Firstly, Patient restraints definition, types, procedure. Secondly, skin traction and skeletal traction, nursing role and patient care during traction Anx finally, How to use antiembolism stocking, its indications, contraindications, procedure and considerations

1. Applying Restraints

2. ODefinition:
Restraints are devices used to limit the
physical activity of a patient or a part of
the body.

3. OTypes of Restraints:-
Several types of restraints are available among the most
common for adults are:
O1. Jacket or vest restraints.
O2. Mitt or hand restraints.
O3. Belt restraints.
O4. Limb restraints.
O5.Elbow restraints

6. OPurposes:
O1- To promote safety and prevent injury.
O2- To allow a medical or surgical treatment to
proceed without patient interference (e.g., to
prevent movements that would disrupt therapy
to a limb connected to tubes or appliance).

7. OAssessment:
-The behavior indicating the possible need for a
restraint.
- Underlying causes for the assessed behavior.
- What other protective measures can be
implemented before applying a restraint
- Status of skin to which restraint is to be applied.
- Circulatory status distal to restraints and of
extremities.

8. OEquipment:
1- Proper restraint (e.g., belt, wrist, mitten)
2- Padding (if needed).

9. OProcedure:
O Step 1: Assess patient’s behavior (e.g., confusion,
disorientation, agitation, restlessness, combativeness,
repeated removal of tubing or other therapeutic devices,
and inability to follow directions).
O Rationale: If patient’s behavior continues despite
treatment or restraint alternatives, use of restraint is
indicated.

10. OStep 2: Follow agency policies regarding
restraints.
OCheck health care provider’s order for purpose,
type, location, and time or duration of restraint.
ODetermine if signed consent for use of restraint is
necessary.

11. Rationale: In acute care settings a licensed health
care provider who is responsible for care of
patient must order least restrictive type of
restraint.
OEach original restraint order is limited to 4
hours for adults 18 years of age and older, 2
hours for children ages 9 through 17, and 1
hour for children younger than age 9.

12. OStep 3: Review manufacturer’s instructions for
correct restraint application and determine most
appropriate size restraint.
ORationale: You need to be familiar with all
devices used for patient care and protection.
Incorrect application of restraint device can
result in patient injury or death.

13. OStep 4: Inspect areas where restraint is to be
placed.
ONote if there is any nearby tubing or devices.
OAssess condition of skin, sensation, adequacy
of circulation, and range of motion (ROM).

14. OStep 5: Identify patient using two identifiers
(e.g., name and birthday or name and account
number) according to agency policy.
OCompare identifiers with information on
patient’s medication administration record
(MAR) or medical record.

15. O Step 6: Provide privacy. Explain to patient and
family purpose of restraint.
O Be sure patient is comfortable and in correct
anatomical position.
OStep7: Pad skin and bony prominences (as
necessary) that will be covered by restraint.
OStep 8: Apply proper size restraint: Follow
manufacturer’s directions.

16. Oa. Belt restraint:
O - Have patient in a sitting position. Apply belt over
clothes, gown.
O Make sure to place restraint at waist, not the chest
or abdomen.
O - Remove wrinkles or creases in clothing. Bring
ties through slots in belt.
O - Help patient lie down if in bed.
O Avoid applying the belt too tightly

17. OThis type of restraint may be contraindicated in
patient who had abdominal surgery.
ORoll belt restraint tied to the bed frame and to
an area that does not cause the restraint to
tighten when the bed frame is raised or
lowered.

19. Belt restraint

20. Ob. Extremity (ankle or wrist) restraint:
Commercially available limb restraints are
composed of sheepskin with foam padding.
OWrap limb restraint around wrist or ankle with
soft part toward skin and secured snugly (not
tightly) in place by Velcro straps.
O Insert two fingers under secured restraint

21. ORationale: Restraint immobilizes one or all
extremities to protect patient from fall or
accidental removal of therapeutic device (e.g.,
intravenous [IV] tube, Foley catheter).
OTight application will interfere with circulation
and cause neurovascular injury.

22. Wrist restraint

23. O c. Mitten restraint:
O Thumb less mitten device restrains patient’s hands.
O - Place hand in mitten, being sure Velcro strap(s) is
(are) around the wrist and not the forearm.
O Rationale: Prevents patients from dislodging
invasive equipment, removing dressings, or
scratching yet allows greater movement than a
wrist restraint.

24. Velcro strap

25. Mitten restraint

26. Od. Elbow restraint (freedom splint):
ORestraint consists of rigidly padded fabric that
wraps around arm and is closed with Velcro.
O-Upper end has a clamp that hooks to patient’s
gown sleeve.

