Teaching Wellness

Reducing Electrical Hazards

Take the following steps to reduce electrical hazards:

 Check cords for fraying or other signs of damage before using an appliance. Do not use it if the
cord is damaged.
 Avoid overloading outlets and fuse boxes with too many appliances; use grounded outlets and
plugs.
 Always pull a plug from the wall outlet by firmly grasping the plug and pulling it straight out.
Pulling a plug by its cord can damage the cord-and-plug unit.
 Ensure that ground fault circuit interrupters have been installed wherever electrical appliances
or equipment can inadvertently come in contact with water, such as near sinks, bathtubs, or
showers, or outdoors.
 Keep electric cords and appliances out of the reach of children, and place protective covers over
wall outlets to protect young children.
 Carefully read instructions before operating electric equipment.
 Always disconnect appliances before cleaning or repairing them.
 Unplug any appliance that has given a tingling sensation or shock when touched, and have an
electrician check the appliance.
 Keep electric cords coiled or taped to the ground away from areas of traffic to prevent people
from damaging the cords or tripping over them.

When major electrical injury does occur, such as macroshock (when the current finds a pathway
through the body), the victim may sustain both superficial and deep burns, muscle contractions, and
cardiac and respiratory arrest, necessitating CPR and life support. Small currents can cause microshock
(when the current flows through a direct pathway to the heart), such as during intracardiac
catheterization. Using machines in good repair, wearing shoes with rubber soles, standing on a
nonconductive floor, and using nonconductive gloves can prevent shock. Rescuers must not touch the
victim until the electricity is shut off or the victim has been removed from contact with the electric
current; otherwise, the rescuer can also receive electrical injury.

Firearms Canada has strict regulations about firearm ownership. Any gun owner is required to
follow a range of safety precautions to ensure that no harm or injury results from improper gun use or
storage. Access to firearms is a serious concern in homes with children and in situations of suicidal
ideation or domestic violence. Members of any household in which guns are present must take full
responsibility for following basic firearm safety rules: Store all guns in sturdy locked cabinets, and make
sure the keys are inaccessible to children; store bullets in a different location from the gun; and do not
use firearms while under the influence of alcohol or other drugs of any kind, including OTC medications
that can change sensorium.
 Radiation Radiation injury can result from overexposure to radioactive materials used in diagnostic
and therapeutic procedures. Clients being examined by using radiography or fluoroscopy generally
receive minimal exposure, and few precautions are necessary. Nurses need to protect themselves,
however, from radiation when some clients are receiving radiation therapy. Exposure to radiation can be
minimized by (a) limiting the time near the source, (b) providing as much distance as possible from the
source, and (c) using shielding devices, such as lead aprons, when near the source. Nurses need to
become familiar with agency protocols related to radiation therapy.

Procedure-Related and Equipment-Related Risks

Risk assessment in the health care setting must include risks related to procedures and equipment.
Whether giving a medication or assisting a person out of bed, nurses need to follow safeguards to
prevent errors or unintentional injury. Nurses must be aware of and adhere to provincial or territorial
regulations of occupational health and safety. In 2015, Canada implemented the Workplace Hazardous
Materials Information System, a national chemical classification and hazard communication standard for
workplace chemicals. The WHMIS incorporates the Globally Harmonized System of Classification and
Labelling of Chemicals (or GHS) for workplace chemicals. Figure 32.8 is an example of a pictogram used
by the GHS.

When an error or unintentional injury does occur, most agencies require that the incident be
reported. Indeed, in some agencies where client safety is a priority, personnel are encouraged to report
near-misses so that an analysis can be conducted and preventive measures put in place to ensure client
safety. For additional information about incident reports, see Chapter 6.

