Applying Restraints
When a nursing assistive personnel (NAP) enters the room of a patient in a belt restraint, he finds the patient's gown bunched around the patient's chest and the patient asking for help. What would the NAP do? A. Check the patient's blood pressure and pulse before smoothing the gown B. Untie the restraint and smooth the patient's gown C. Put on the call light for help D. Ask the patient what specific help she would like
B Rationale: The NAP would untie the restraint, smooth the patient's gown, and replace the restraint. Checking the patient's blood pressure and pulse is not appropriate at this time. Putting on the call light is not appropriate, since the call light is intended to summon the NAP. Asking the patient what help is needed is not appropriate. The difficulty is obvious, and the patient may have a cognitive impairment that makes clear expression of his or her needs impossible.
To which patient might the nurse apply a physical restraint? A. An 83-year-old patient with dementia and a history of wandering whose fall risk assessment indicates a high risk of falling. B. A 42-year-old critical care patient with a traumatic brain injury who has repeatedly tried to pull out her shunt. C. A 74-year-old patient confined to bed who is at risk of pressure ulcers. D. A 60-year-old patient with dementia who seemed increasingly confused shortly after having had restraints applied for 1 hour that morning.
B Rationale: The critical care nurse might apply a physical restraint to keep this 42-year-old patient from injuring herself by dislodging her shunt. Disruption of therapy causes patient injury, pain, or discomfort and increases the risk of infection. There is no evidence that the use of restraints prevents falls or reduces wandering. Research has shown that patients suffer fewer injuries if left unrestrained. Use of physical restraints does not prevent pressure injuries; to the contrary, pressure injury formation is a possible complication associated with the use of physical restraints. Any patient with a physical restraint must be monitored frequently for skin integrity, pulse, temperature, and color, as well as sensation and range of motion of the restrained body part. The nurse would not apply a physical restraint to a patient who had exhibited increased confusion, disorientation, or agitation during the previous application of a restraint. Instead, the nurse would evaluate the cause of the behavior and try to eliminate it, provide appropriate sensory stimulation, reorient the patient, use restraint alternatives, and enlist the family's support if possible.
What would the nurse instruct nursing assistive personnel (NAP) to report when caring for a patient in a wrist restraint? A. "Tell me if the patient's pulse changes." B. "Tell me if the skin under the restraint becomes abraded or raw." C. "Let me know if you think she's ready for them to come off." D. "Let me know if the patient needs anything for pain."
B Rationale: When caring for a patient in a wrist restraint, the nurse would instruct NAP to report the condition of the skin beneath the restraint. When caring for a patient in a wrist restraint, the nurse would assess the patient for pulse changes in the extremity to which the restraint has been applied. This skill would not be delegated to NAP. Patient assessment is a nursing responsibility, and the nurse would make the determination of when a patient's restraints can be removed, in accordance with agency policy and all applicable laws and regulations. Assessment of pain is a nursing responsibility and cannot be delegated to NAP.
ALERT
Because of the association with fatal injuries, many health care organizations now prohibit the use of jacket (vest) restraints. Limit the use of restraints when physically possible. Use and type of restraint must be based on a thorough assessment of the patient when other therapies have been ineffective. Place the patient in the lateral position, or elevate the head of the bed. The patient with extremity restraints is at risk for aspiration if placed in the supine position. Use a quick release tie to secure the restraint. Ensure that the restraint does not interfere with equipment, such as an IV, and is not placed over an access device, such as an arteriovenous shunt. Do not attach the straps of a restraint to the side rails of the bed. Do not tie the straps of a restraint into a knot. Check the skin under the restraint for abrasions. Change wet or soiled restraints to prevent skin breakdown. Remove a restraint immediately if the patient has an alteration in neurovascular status of an extremity, such as cyanosis, pallor, or coldness of the skin, or if the patient complains of tingling, pain, or numbness in the restrained extremity.
Apply the proper size restraint, and follow the manufacturer's instructions for use.
Belt restraint: Help the patient into a sitting position. Apply the belt over the patient's clothes, hospital gown, or pajamas. Smooth out wrinkles or creases in the patient's clothing. Be sure to place the restraint at the waist, not the chest or the abdomen. Bring the ties through the slots in the belt. Avoid applying the belt too tightly. Assist the patient to a supine position if he or she is in bed. Ask the patient to take a deep breath to ensure there is no restriction to breathing. Attach the restraint securely to a stationary part of the bed frame. Extremity (ankle or wrist) restraint: Commercially available limb restraints are made of sheepskin or foam padding. Wrap the limb restraint around the patient's wrist or ankle, with the soft part toward the patient's skin, and secure it snugly, but not tightly, by using the Velcro straps or clips. Check to make sure the restraint is not too tight by inserting one finger under the secured restraint. Secure the strap through the D-ring. Use a quick release tie to secure the restraint to the stationary part of the bed frame. Mitt restraint: A thumbless hand mitt device is used to restrain a patient's hands. Place the patient's hand in the mitt, making sure that the Velcro strap(s) are around the patient's wrist, and not the forearm. Check to see that one finger slides easily beneath the restraint. Elbow restraint: This device is a rigid, padded, fabric splint that immobilizes the elbow joint. It can be removed by the patient. This will help the patient stop picking at an IV line. Place restraint around the patient's arm so the elbow joint rests against the padded area. Keeping the elbow rigid, secure splint with Velcro straps. Check fit of restraint. Hook clip to upper end of sleeve of patient's gown.
Why does the nurse instruct nursing assistive personnel (NAP) to remove the wrist restraint of a confused patient every 2 hours? A. To try a less restrictive type of restraint if a more confining restraint has proved effective B. To double-check the size by inserting one finger between the wrist and the restraint C. To check the skin integrity and range of motion of the wrist D. To comply with Joint Commission standards
C Rationale: The nurse instructs the NAP to remove the wrist restraint of a confused patient every 2 hours to ensure that the wrist is checked for skin integrity, pulse, temperature, color, sensation, and range of motion. In acute care settings, the health care provider must order the least restrictive type of restraint first, not after a more confining restraint has proved effective. The nurse would select the appropriate size restraint for the patient, according to the manufacturer's instructions, when the restraint is initially applied, and he or she would double-check the fit when the restraint is applied, not 2 hours later. The fit need not be checked at 2-hour intervals thereafter. The Joint Commission policy states that, in most circumstances, a physical restraint may be maintained up to 4 hours in an adult.
The nurse is discussing the risk of falling with the wife of a patient with cognitive impairment. What is the nurse's best response when the patient's wife says, "I don't like him being tied down in the bed?" A. "I'm sure you don't want him to fall again." B. "Can you suggest an alternative?" C. "What did you do to prevent him from falling when he was at home?" D. "We will try all other alternatives before using physical restraints."
D Rationale: The nurse stating they will try all other alternatives before using physical restraints is the correct answer because the response attempts to reassure the family that restraints will be used only as a last resort. The nurse stating that you don't want him to fall again is not the correct answer because it appears to use guilt to secure family consent. Asking the patient's wife for an alternative suggestion is not the correct answer because it indicates impatience with the family's concerns and places an inappropriate responsibility on the patient's wife. Asking the patient's wife what she did to prevent him from falling when he was at home is not the correct option, because it appears to place responsibility for the patient's safety on the family. In addition, the patient's condition and circumstances are different in the facility than they were at home, so using the same fall-prevention strategies is likely to be ineffective.
beginning steps
Gather the necessary equipment and supplies. Perform hand hygiene. Provide for the patient's privacy. Use a calm approach and introduce yourself to the patient, including both name and title or role. Verify health care provider's orders. Determine if signed consent is necessary. Identify the patient using two identifiers, such as the patient's name and birth date or the patient's name and account number. Explain the procedure to the patient and ensure that he or she agrees to treatment. Consult with practitioner for non-compliant patients and confirm orders before proceeding. Adjust the bed to the proper height, and lower the rail closest to you. Be sure that the patient is comfortable and in the correct anatomical position. