge and record on the
client’s chart any constant reddened or broken skin
areas under the restraint
At the first sign of cyanosis or pallor, coldness of a skin
area, or a client’s complaint of a tingling feeling, pain,
or numbness, release the restraint and exercise the limb,
If there is any bruises do dressing as per doctors order.
Lubricate dry skin with moisturizing creams or
ointments
Skin Care
Restraints are never used as the first alternative to manage
these types of situations. There are other measures that can
be taken by the family or staff to try to prevent restraint use.
These are some of the things you can do to help your child
Talk to your healthcare providers about your patient and let
us know if he/she has any special needs. Tell us what works
best to calm your patient.
Speak to your patient about medical procedures or
equipment in a manner he/she can understand.
If at all possible, stay with your patient to provide comfort
and to reduce anxiety. If you are not able to stay around the
clock, ask a close adult family member or friend to visit
when you cannot stay with your patient.
Alternatives to restraints
Provide your child’s favorite play activities like toys,
games, video games, videotapes, and music to distract
attention away from his/her medical devices or
condition.
Please tell us if your patient is in pain. We want to do
everything we can to control your patients’s pain.
Reduce the amount of noise, light, and/or visitors in
your child’s room to help decrease excitement.
Your nurse can contact a Child Life Specialist if your
child is having difficulty coping with hospitalization.
Alternatives to restraints
The reason for applying the restraints must be explained
to both the child and the parents.
The consent should be taken from the patient before
applying restraints.
While applying the restraint and periodically during the
period of restraint, the nurse should talk soothingly to the
child to provide stimulation and diversion.
When restraints are applied, they should be put on
effectively, yet as loosely as possible to prevent
interferences with respiration and circulation and so that
the child can move safely, to some degree.
Sufficient padding must be used under extremity
restraints to prevent skin irritation
Nursing Management
The ties on restraints should be attached to the crib
frame instead of the crib rails to prevent traction on the
restraint or injury to the child when the crib rail is
raised and lowered
Restraints should be checked every 15 to 30 minutes to
determine whether they are constricting the respiration
or circulation in any way.
Periodically, at least every 2 hours, the child should be
removed from the restraints, held if possible and played
with, to increase body contact and sensory input.
Before the restraints are reapplied, the child’s position
should be changed to improve physiological
functioning
Nursing Management
A restraint or seclusion should be applied by health care prescriber
or Licensed Independent Practitioner.
If the child’s behavior is threat to others the RN can do restraint.
But with in 1 hour she has to get verbal or written order from the
physician.
Children with following conditions are contraindications for
chemical restraints
Abnormal airway
Raised ICP
Depressed conscious level
History of sleep apnea
Respiratory failure
Cardiac failure
Neuromuscular disease
Points to remember
Restraints and seclusions should not be used as punishments.
Children should never be left alone while in behavioral restraint
or secluded.
The use of side rails, safety belts, protective nets, helmets and
postural support devices used to promote good body alignment
are not restraints.
Verbal or written orders for restraint and seclusion are limited to
4 hours for patients 18 years of age and older
2 hours for children 9 to 17 years of age
1 hour for children younger than 9 years of age
Seclusion and restraints should not be ordered on a PRN basis.
Points to remember
Restraints play a crucial role in healthcare settings to protect patients during procedures and examinations. They come in various forms such as physical, chemical, and seclusion, with the primary goal of ensuring patient safety and facilitating medical treatments. Proper application, periodic monitoring, and adherence to guiding principles are essential for the safe and effective use of restraints.
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Presentation Transcript
Restraints Presented by, Mrs.T.L Mrs.T.L. DIVYA, . DIVYA, Asst. Professor, Pediatric Nursing Asst. Professor, Pediatric Nursing Department, Department, Annammal Annammal College Of Nursing, College Of Nursing, Kuzhithurai. Kuzhithurai.
INTRODUCTION Adults may need to be restrained for some diagnostic procedures, therapeutic procedures or during the physical examination and sometimes to protect from an injury An appropriate safe and comfortable restraint should be selected. The restraint may be provided manually with help of some device
Definition Restraints are protective devices used to limit the physical activity of a client or to immobilize a client or extremity. Restraints are used to protect the client, allow for treatment in a safe environment, and reduce the risk of injury to others.
Types Of Restraints Physical restraints reduce the client s movement through the application of a device. Most states require a physician s order for the application of physical restraints. Chemical restraints are medications used to control the client s behavior. Commonly used chemical restraints are anxiolytics and sedatives. Seclusion is defined as the involuntary confinement of a person in a room or an area where he or she is physically prevented from leaving.
