Nursing Skill 1-9

NURSING SKILL 1-9: USING RESTRAINTS RATIONALE Physical restraints should be considered as a last resort after other care alternatives have been unsuccessful. When it is necessary to apply a restraint, the least restrictive method should be used and it should be removed at the earliest possible time. Consider the laws regulating the use of restraints and facility regulations and policies. Ensure compliance with ordering, assessment, and maintenance procedures. Always treat Choosing Alternative to Restraints patient with respect and protect their dignity. Determine whether behavior pattern exists. Assess for pain and treat appropriately. Rule out physical causes for agitation. Assess respiratory status, v/s, blood glucose level, fluid and electrolyte issues, and medications. Involve the family/SO to stay with the patient. Reduce stimulation, noise and light. Distract and redirect, using a calming voice. Check environment for hazards: Provide for basic needs relative to nutrition, fluids, and toileting. Institute bowel and bladder programs. Provide frequent orientation and explanations of care. Use night light. Use an alarm system (e.g.: bed or position-sensitive alarms) to warn an unassisted activity. Allow restless patient to walk after ensuring that environment is safe. Use a large plant or piece of furniture as a barrier to limit wandering from designated area. Use low-height beds. Place floor mats on each side of the bed. Ensure the use of glasses and hearing aids, if necessary. Use full-length body pillows. Arrange for a bedside commode. Make the environment as homelike as possible; provide familiar objects. Provide a warm beverage. Provide comfortable rocking chairs. Use therapeutic touch. Play music or video selection of the patients choice. Offer diversional activities, such as games, television, and books. Encourage daily exercise/provide exercise and activities or relaxation techniques. Consider relocation of the patient room closer to the nursing station. Conceal tubes and tubing necessary for care. Anchor tubing securely. Conceal tubing with gauze wrap; unwrap regularly to assess site for complications. Investigate possibility of discontinuing bothersome treatment devices (e.g.: IV line, catheter, feeding tube). ____________________________________________________________________________ (Adapted from Letezia, M., Babler, C. and Cockrell, A. [2004]. Repeating the call for restraint reduction, MEDSURG Nursing, 13 (1), 9 12, and Napierkowski, D. [2002]. Using restraints with restraints. Nursing, 32, [11], 58 62.)

General Guidelines for Restraint Use Nursing Skill 1-9 2 The patient has the right to be free from restraints that arent medically necessary. Restraints are not used for the convenience of the staff or to punish a patient. The patients SO must be involved in the plan of care. They must be consulted when the decision is made to use restraint. The SO must be instructed regarding the facilitys restrain policy and alternatives to restraints that are available. Alternatives to restraints and less restrictive interventions must have been implemented and failed. All alternative used must be documented. The restraints must be ordered by a physician or other licensed independent practitioner. The order can never be for us on as needed basis. Once in place, the patient must be monitored and reassessed. Adult patients must be reassessed within 4 hours; children (9-17 years) within 2 hours; and children < 9 within 1 hour. A physician or licensed independent practitioner must reevaluate and assess the patient q 24 hours (in the medical-surgical setting). Assess the patients v/s and visually observe the patient q 2 hours for medical patients. Personal needs must be met. Provide fluids, nutrition, and toileting assistance q 2 hours. Assess skin integrity 2 hours and provide ROM exercises. Documentation regarding why, how, where, and for how long the restraints were placed, and patient monitoring are vital. ____________________________________________________________________________ (Modified form Klee, K. [2004]. Restraints regulation: The tie that binds. Nursing Management, 35, (11), 36-38; and Napierkowski, D. [2002]. Using restraints with restraint. Nursing, 32, (11), 58-62.)

