2. DEFINITION
🞭 Restraints are protective devices which are
either attached are adjacent to the patients
body and are used for immobilization or
restricting the activity.
3. PURPOSES
🞭 To protect the immediate safety of the patients
or others.
🞭 To prevent patients from falling.
🞭 To prevent interruption of therapy.
🞭 To prevent a confused patient form removing
any life support equipments.
🞭 To reduce the risk of injury to others
4. TYPES OF RESTRAINTS
TYPES INDICATIONS IMAGES
1.MITTENS RESTRAINTS •Patient who scratch
themselves or pull out
tubes.
2. LAP OR BELT IN THE
CHAIR
•Patients at risk of sliding or
falling form the chair.
5. 3. BED RAIL OR SIDE RAILS •Patient at risk of fallings.
4. CHAIR WITH BELT •Patient at risk of
wandering or falling.
5. ABDOMINAL BELT •Patients at risk of falling or
self-harm.
6. 6.WRIST RESTRAINT •Patient at risk of pulling
out the tubes.
7. ELBOW RESTRAINT •Patients at risk of pulling
out the tubes.
8.MUMMY RESTRAINT •To restrict the movement
of the limb in small children
during procedures.
7. HAZARDS OF RESTRAINTS
🞭 Tissue damage due to constant friction.
🞭 Damage to other parts of body such as
dislocation.
🞭 Development of pressure sores.
🞭 Never damage or ischemia.
🞭 Foot drop or wrist drop.
🞭 Asphyxia or aspiration pneumonia.
🞭 Patients feel that he or she is punished.
8. GENERAL INSTRUCTIONS
🞭 Explain the need for application and type of
restraints.
🞭 Consider the emotional impact of application
on family and friends.
🞭 Restraints shouldn’t be applied without doctors
order.
🞭 Consent should be obtained before application
of restraints.
🞭 Restrains should be used with greatest care.
9. 🞭 Circulation must not be occluded.
🞭 Pad the bony prominences.
🞭 While applying restraints, see that the normal
body position can be assumed.
🞭 Untie the restraint at least every 4 hours.
🞭 Patient with restraint should be visited at least
every 30-60 minutes.
🞭 Skin folds should be clean and dry prior to
application of restraint.
🞭 Ensure that there are no wrinkles in restraints.
10. NURSES RESPONSIBILITES
🞭 Monitor a patient in restraint every 15 minutes for: signs of
injury, circulation and rage of motion , comfort and
readiness for discontinuation of restraint.
🞭 Documentation every 2 hours.
🞭 Assess the clients behaviour and the need for restraint and
applies as a last resort.
🞭 Get written order and obtain consent as per hospital policy.
🞭 Must communicates with the client and family members.
🞭 Explain the client the reason for the restraint and
cooperation.
🞭 Arrange adequate assistance form competent staff before
carrying out the restraint procedure.
11. 🞭 Apply the least restrictive, reasonable and appropriate
devices.
🞭 Arrange the client under restraint in a place for easy, close
and regular observatin.
🞭 Particular attention to his/her safety, comfort and dignity,
privacy and physical and mental conditions.
🞭 Attend the clients biological and psychosocial needs during
restraint at regular intervals.
🞭 Review the restraint regularly or according to institutional
policies.
🞭 Consider the earliest possible discontinuation of restraint.
🞭 Document the use of restraint for record and inspection
purposes.
12. NURSING PROCEDURE
🞭 Check the physician order.
🞭 Identify the patients.
🞭 Explain the procedure to the patients and his/her relatives.
🞭 Allow the patient to ask question and encourage his/him to
participate in the procedure as much as possible.
🞭 Ensure patients privacy.
🞭 Wash and dry hands.
🞭 Arrange the articles near the patients bed side.
🞭 Make sure that the restraints are correct size for the patients
build and weight.
🞭 Obtain adequate assistance to manually restrain the patient.
13. 🞭 Mummyrestraint:
🞭 The child is placed in an open blanket which is
adjusted in such a way that one edge is under
the child's neck and another extends beyond its
feet.
🞭 The child's arms are placed by the sides.
🞭 Elbowrestraint:
🞭 Elbow is extended, padded and bandaged with
a wooden spatula placed on the anterior or
flexor aspect,
14. 🞭 Jacket restraint:
🞭 The jacket is put on the child keeping the laces
at the back, so that child cannot touch them
🞭 The long tapes on the jacket are fixed to the
under structure of the crib.
🞭 Clove-hitchrestraint:
🞭 The wrist or ankle is placed in the loops of
device. The ends of the device are pulled to
make it firm and tied to the cot frame. It should
be tight enough to prevent slippin off the hand
or foot.
15. 🞭 After an hour placing a restraint, the patient
should be evaluated.
🞭 The nurse assigns a qualified staff member to
observe the client.
🞭 Conduct an assessment of the patients,
a) Vital signs, respiratory status , circulation , skin
integrity and mental status.
b) Provides relief from restraints by releasing one
limb at a time and providing active range of
motion exercise.
c) Provides hydration, food and toileting.
d) Evaluates the need for continuation of restraints.
16. 🞭 If restraints are no longer needed the nurse
releases the patient form restraints before the
physicians order expires.
🞭 Wash hands.
🞭 Replace the articles.
🞭 Document the procedure.
iii.
i. Events that led to the use of restraints.
ii. An alternative intervention attempted and
patients responses.
Time of initiation and time of discontinuation of
restraints, clients mood and psychomotor
behavior.
