7. Pad bony prominences under a restraint to avoid skin abrasions.
8. When applying the restraints, see that the normal body positions can be assumed or place the body parts in its normal positions e.g., the arms are placed in a flexed position.
9. Untie the restraints at least every four hours, give the exercises to the limbs, provide skin care and reapply them.
10. Clients in restraints should be observed frequently. They should be visited at least every 30 to 60 minutes. They should not have a feeling they are ‘abandoned’.
11. Clients with depressed level of consciousness may have difficulty in handling their secretions and vomitus which may cause aspiration into their lungs and cause suffocation. There should be constant observation over these clients. The restraints may be applied on these clients after placing them in a quarter prone positions.
12. The restraints should not be left within the reach of irrational clients. They may use them as a weapon or as a means of committing suicide.
13. Do not apply linen restraints with a regular knot. Such a knot may be difficult to release quickly in case of emergency. Use a bow, but place it where the client cannot easily reach it. Wherever possible use a clove hitch knot around the limbs to prevent cutting the blood supply.
14. Fasten the restraints to the bed frame and not to the side rails. The arms or legs may be injured when the side rails are lowered and if the restraints are attached to the side rails.
15. Wrist restraints must always be used when ankle restraints are used. The client may be able to take off the ankle restraints if his hands are free.
16. Never apply restraints over an I.V. site. Ensure that the I.V. and other tubings and equipments are not interfered by the restraints.
17. When removing restraints, remove one restraint at a time and watch for the client’s reaction before removing the next.
18. The skin folds (e.g., axilla) should be clean and dry prior to the application of restraints.
19. Ensure that there are no wrinkles or bulges in the restraints which may irritate the skin after application.
20. Before applying the mitt restraints, a hand roll may be used to keep the client’s finger in a functional position.
21.Do not leave the client restrained in chairs. When the client is placed in a chair or wheel chair with the help of restraints, place the back of the chair against a wall to prevent the client from tipping the chair over.
AUTHOR: SUSHMITHA ZEENA
Immobilization and Ambulation – Restraints – Types, Hazard and General Instructions
Restraints are protective devices employed to prevent a client from harming himself or others, to immobilize a part, to restrict the activity and to promote a feeling of security in a client who needs control.
TYPES OF RESTRAINTS
Restraints are made up of linen, canvas, leather, plastic, metal or wood. The common types of restraints are:
Anklets and Wristlets
There are used to restrict the activity of limbs in a client who is potentially harmful to himself or others (e.g. irrational clients) to prevent the client from removing any appliances used in treatment (e.g. nasal tubes) and to immobilize one or more limbs during a procedure (e.g., suturing a wound).
A simple form of an ankle and wrist restraints may be made by padding the wrist or ankle with a thick layer of cotton or gauze, and a bandage is tied over this using clove hitch (which will not tighten upon pulling) and the ends of this bandage is then tied to the bed frame under the mattress. Commercially prepared cuffs are also available.
Elbow and Knee Restraints
The purpose of elbow and knee restraints is to prevent flexion of the elbow and knee joints. These types of restraints can be made by making pockets or slots on a piece of cloth into which tongue blades will fit into. These restraints are then wrapped around the elbow or knee joints and tied at the ends.
These are commonly used for children or confused patients in order to prevent them using their fingers or hands for removing tubes, dressings and other appliances used in a treatment, preventing them injuring the tissues (skin) by scratching and from unfastening other restraints applied on the body.
Commercially prepared mitts are available or a nurse can improvise them using a variety of materials readily available (e.g., a sleeve of a shirt or a stockinet)
These are used for both children and adults. The jacket is usually put on with the ties at the back, the straps from the jacket are then tied to the bed frame under the mattress, thus preventing the client from sitting on the bed. Chest restraints are also used for a client who is sitting on a chair or wheel chair to maintain his position and to prevent him from falling.
Mummy restraints are used to restrict the movements of the limbs in a small child during a procedure (e.g., during an eye irrigation). This can be done by wrapping the body with a towel.
Safety belts are made up of electrically non-conductive materials. These are frequently used on stretchers and operation tables in order to prevent the client from falling. The belt which goes around the client’s waist is attached to longer belt which is then tied to the bed frame under the mattress.
Splints, plaster casts, sand bags, bandages, binders, slings etc are used to restrict the movements of different parts of the body.
a. Side Rails
These are attached to both sides of the bed to prevent the client from getting out or falling out of the bed. Side rails must be kept raised on beds of all clients who have altered levels of consciousness, the elderly the debilitated clients and children.
b. Seclusion or Quiet Rooms
These rooms are specially designed to be hazard free and are commonly used for psychiatric clients. These rooms are usually located near the nurse’s duty room, so that the client will be observed frequently, through an observation window provided in the room. There should be no articles inside the room which can harm the client or the client may use it to harm him or others.
Objectives for Restraints
1. To reduce the clients from falling out of a bed or from a chair or wheel chair.
2. To prevent interruption of therapy such as traction, IV infusions, nasogastric tube feeding or Foley catheter.
3. To prevent the confused or combative client from removing any life support equipments that is needed.
4. To reduce the risk of injury to others by the client.
HAZARDS OF RESTRAINTS
1. Tissue damage under the restraints due to constant friction.
2. Damage to other parts of the body, e.g., dislocation of the shoulder joint if the client struggles during the application of arm restraints.
3. Development of pressure sore if the client is kept restrained for longer period of time and does not have frequent change of position, and skin care.
4. Development of hypostatic pneumonia due to immobility.
5. Ischaemia or nerve damage (paralysis) due to constrictive restraints.
6. Foot drop and wrist drop.
7. Asphyxia and aspiration pneumonia, if the client is restrained in a supine position and has an altered level of consciousness and vomits.
8. Development of other complications developed indirectly due to the application of restraints such as:
a. Inability of the client to escape injury or death in case of fire or such other emergencies.
b. Inability of the nursing staff to resuscitate a client in time in case of cardiac arrest. It takes time to remove the appliances and rescue the client.
9. Psychic injury: the client feels that he is punished.
10. Strangling and death.
1. Explain the need for the application of a restraint and the type of the restraint that are to be used. The client should not have the feeling that is ‘punished’ which may create aggressive responses in the client.
2. It is equally important that the client’s family and friends understand the need for restraints.
3. Since some form of restraints might cause strangling and death of clients especially in children, they must be used with greatest care. The nurse must apply the restraint correctly and must use it only when it is inevitable but with an approval of the doctor.
4. Always get assistance when restraining an agitated client.
5. Allow the client as much freedom as possible to move and at the same time serve the purpose of the restraint.
6. The client’s circulation must not be occluded by the restraint. Observe the part below the restraint for pallor, numbness, blueness etc. loosen the restraints if the client complaints signs of circulatory failure.