LEVEL I – GRANT



TRINITY VALLEY COMMUNITY COLLEGE

ASSOCIATE DEGREE NURSING

RNSG 1216

PROCEDURE GUIDE AND CHECK-OFF SHEET

RESTRAINTS

Restraints are devices used to restrict or control a patient for the purpose of protecting the patient from harming himself or others. Restraints enable the patient to receive treatment without patient interference.

Delegation: Restraint devices require a physician’s order. The decision to restrain cannot be delegated. Observation of the restrained patient and reapplication of restraints after assisting with feeding and toileting may be delegated to unlicensed assistive personnel that have been trained. The nurse retains the responsibility of assessing and supervising the need for the restraints.

|Procedure |Scientific Rationale |

|1. The following equipment is needed for this skill: | |

|Specific restraint device (vest, belt, wrist, ankle, mitten) | |

|Note: Refer to types of restraints at end of procedure. | |

|Padding. | |

|Assess the need for restraints and consider other alternatives. |Assessment determines if there is a risk for injury to themselves or |

|Assess for underlying reason or restlessness, agitation, or |others and a risk for complications due to interruption of medical care. |

|confusion. |Considering other alternatives prevents the use of physical restraints |

| |when not necessary. |

|3. Choose the least restrictive type of restraint. | |

|Restricts movement as little as possible. |Restrain the patient only to extent necessary to accomplish the |

| |restraint’s purpose. |

|Make sure it does not interfere with patient’s treatment or |Determines if complications may develop. |

|health problem. | |

|Restraint is readily changeable. |Prevents minimal disturbance to patient. |

|Restraint is safe for patient. |Prevents self-inflict injury. |

|Restraint is least obvious to others. |e. Less obvious the restraints, more comfortable patient and family feel. |

|Ensure that physician’s order has been provided or in the case of|Prevents potential legal action. Be familiar with facility’s restraint |

|an emergency, within 24 hours. |policy. |

|5. Application of restraints: | |

|Pad bony prominence before applying restraint. |Abrasions of the skin can occur without the use of padding. |

|Make sure two fingers can be inserted between restraint and limb.|Ensures proper circulation of limbs. |

|Avoid constricting patient’s breathing. | |

|Apply restraint so patient can move freely as possible without |Ensures proper chest expansion. |

|defeating purpose. |Prevents restraint from being too tight or too loose when side rail is |

|Tie restraint to bed frame, not side rail. |moved. |

|Tie restraint in location where patient cannot reach. |Prevents removal by patient. |

|Tie restraint with a slip knot. (One that does not tighten when |Quick release knots ensure quick release of restraint and does not tighten|

|patient pulls and is easy to release). |when the patient pulls on the |

| |restraint. |

|6. Monitoring restraints: | |

|Be familiar with facility’s policy on restraints. |a. Prevents potential legal action. |

|Check patient’s skin for redness or broken skin and circulation | |

|every 30 minutes. Check for temperature, sensation, and motion. |b. Prevents complications from poor circulation if restraints are too |

|Remove at first indication of cyanosis, pallor, coldness, |tight or too restrictive. |

|numbness, or pain. | |

|Release restraint according to policy. (usually every 2 hours) | |

|Provide a regular schedule for toileting, nutrition, and skin | |

|care. (usually every 2 | |

|hours) |c. Prevents complications from restraints and provides opportunity for |

|Reassess need for restraints.(usually every 2 hours) |range of motion exercises. |

| |d. Ensures meeting patient’s needs. |

| | |

| | |

| |e. Determines the need for continuation of restraints. |

| 7. Documentation: |All data must be entered in patient’s record. |

|Rationale or behavior leading to application of restraint. | |

|Type of restraint. | |

|Time of application. | |

|Ongoing assessment (respiratory status, circulation, condition of| |

|skin) and interventions to prevent complications. | |

|Time restraints are discontinued and patient’s response. | |

|Frequency of care given. | |

• Vest Restraint:

▪ Prevents patient from getting out of bed or chair

▪ Secures both shoulders and waist

▪ Place vest with opening at front or back (should be labeled)

▪ Pull tie on end of vest flap across chest and place through slit on opposite side

▪ Repeat other tie

▪ Use quick release knot around bed frame or chair leg

▪ Ensure breathing is not compromised

• Belt Restraint:

▪ Secures patient at waist

▪ Ensures safety of patients being moved on stretchers or wheelchairs

▪ Also, used for patients confined to chairs

▪ One belt is placed under the patient and the other belt is placed aross the waist

▪ Use quick release knot around bed frame or chair back

• Wrist or Ankle Restraint:

▪ Secures hands or ankles to prevent injury or pulling out equipment

▪ Pad bony prominences before application

▪ Apply padded portion of restraint around ankle or wrist

▪ Pull tie through slit or buckle

▪ Use quick release knot around bed frame

• Mitten Restraint:

▪ Prevents use of hands

▪ Apply so fingers can be slightly flexed

N:ADN/ADN Syllabus/CBC Curriculum/Level I/1216/Performance Checklist for Basic Skills - Restraints Reviewed 04/16

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