Restraining Clients

Restraints are physical, chemical, or environmental measures used to control the physical or
behavioural activity of a person or a portion of his or her body. Physical restraints comprise any manual
method or physical or mechanical device, material, or equipment attached to the client’s body (e.g., vest
or wrist restraint); they cannot be removed easily, and they restrict the client’s movement.
Environmental restraints control a person’s mobility, such as when two full bedside rails or four split
bedside rails are raised or the client is placed on a secured unit. Chemical restraints are medications,
such as neuroleptics, anxiolytics, sedatives, and psychotropic agents, used to control disruptive
behaviour. Generally, the only justifiable reasons for applying restraints are to avoid or prevent
purposeful or accidental harm to a client when all other methods have been tried or to do what is
required to provide medically necessary treatment that could not be provided through any other means.
To reiterate, restraints should be used only after all other possible means of ensuring safety have been
unsuccessful and documented. If restraints are deemed necessary, then a policy of least restraint—the
use of the minimum amount of restraint needed to ensure safety (e.g., by securing one hand rather than
both)—should be applied. Most agencies have strict policies and procedures related to the use of
restraints.

Restraints can contribute to muscle atrophy, skin deterioration, urinary incontinence, constipation,
and respiratory infection because the client is more likely to remain recumbent or confined to bed when
restrained. Coroners’ reports have linked restraints to deaths, such as death by suffocation from
becoming trapped between bedrails when trying to climb out of bed, strangulation when the ties of a
restraint vest encircle the neck, or aspiration from vomitus when protective movements are limited by
restraints. In addition to the physical safety concerns, many consider restraints to be demeaning and to
limit a client’s autonomy. They can be harmful psychologically, such as by making clients feel ashamed
or guilty. For clients with a history of sexual abuse or other forms of violence, being placed in restraints
has been linked to flashbacks and potential exacerbation of posttraumatic stress disorder (PTSD)
symptoms. The focus in health care is to explore ways to prevent, reduce, and eliminate the use of
restraints while protecting a client’s safety, rights, and dignity.

Legal Implications of Restraints Because restraints restrict the individual’s freedom, their use has
legal implications. Nurses need to know agency policies and provincial or territorial laws about
restraining clients. A clear understanding of what constitutes a restraint is important. For example, if a
client has the side rails up to help with side-to-side movement in the bed, then this situation is not one
of restraint; if, however, the side rails are up to confine the client, then the use of side rails is considered
an environmental restraint. Most agencies and provincial or territorial legislation require informed
consent of the client or the legal representative before implementing restraints in nonemergency
situations. A collective prescription or policy will generally identify the steps to be followed before using
restraints. Some institutions allow for individual decision making in emergency situations, but the trend
is toward documented interdisciplinary and client or family dialogue before the use of restraints.
Continued use of restraints must also be addressed, often within specific time frames (e.g., involuntary
restraint may require reassessment every 2 to 4 hours, and voluntary restraint is generally reviewed
every 8 or 24 hours). Most agencies require visual or auditory supervision of any client in restraint so
that any safety issues can be quickly addressed. (See the Clinical Alert box regarding restrained clients.)

Clients have the right to be free from restraints that are not medically necessary. As a result, there
must be justification that the use of restraints will protect the client and that less restrictive measures
were attempted and found ineffective. Restraints cannot be used for staff convenience or client
punishment. To reiterate, generally, the only justifiable reasons for applying restraints are to avoid or
prevent purposeful or accidental harm to a client when all other methods have been tried and have
failed and to do what is required to provide medically necessary treatment that could not be provided
through any other means. Given that the above conditions are met and physical restraints are needed, it
is important for the nurse to be able to correctly apply the restraints without endangering client safety.

Selecting a Physical Restraint Before selecting a physical restraint, nurses need to understand its
purpose clearly and measure it against the following five criteria:

1. It restricts the client’s 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 client’s treatment or health problem. If a client has poor blood
circulation to the hands, apply a restraint that will not aggravate that 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.
4. It is safe for the particular client. Choose a physical 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. It is the least obvious to others. Clients and visitors can be embarrassed by a physical restraint,
even though they understand why it is being used. The more discreet the restraint, the more
comfortable people feel.

Clinical Alert

Restrained clients may become more restless and anxious as a result of loss of self-control. The nurse
must keep in mind that such behaviours may be the result of pain or hypoxia from improper restraint
application. A client who was agitated and suddenly becomes quiet must be assessed to ensure that the
change in behaviour is the result of calmness rather than a hypoxic or other physiological event.

Types of Physical Restraints Several types of physical restraints are available. Among the most common
for adults are jacket or vest restraints, belt restraints, mitt or hand restraints, and limb restraints.
Although bed rails can be used to aid in turning or repositioning and reduce the risk of clients falling out
of bed during transport, they are also seen as restraints in that they can limit purposeful movement.
Geri-chairs and wheelchairs with lap trays are also classified as forms of restraints. Physical restraints for
infants and children include mummy restraints, elbow restraints, and crib nets. When considering or
using restraints, the nurse will find Practice Guidelines 32.2 helpful.

Several types of vest restraints are used, but all are essentially sleeveless jackets or vests with
straps (tails) that can be tied to the bed frame under the mattress. These body restraints are used to
ensure the safety of confused or sedated clients in beds or wheelchairs. “Front” and “back” labels on
vest restraints ensure that they are applied correctly and safely.

Belt or safety strap body restraints (Figure 32.9) are used to ensure the safety of 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 armrests. To prevent the person from slumping
forward, the nurse then attaches a shoulder Y strap to the bar and over the client’s shoulders to the rear
handles. Other safety belt models have a three-loop design. One loop surrounds the person’s waist and
the other two attach to the rear handles. If such restraints are unavailable, the nurse can place a folded
towel or small sheet around the client’s waist and fasten it at the back of the wheelchair. Belt restraints
can also be used for certain clients confined to bed or to chairs.

A mitt or hand restraint (Figure 32.10) 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 at a head bandage following neurosurgery. Hand or mitt
restraints allow the client to be ambulatory and to move the arm freely rather than be confined to a bed
or a chair. Mittens need to be removed on a regular basis to permit the client to wash and exercise the
hands. The nurse also needs to take off the mitten to check the circulation to the hand.

Limb restraints (Figure 32.11) can be used to immobilize a limb, primarily for therapeutic reasons (e.g.,
to maintain an intravenous infusion). See Skill 32.3 for applying restraints. See also the Lifespan
Considerations box on the use of restraints that follows.

Evaluating

To prevent client injury, the nurse’s role is largely that of an educator, and desired outcomes
reflect the client’s acquisition of knowledge of hazards, behaviours that incorporate safety practices, and
skills to perform in the event of certain emergencies. The nurse needs to individualize these for clients.
Examples of desired outcomes include the client being able to do the following:

 Describe methods to prevent specific hazards (e.g., falls, suffocation, scalds, fires,
drowning, electric shock)
 Report use of home safety measures (e.g., fire safety measures, smoke detector and CO
detector maintenance, fall-prevention strategies, burn-prevention measures, poison-
prevention measures, firearm safety precautions, water safety precautions, motor
vehicle safety)
 Alter home physical environment to reduce the risk of unintentional injury
 Describe emergency procedures such as for poisoning or fire
 Describe age-specific risks, work safety risks, or community safety risks
 Demonstrate correct use of child safety seats

SKILL 32.3 APPLYING PHYSICAL RESTRAINTS

1. PURPOSES
 To promote safety and prevent injury only when all other less restrictive measures have
been exhausted
 To allow a medical or surgical treatment to proceed without client interference (e.g., to
prevent movements that would disrupt therapy to a limb connected to tubes or an
appliance)
2. ASSESSMENT
Assess
 The behaviour indicating the possible need for a restraint
 Underlying causes for the assessed behaviour
 What other protective measures can be implemented before applying a restraint
 The status of skin to which a restraint is to be applied
 The circulatory status distal to restraints and of extremities •
 The effectiveness of other available safety precautions
Clinical Reasoning
 Was something that might explain why this client seems to need restraints (e.g., hypoxemia,
psychological distress) missed during the assessment phase? If that reason could be identified
and addressed, would it mean that restraints are not needed? If the client is agitated or angry,
was an opportunity given to share his or her feelings and frustrations? How will the client and
the family interpret the use of the physical restraint, and how can the nurse buffer the
potentially negative feelings? Is it possible that the family and the client see the restraints as
helpful and are relieved that restraints will be used, for example, when it is feared that the
client might self-extubate unless the hand is gently restrained?
3. PLANNING
Review institutional policy for restraints, and seek consultation, as appropriate, before
independently deciding to apply a restraint. Many Canadian institutions require interdisciplinary
discussions and informed client or legal guardian consent before instituting restraints.
Equipment
 Appropriate type and size of restraint
4. IMPLEMENTATION
Performance
a Once consent has been obtained and before performing the procedure, introduce
yourself to the client, and verify the client’s identity by using two identifiers. Explain to
the client and the family what you are going to do, why it is necessary, and how they can
participate. Allow time for the client to express his or her feelings about being
restrained. Provide needed emotional reassurance that the physical restraints will be
used only when absolutely necessary and that the nurse will be in close contact with the
client in case assistance is required.
b Perform hand hygiene, and follow other appropriate infection prevention and control
procedures.
c Provide for client privacy, if indicated.
d Apply the selected restraint.
Belt Restraint (Safety Belt)
 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 a long portion and a shorter portion, place the long portion of the belt
behind (under) the client confined to bed and secure it to the movable part of the bed
frame. Rationale: The long, attached portion will then move up when the head of the
bed is elevated and will not tighten around the client.
 Place the shorter portion of the belt around the client’s waist, over the gown. There
should be a finger’s width between the belt and the client.
 Or attach the belt around the client’s waist, and fasten it at the back of the chair.
 Or if the belt is attached to a stretcher, secure the belt firmly over the client’s hips or
abdomen. Rationale: Belt restraints must be applied to all clients on stretchers, even
when the side rails are up.
Jacket Restraint
 Place the vest on the client, with opening at the front or the back, depending on the
vest type.
 Pull the tie on the end of the vest flap across the chest, and place it through the slit in
the opposite side of the chest.
 Repeat for the other tie.
 Use a half-bow (quick-release) knot to secure each tie around the movable bed frame
or behind the chair to a chair leg (see ❶ and ❷). Rationale: A half-bow (quickrelease)
knot does not tighten or slip when the attached end is pulled but unties easily when the
loose end is pulled.
 Or fasten the ties together behind the chair by using a slip or quick-release knot.
 Ensure that the client is positioned appropriately to enable maximum chest expansion
for breathing.
Mitt Restraint
 Apply the commercial thumbless mitt (see Figure 32.10) to the hand to be restrained.
Make sure the fingers can be slightly flexed and are not caught under the hand.
 Follow the manufacturer’s directions for securing the mitt.
 If a mitt is to be worn for several days, remove it at regular intervals per agency
protocol. Wash and exercise the client’s hand, then reapply the mitt. Check agency
practices about recommended intervals for removal.
 Assess the client’s circulation to the hands shortly after the mitt is applied and at
regular intervals. Rationale: Client complaints of numbness, discomfort, or inability to
move the fingers could indicate impaired circulation to the hand.
Wrist or Ankle Restraint
 Pad the bony prominences on the wrist or ankle, if needed, to prevent skin breakdown.
 Apply the padded portion of the restraint around the ankle or wrist.
 Pull the tie of the restraint through the slit in the wrist portion or through the buckle
and ensure that the restraint is not too tight (see ❸).
 By using a half-bow knot (quick-release knot), attach the other end of the restraint to
the movable portion of the bed frame. Rationale: If the ties are attached to the movable
portion, the wrist or ankle will not be pulled when the bed position is changed.
e Adjust the plan of care, as required, for example, to include releasing the restraint,
providing skin care, helping with range-of-motion exercises, and attending to the client’s
physical needs by providing fluids, nutrition, and toileting care.
f Record on the client’s chart the behaviour(s) indicating the need for the restraint, all
other interventions implemented in an attempt to avoid the use of restraints and their
outcomes, and the time the physician was notified of the need for restraint. Also, record
the following:
 The type of restraint applied, the time it was applied, and the goal for its
application
 The client’s response to the restraint, as well as the rationale for its continued
use
  The times that the restraints were removed and skin care given
 Any other assessments and interventions
 Explanations given to the client and significant others
1. Evaluation
 Perform a detailed follow-up of the need for the restraints and the client’s
physical and emotional responses. Relate these findings to previous data, if
available. Evaluate circulatory status of restrained limbs at least on an hourly
basis.
 Evaluate skin status beneath restraints at least on an hourly basis.
 Remove the restraints as soon as they are no longer needed, and document
the removal.
 When restraints are released, ensure that the client is not experiencing any
emotional or physical consequences. Reaffirm that the physical restraints were
a last resort to protect the client and that they were not a form of punishment.
 Report significant deviations from normal to the appropriate members of the
health care team.