27. Insert patient’s arm so elbow joint rests against
padded area, keeping joint rigid
Rationale: Commonly used with infants and
children to prevent elbow flexion (e.g., when IV
line is placed in antecubital fossa).
May also be used for adults.

29. O Step 12: Remove restraints at least every 2 hours or
according to agency policy, and assess patient each
time. If patient is violent or noncompliant, remove one
restraint at a time and/ or have staff assist while
removing restraints.
Rationale: Removal provides opportunity to change
patient’s position, offer nutrients, perform full ROM,
toilet, and exercise patient.

30. O Step 13: Secure call light.
O Step 14: Leave bed or chair with wheels locked. Keep
bed in lowest position.
O Rationale: Locked wheels prevent bed or chair from
moving if patient tries to get out. Placing bed in lowest
position reduces chance of injury if patient falls out of
bed.

31. Traction

33. Definition:
It is means of immobilization using a pulling
force applied to a part of the body while a second
force called counter traction pulls in the opposite
direction.

34. O - Traction usually applied while patient is in bed. The
pull is achieved by using weights in the form of
sandbags, free weight discs; counter pull is produced
by patient's own weight.

35. OTypes of traction:
1. Skeletal traction: involves placing a pin or wire in the
fractured bone. After one of these devices has been
inserted, weights are attached to it so the bone can be
pulled into the correct position. This is done through a
surgery.
2. Skin traction: non invasive traction. It involves applying
splints, bandages, or adhesive tapes to the skin directly below
the fracture. Once the material has been applied, weights are
fastened to it.

36. 2.Skeletal traction:

37. 1. Skin traction:

38. OEquipments needed:
1. Ropes, pulleys and weights.
2. Tape.
3. Foam rubber, or plastic sheeting.
4. Traction foam boot.
5. Elastic bandage.

41. O Preparation:
O 1- Explain procedure to the patient.
O 2- Provide a trapeze to assist the patient to move and lift
the body for back care if he or she is unable to turn.
O 3- Provide a bedpan as required to minimize the patient's
movement during elimination.

42. The trapeze

43. O Assess the presence of pain in the area; exact location,
degree, duration and description of pain (e.g., sharp, needle
like) and identification of any movement or activity that
wound initiate the pain.

44. O Planning:
O 1- A physical therapist or orthopedic technician
generally performs initial setup of traction.
O 2- The nurse is responsible for caring for the patient in
traction and ensuring that the traction is functioning
properly.

45. O Procedure:
O Step 1: Organize equipment and review the patient
medical history.
O Step 2: Place bed in semi-trendelenburg position.
Make sure this position will not compromise patient's
condition verify with physician before moving patient
to this position.

48. O Step 3: Inspect skin for any signs of abrasion or
lesions that could be disturbed when skin traction is
applied. Make sure skin is clean and dry.
O Rationale: Skin traction (tape and pressure) placed
over abraded areas could aggravate skin condition.

49. O Step 4: Assess the neurovascular status of the affected
extremity. Conduct a neurovascular assessment 30
minutes following application of the bandages, then
every 2 hours for the first 24 hours. If the patient’s
status is normal then assess every 4 hours during the
traction. If the patient's status is not normal, continue
assessments hourly.

50. O Step 5: Have a second person support the affected
extremity so that you can apply the elastic bandage
and foam boot.
O Rationale: Ensures that the affected extremity
remains in alignment reduces discomfort, allows the
nurse the ability to apply the foot boot and elastic
bandages (from the ankle up to knee)

51. O Step 6: Place heel protectors under the heels, sacrum,
shoulders and other pressure areas.
O Step 7: Position the patient in the center of the bed in
good body alignment.
O Rationale: Ensures effective counter pull without
compromising neurovascular status.

52. O Step 8: Check patient's position every 1-2 hours to
ensure that the patient is in proper position.
O Step 9: Teach the patient ways to prevent problems
associated with immobility.
O a- Teach the patient deep-breathing and coughing
exercises to prevent hypostatic pneumonia.

53. O b- Teach the patient appropriate exercises to maintain
and develop muscle tone, prevent muscle contracture
and atrophy and promote blood circulation - Rage of
motion exercises.
O c- Clinical signs of thrombi and emboli; Regularly
assess for evidence of emboli. Inspect the patient's
involved extremity for redness, swelling, and pain.

54. O Step10 : assess pressure areas for signs of skin
irritation or breakdown.
Note in particular:
O (a) bony prominence e.g., the heels, ankles, sacrum,
elbows and shoulders
O (b) areas susceptible to pressure from the traction
e.g., the tibia.

55. O Step11 : assess for presence of skin allergies, signs of
infection or injury.
O Step12 : assess for Inflammation and drainage at the
pin sites for skeletal traction.

