2. RESTRAINTS
are devices used to limit the
physical activity of a client or a
part of the body.
Restraints are frequently used
for older adults with dementia
who are confused and may
pose a threat to themselves
4. CLASSIFICATIONS OF RESTRAINTS
01 Physical Restraints
Physical restraints include “any manual method, physical or mechanical
device, material, or equipment that immobilizes or reduces the ability of a
patient to move his or her arms, legs, body, or head freely” (CMS, 2008).
5. CLASSIFICATIONS OF RESTRAINTS
02 Chemical Restraints
Chemical restraints involve using a medication to control
behavior or to restrict the client’s freedom of movement
and is not a standard treatment for the client’s medical
or psychological condition (CMS, 2008).
03 Seclusion
Seclusion is defined as the confinement of
a patient in a locked room from which they
cannot exit on their own.
6. Selecting a Restraint
1. It restricts the client’s movement as little as possible.
2. It is safe for the particular client. Choose a restraint with
which the client cannot self-inflict injury.
3. It does not interfere with the client’s treatment or health
problem.
4. It is readily changeable. Restraints need to be changed
frequently, especially if they become soiled.
5. It is as discreet as possible. The less obvious the restraint,
the more comfortable people feel.
7. Purpose of Applying Restraints
To promote safety and prevent injury
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
appliance)
8. ASSESSMENT
The behavior indicating the possible need for a
restraint
Underlying cause for assessed behavior
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
9. IMPLEMENTATION
Performance
1. Prior to performing the procedure, introduce self and verify the client’s
identity using agency protocol. Explain to the client and family what you
are going to do, why it is necessary, and how they can participate. Allow
time for the client to express feelings about being restrained. Provide
needed emotional reassurance that the restraints will be used only when
absolutely necessary and that there will be close contact with the client in
case assistance is required.
2. Perform hand hygiene and observe other appropriate infection prevention
procedures.
3. Provide for client privacy if indicated.
4. Apply the selected restraint.
10. IMPLEMENTATION
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 bedridden client and secure it to
the movable part of the bed frame. 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.
11. IMPLEMENTATION
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.
12. IMPLEMENTATION
Jacket Restraint
• Place vest on client, with opening at the front or the back,
depending on the 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.
13. IMPLEMENTATION
• Use a half-bow knot (a type of quick-release knot) to secure each tie around
the movable bed frame or behind the chair to a chair leg.
14. IMPLEMENTATION
• Fasten the ties together behind the chair using a slip or
quick-release knot.
• Ensure that the client is positioned appropriately to enable
maximum chest expansion for breathing.
15. IMPLEMENTATION
Mitt Restraint
• Apply the commercial thumbless mitt 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.
16. IMPLEMENTATION
• 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 policies about recommended intervals
for removal.
• Assess the client’s circulation to the hands shortly after the mitt
is applied and at regular intervals.
17. IMPLEMENTATION
Wrist or Ankle Restraint
• Pad 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.
• Using a half-bow knot, attach the other end of the restraint to the
movable portion of the bed frame.
19. IMPLEMENTATION
6. Document on the client’s chart the behavior(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 primary care provider was
notified of the need for restraint. Also record:
• The type of restraint applied, the time it was applied, and the goal for its
application.
• The client’s response to the restraint, including a rationale for its
continued use
20. IMPLEMENTATION
• The times that the restraints were removed and skin care given
• Any other assessments and interventions
• Explanations given to the client and significant others.
• Perform a detailed follow-up of the need for the restraints and
the client’s response. Relate these findings to previous data if
available.
EVALUATION
21. • Evaluate circulatory status of restrained limbs.
• Evaluate skin status beneath restraints.
• Remove the restraints as soon as they are no longer needed and
document.
• Report significant deviations from normal to the primary care
provider.
EVALUATION