EQUIPMENT Appropriate cloth restraint for the extremity that is to be immobilized Extremity restraint Jacket or Vest restraint Elbow restraint Leather restraints (whenever cloth restraints are not strong enough) Small blanket or sheet Padding, if necessary, for bony prominences ASSESSMENT Assess the patients physical condition and for the potential for injury to self or others. Evaluate the appropriateness of the least restrictive restraint device. Inspect the extremity where the restraint will be applied. NURSING DIAGNOSIS Risk for Injury Risk for Impaired Skin Integrity Anxiety Impaired Physical Mobility Acute Confusion Bathing/Hygiene Self-Care Deficit Feeding Self-Care Deficit Toileting Self-Care Deficit

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PLANNING Outcome: The patient is constrained by the restraint, remains free form injury, and the restraint does not interfere with therapeutic devices. (Other outcomes may be appropriate depending on the specific nursing diagnosis identified for the patient: the patient does not experience impaired skin integrity; does not injure himself/herself due to restraints; and the patients SO will demonstrate and understanding about the use of the restraint and their role in the patients care.) IMPLEMENTATION ACTION 1. Determine need for restraints. Assess patients physical condition, behavior, and mental status. RATIONALE 1. Restraints should be used only as a last resort when alternative measures have failed and the patient is at increased risk for harming himself or others. Policy protects the patient and the nurse and species guidelines for application as well as type of restraint and duration. 2. Policy protects the patient and the nurse and species guidelines for application as well as type of restraint and duration. Joint Commission on Accreditation of Healthcare Organizations (JCAHO) standards require that a new order for restraints must be written every 24 hours. 3. Identifying the patient ensures the right patient receives the intervention and helps prevent errors. 4. Explanation to patient and family may lessen confusion and anger and provide reassurance. A clearly stated agency policy on application of restraints should be available for patient and family to read. In a long-term care facility, the family must give consent before a restraint is applied. 5. Reduces spread of microorganisms.

2. Conrm agency policy for application of restraints. Secure a physicians order, or validate that the order has been obtained within the past 24 hours.

3.

Identify the patient.

4. Explain reason for use to patient and family. Clarify how care will be given and how needs will be met. Explain that restraint is a temporary measure.

5.

Perform hand hygiene.

Extremity Restraint 6. Apply restraint according to 6. Proper application prevents manufacturers directions: injury. a) Choose the least restrictive type of device that allows the greatest a) This provides minimal restriction. possible degree of mobility. b) Pad bony prominences. c) Wrap the restraint around the b) This provides minimal restriction. extremity with the soft part in c) This prevents excess pressure on contact with the skin. If hand mitt is extremity. A quick-release knot being used, pull overhand with ensures that restraint will not

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cushion to the palmar aspect of hand Secure in place with the Velcro straps or reverse clove hitch. d) Ensure that two ngers can be inserted between the restraint and patients wrist or ankle. e) Maintain restrained extremity in normal anatomic position.

tighten when pulled and can be removed quickly in an emergency. d) Proper application ensures that there is no interference with patients circulation. e) Maintaining a normal position lessens possibility of injury.

Jacket or Vest Restraint 6. Apply restraint according to 6. Proper application ensures that manufacturers directions: there is no interference with patients a) Choose the correct size of the respiration. least restrictive type of device that a) This provides minimal restriction. allows the greatest possible degree of mobility. b) Pad bony prominences that may b) Padding helps prevents injury. be affected by the vest. c) Assist to a sitting position, in not c) This will assist the nurse in contraindicated. helping the patient into the vest. d) Place vest on patient over gown, d) Placing the V in the back may with flaps crisscrossing over the cause the patient to choke. abdomen if appropriate. The V opening should be on the patients front. e) Wrinkles in the vest behind the e) Pull the tabs secure. Ensure that patient may led to skin there are no wrinkles in the vest impairment. behind the patient. f) This prevents impaired f) Insert fist between restraint and respirations. patient to ensure that breathing is not constricted. Assess respirations after restraint is applied. g) Secure the restraint. g) If the patient is in a wheel chair, lock the wheels and place the restraints under the arms rests and tie behind the chair. Elbow Restraint 6. Apply restraint according to 6. Proper application ensures that manufacturers directions: there is no interference with patients a) Choose the correct size of the circulation. least restrictive type of device that a) This provides minimal restriction. allows the greatest possible degree of mobility. b) Pad bony prominences that may b) Padding helps prevent injury. be affected by the restraint. c) Spread elbow restraint out flat. c) Elbow restrain should be placed in Place middle of elbow restraint middle of arm to ensure that behind patients elbow. The patient cannot bed the elbow. restraint should not extend below Child should be able to move the wrist or place pressure on the wrist. Pressure on the axilla may axilla. lead to skin impairment. d) Wrap restrain snugly around d) Wrapping snugly ensures that

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patients arm, but make sure that two fingers can easily fit under restraint. e) Wrap Velcro straps around restraint. f) Apply restrain to opposite arm if patient can move arm. g) Thread Velcro strap from one elbow restrain across the back and into the loop on the opposite elbow restraint. h) Assess circulation to fingers and hand.

patient will not be able to remove the device. Being able to insure two fingers helps to prevent impaired circulation from restraint. e) Velcro straps will hold the restraint in place and prevent patient from removing restraint. f) Bilateral elbow restraints are needed if patient can move both arms. g) Strap across the back prevents patient from wiggling out of elbow restraints. h) Circulation should not be impaired from elbow restraint.

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Leather Restraints (Whenever cloth restraints are not strong enough) 6. Apply restrains according to 6. Proper application ensures that manufacturers directions: there is no interference with a) Pad body prominences. patients circulation. a) Protects the skin and prevents b) Wrap the restraint around the breakdown. extremity with the soft part in b) Prevents excess pressure on contact with the skin. extremity. c) Ensure that two fingers can be inserted between the restraint and c) Proper application ensures that patients wrist or ankle. there is no interference with patients circulation. Maintaining d) If using locking leather restraints, a normal position lessens ensure that key is available at all possibility of injury. times. d) Leather restraints cannot be cut easily in emergency situation. Key must be available to release e) Fasten restraint to bed frame, not patient quickly if needed. side rail. Site should be readily e) Securing restraint to a side rail accessible to the patient. may cause injury to patient if side rail is lowered. Securing restraint out of patients reach promotes security. 7. Use a quick-release knot to tie the restraint to the bed frame, not side rail (Figures 4 and 5). The restraint may also be attached to chair frame. The site should not be readily accessible to patient. 7. A quick-release knot ensures that restraint will not tighten when pulled and can be removed quickly in an emergency. Securing the restraint to a side rail may injure the patient when the side rail is lowered. Tying restraint out of patients reach promotes security. 8. Improperly applied restraints may cause skin tears, abrasions, or bruises. Decreased circulation may result in paleness, coolness, decreased sensation, tingling, numbness, or pain in extremity. Use of restraints may decrease environmental stimulation and result in sensory deprivation.

8. Assess the patient at least every hour or according to facility policy. Assessment should include: the placement of the restraint, neurovascular assessment of the affected extremity, and skin integrity. In addition, assess for signs of sensory deprivation, such as increased sleeping, daydreaming, anxiety, panic, and hallucinations. 9. Remove restraint at least every 2 9. Removal allows nurse to assess hours, or according to agency policy patient and re-evaluate need for and patient need. Perform range-ofrestraint. It also allows interventions motion exercises. for toileting, provision of nutrition and liquids, exercise and change of position. Exercise increases circulation in restrained extremity. 10.Evaluate patient for continued need 10.Continued need must be of restraint. Reapply restraint only if documented for reapplication. continued need is evident and order is still valid. 11.Reassure patient at regular 11.Reassurance demonstrates caring

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intervals. Provide continued explanation of rationale for interventions, reorientation if necessary, and plan of care. Keep call bell within easy reach. 12.Perform hand hygiene.

and provides opportunity for sensory stimulation as well as ongoing assessment and evaluation. Patient can use call bell to summon assistance quickly. 12.Reduces spread of microorganisms.