Use of Restraints To carry out the physical examination To provide the safety to patient To protect the patient from injury To complete the diagnostic and therapeutic procedures To maintain the patient in prescribed position To reduce the discomfort of patient during some tests and procedures like specimen collection
Principles Restraints are used only when necessary and not as a substitutes for punishment. Improperly applied can cause skin irritation and impaired circulation. Restraints should not be too tight not too loose. Careful observation and periodic checking is essential to prevent complication (every 15 mins). Proper explanation is essential before the application of restraints.
Two major types of restraints Behavioral Restraint (Almost exclusively in ER) Used for the control of aggressive/violent behavior or behavior that is dangerous to self or others. Medical/Surgical Restraint (Most common on units) Used for care management for a patient who is exhibiting behavior that is interfering with treatment (e.g. pulling on IV, Foley, or dressings).
Types of restraints 1. Medical surgical restraints Mummy restraint Elbow restraint Arm boards Jacket restraint Orthopedic appliances Helmets 2. Behavioral restraints Elbow restraint Jacket restraint seclusion
Restraint cloths with pocket and spatulas
Mummy Restraint Purposes To immobilze the arms and legs of an infant. When the child s head and neck to be examined. When the jugular puncture is to be done When the scalp vein needle is to be inserted When a gastric lavage is to be done While bathing to provide warmth of the body. While passing Ryle s Tube. Checking weight.
Mummy Restraint Procedure Take the blanket or draw sheet and spread it over the bed or table. Place the baby on backside Keep the one hand of baby near the body and wrap the baby s body by holding the corner of the sheet and tuck it under the body in opposite side. Now place another hand near the body and wrap the child s body by holding another corner of sheet and tuck it. Now take the rounded sheet at bottom near the leg and fold it towards the chest and tuck it at upper level of sheet or we can pin it at lower level of sheet.
Modified Mummy Restraint Purpose To examine the chest and abdomen
Elbow Restraint This is used to hold the elbow in an extended position so that the patient cannot reach the face. Purposes When the patient has had surgery on face or head When the patient has eczema or other skin disorders on face and head When the scalp vein needle is in place.
Elbow Restraint Procedure The elbow restraint is made up of double piece of clothe or other strong material, with pockets sewn into which tongue blades are inserted. The tongue blades should be strong enough to reach from the axilla to the wrist, so that the elbow cannot be bent when the restraint is applied around the arm.
Jacket Restraint Purpose To prevent the patient falling from a highchair and wheel chair
Jacket Restraint Procedure The jacket is put on with the strings in the back so that the patient cannot reach them. Secure ties of jacket to a non movable part of the bed frame or wheelchair. Use the knot that cannot be quickly released. Reposition the patient release immmobilizing restraints and perform range of motion every 1-2 hours.
Jacket Restraint Danger of jacket restraint Jacket restraint is that of strangulation through pressure of the restraint that has slipped out of place and encircled a patient s neck.
Abdominal Restraint This restraint is used to hold the patient in a supine position on the bed. Abdominal restraint should not be too tight, so that it cannot interfere with respiration and bowel movement. For this restraint, use wide size wooden strips. Place the cotton pad approximately to provide the proper comfort.
Extremity restraint (Ankle or Wrist) It is used to immobilize the extremities
Clove hitch knot restraint The material for clove hitch can be soft cloth, crepe bandage and 2 inch wide gauze bandage. First apply the cotton pad over the wrist, ankle to prevent discomfort. Prepare figure of eight by the bandage and place it in the wrist or in the ankle. Tie the bandage by knot. Knot should not be too tight or too loose. Patient can remove the knot if it is too loose. Too tight knot can interfere in blood circulation. The fingers and toes should be checked for discoloration or any skin rash etc.
Finger Restraint It can be completed by making mitten. The mitten covers all the fingers of a hand and restrict the movements of the fingers. The hand can be wrapped by gauze or hand can be put in a bag like pouch and tie it properly at the wrist of the patient. Finger restraints are used in case of facial surgeries, burns, IV infusions, any eczema of face and body parts. Keep the mittens soft and it should not interfere with the circulation.
Crib-net Restraint In this a net is used to cover the patient s cot. Net is attached to the cot frame. This net restraint is used to prevent the patients climbing over the side rails of cot. In this net when side rails are up, the patient can stand but cannot climb over the side rails of cot. Inside the crib net, the patient is totally free to move, no movement is restricted. It mainly prevents the patient to climb and fall from the side rails of cot.
Safety belts These are made up of electrically nonconductive materials. These belts are used on stretcher and operation tables to prevent the patient from falling. These belts go around the patient s waist and tied to the frame of bed under the mattress.
Side rails These are available especially in patients cot. The rails are made up of iron or steel. These can be raised when ever need arises and can be decreased as per convenience. The main purpose of side rails are to prevent from fall. These are used for patients with convulsive disorder also.
RESTRAINTS MONITORING BEHAVIORAL Use Prevention Management of Aggressive Behavior (PMAB) interventions for escalating behaviors in all clinical settings. MEDICAL/SURGICAL Observe every 2 hours for behaviors and physical conditions and document Observe every 15 minutes for behaviors and physical conditions and document on BehavioralRestraint/Seclusion Flowsheet Offer liquid, nutrition, comfort, and bathroom every 2 hours Remove restraints every 2 hour for no less than 5 minutes for range of motion and skin care. Offer liquid, nutrition, comfort, and bathroom every 2 hours Remove restraints every 2 hours for no less than 10 minutes for range of motion and skin care. 39
Why has the practice of using physical restraints become so regulated and monitored?
Adverse Consequences of Physical Restraint Due to enforced immobilization: Physical Increased weakness & falls New pressure ulcers New onset incontinence Joint contractures
Adverse Consequences (cont.) Psychological/Mental Impact Independent predictor of delirium Increased agitation Depression Demoralization
Adverse Consequences (cont.) Indirect: death Direct effects Death Anoxic encephalopathy Brachial nerve damage Wrist fractures
Key elements of restraint documentation Reason for the restraint. Method of restraint. Application: Date, time, and client s response Duration. Frequency of observation and client s response. Safety: Release from restraints with periodic, routine exercise and assessment for circulation and skin integrity. Assessment of the continued need for restraint. Client outcome.
Skin Care Free all restraints at least every 2 to 4 hours, and provide range-of-motion exercise and skin care Instantly report to the nurse in charge and record on the client s chart any constant reddened or broken skin areas under the restraint At the first sign of cyanosis or pallor, coldness of a skin area, or a client s complaint of a tingling feeling, pain, or numbness, release the restraint and exercise the limb, If there is any bruises do dressing as per doctors order. Lubricate dry skin with moisturizing creams or ointments
Alternatives to restraints Restraints are never used as the first alternative to manage these types of situations. There are other measures that can be taken by the family or staff to try to prevent restraint use. These are some of the things you can do to help your child Talk to your healthcare providers about your patient and let us know if he/she has any special needs. Tell us what works best to calm your patient. Speak to your patient about medical procedures or equipment in a manner he/she can understand. If at all possible, stay with your patient to provide comfort and to reduce anxiety. If you are not able to stay around the clock, ask a close adult family member or friend to visit when you cannot stay with your patient.
Alternatives to restraints Provide your child s favorite play activities like toys, games, video games, videotapes, and music to distract attention away from his/her medical devices or condition. Please tell us if your patient is in pain. We want to do everything we can to control your patients s pain. Reduce the amount of noise, light, and/or visitors in your child s room to help decrease excitement. Your nurse can contact a Child Life Specialist if your child is having difficulty coping with hospitalization.
Nursing Management The reason for applying the restraints must be explained to both the child and the parents. The consent should be taken from the patient before applying restraints. While applying the restraint and periodically during the period of restraint, the nurse should talk soothingly to the child to provide stimulation and diversion. When restraints are applied, they should be put on effectively, yet as loosely as possible to prevent interferences with respiration and circulation and so that the child can move safely, to some degree. Sufficient padding must be used under extremity restraints to prevent skin irritation
Nursing Management The ties on restraints should be attached to the crib frame instead of the crib rails to prevent traction on the restraint or injury to the child when the crib rail is raised and lowered Restraints should be checked every 15 to 30 minutes to determine whether they are constricting the respiration or circulation in any way. Periodically, at least every 2 hours, the child should be removed from the restraints, held if possible and played with, to increase body contact and sensory input. Before the restraints are reapplied, the child s position should be changed to improve physiological functioning
Points to remember A restraint or seclusion should be applied by health care prescriber or Licensed Independent Practitioner. If the child s behavior is threat to others the RN can do restraint. But with in 1 hour she has to get verbal or written order from the physician. Children with following conditions are contraindications for chemical restraints Abnormal airway Raised ICP Depressed conscious level History of sleep apnea Respiratory failure Cardiac failure Neuromuscular disease