56. Step 13: Ensure That all weights hang freely and not rest
against the bed or floor when the bed is in the lowest
position.
Step 14: Ensure that ropes are intact and not frayed,
knotted or kinked between their points of attachment.
Step 15: Provide pin site care daily if indicated by the
primary care provider's orders and agency protocol.

57. O Step 16: Dispose of soiled equipment according to
agency protocol.
O Step 17: Remove and discard gloves if used. Perform
hand hygiene.
O Step 18: Document findings in the patient record.

58. OApplying anti-embolism
stocking

59. ODefinition:
Anti-embolism stockings are firm elastic hose that compress
the veins of the legs.
OTypes of anti-embolism stocking:
1- One type extends from the foot to the knee.
2- Another type extends from the foot to mid-thigh.

61. OPurposes:
1- To facilitate venous return from the lower extremities.
2- To prevent venous stasis and venous thrombosis.
3- To reduce peripheral edema.

62. OIndications:
1- After surgery.
2- Patients who are immobile.
3- Patients who have vascular disorders such as
thrombophlebitis, varicose veins, and other conditions of
impaired circulation of the lower extremities.

63. O Contraindications:
1-Suspected or proven peripheral arterial disease.
2- Peripheral arterial bypass grafting.
3-Local conditions for example skin dermatitis,
gangrene or recent skin graft.
4- Severe leg oedema or pulmonary oedema from
congestive heart failure.
5- Diagnosis of DVT (Deep Venous Thrombosis).

64. OAssessment:
Assess both lower extremities for the following:
1- Rates, volumes, and rhythms of posterior tibial and
dorsalis pedis pulses (note if unequal bilaterally).
2- Skin colour (note pallor, cyanosis, or other
pigmentation).
3- Sensation (note any numbness, tingling, pain).

65. 4- Skin temperature (e.g., warm, cool).
5- Presence of edema (pitting or non-pitting).
6- Skin condition (e.g., thickened, shiny, taut, and
hairless).

67. Planning:
Before applying antiembolism stockings, determine any
potential or present circulatory problems and the
surgeon’s orders involving the lower extremities.

68. OEquipment:
O - Measuring tape.
O - Clean antiembolism stockings of appropriate size
and type ordered (e.g., knee or mid-thigh).

69. Implementation:
Preparation:
O Take measurements as needed to obtain the
appropriate size stockings:
- Measure the length of both legs from the heel to the
gluteal fold (for thigh-length stockings) or from the heel
to the popliteal space (for knee-length stockings).

70. O Measure the circumference of each calf and each thigh
at the widest point. Compare the measurements to the
size chart to obtain stockings of correct size.
O Large stockings do not place adequate pressure on the
legs to facilitate venous return and may bunch,
increasing the risk of pressure and skin irritation.
O Stockings that are too small may impede blood flow to
the feet and cause discomfort.

71. O Procedure:
O Step1. Introduce yourself to the patient, and verify the
patient’s identity.
O Step 2: Explain to the patient what you are going to
do, why it is necessary, and how he or she can
participate.
O Step 3: Perform hand hygiene, and follow other
appropriate infection prevention and control
procedures.
O Step 4: Provide for patient privacy.

72. O Step 5: Select an appropriate time to apply the
stockings:
- Apply stockings in the morning, if possible, before
the patient gets up from bed.
O Rationale: In the sitting and standing positions, the
veins can become distended, resulting in edema; the
stockings should be applied before this happens.

73. O - Assist the patient who has been ambulating to lie
down and elevate the legs for 15 to 30 minutes before
applying the stockings.
O Rationale: This facilitates venous return and reduces
swelling.

74. O Step 6. Prepare the patient:
- Assist the patient to the lying position in bed.
- Wash and dry the legs, as needed.
O Step 7. Apply the stockings:
- Reach inside the stocking from the top, and grasping
the heel, turn the upper portion of the stocking inside
out over the foot portion.

76. O Rationale: Firm elastic stockings are easier to fit over
the foot and calf when inverted in this manner, rather
than bunching the stocking up.
O - Ask the patient to point the toes, and position the
stocking on the patient’s foot, taking care to place the
toe and heel portions of the stocking appropriately.

77. O - Grasp the upper edge of the stocking, and gently pull
the stocking over the leg, turning it right side out in
the process.
O - Inspect the patient’s leg and stocking, smoothing any
folds or creases.
O - Ensure that the stocking is not rolled down or
bunched at the top or ankle.

79. O Remove the stockings for 30 minutes every 8 hours,
inspecting the legs and skin while the stockings are
off.
O - Soiled stockings can be laundered by hand with
warm water and mild soap. Hang to dry.

80. O Step 8: Document the procedure. Record the
procedure, your assessment data, and when the
stockings are removed and reapplied.

81. Thank you