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Mummy Restraint 6. Apply restraint according to 6. Proper application prevents injury. manufacturers directions: a) Open blanket or sheet. Fold one a) This position the patient correctly corner to the center. Place the on the blanket. patient on the blanket, shoulders at the fold, and feet toward the opposite corner. b) Wrapping snugly ensures that b) Position the patients right arm (if child will not be able to wiggle restraining right arm) alongside his out. body. The left arm should not be constrained at this time. Pull the right side of the blanket tightly over the childs right shoulder and chest. Secure under the left side of his body. c) Wrapping snugly ensures that c) Position the left arm along the child will not be able to wiggle patients body. Pull left side of the out. blanket tightly over the patients left shoulder and chest. Secure under the right side of his body. d) Ensures that patient will not be d) Fold the lower corner up and pull able to wiggle out. over the patients body, Secure under the childs body on each e) Prevents injury. Reassurance side or with safety pins. demonstrates caring and provides e) Stay with child while mummy warp opportunity for ongoing is in place. Reassure child and assessment and evaluation. parents at regular intervals. One examination or treatment is completed, unwrap the child. . 7. Perform hand hygiene. 7. Reduces spread of microorganisms. EVALUATION The expected outcomes are met when the patient is constrained by the restraint, remains free form injury, and the restraint does not interfere with therapeutic devices; the patient does not experience impaired skin integrity; does not injure himself/herself due to restraints; and the patients SO will demonstrate and understanding about the use of the restraint and their role in the patients care. SPECIAL CONSIDERATIONS EXTREMITY RESTRAINT Patient has an IV catheter in the right wrist and is trying to remove drain from wound: The left wrist may have a cloth restraint applied. Because of the IV in the right wrist, alternative forms of restraints should be tried, such as a cloth mitt or an elbow restraint. Patient cannot move left arm: Do not apply restraint to an extremity that is immobile. If patient cannot move the extremity, there is no need to apply a restraint. Restraint may be applied to right arm after obtaining a physicians order. Do not position patient flat in a supine position with wrist restraints. If patient vomits, aspiration may occur.

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Check restraint for correct size before applying. Too large restraint may free the extremity; too small, circulation may be affected. Consider keeping scissors with emergency supplies in case the restraints cannot be untied quickly.

JACKET OR VEST RESTRAINT Patient slides down and neck is caught in restraint: Immediately release restraint. Determine alternate methods for restraining. Patient slides down and out of the restraint: Apply smaller vest restraint. Vest restraints come in various sized, and the patient should not be able to slide out of vest. Patient is exhibiting signs of respiratory distress: Release vest. Vest may be applied too tightly and cause difficulty with chest expansion. Consider keeping scissors with emergency supplies in case the restraints cannot be untied quickly. ELBOW RESTRAINT Skin breakdown is noted on elbows: ensure that restraints are being removed routinely for at least 30 minutes and a skin inspection is done. If restraints are still needed, a padded dressing may be applied under the elbow restraint. Patient cries when elbow is moved: Restraints need to be removed more frequently, with active and or passive ROM. If elbow is not moved, it will become stiff and painful. LEATHER RESTRAINT Do not position patient flat in a supine position with wrist restrained. If patient vomits, aspiration may occur. Have the key for locking leather restraints readily available at all times. MUMMY RESTRAINT Application of mummy does not control the patients body movement to allow for needed examination or treatment: Reassess situation and consider more restrictive type of restraint. REFERENCES Christensen, B. L. & Kockrow, O. (2006). Foundations of Nursing, 5th ed. Canada: Mosby Elsevier, pp. 357 360. Lynn, P. (2008). Taylors Clinical Nursing Skills: A Nursing Process Approach, 2nd ed. Philadelphia: Lippincott Williams and Wilkins, pp. 103 119. Taylor, C., et. al. (2008). Fundamentals of Nursing: The Art and Science of Nursing Care, 6th Ed. Philadelphia: Lippincott Williams and Wilkins, pp. 692 694.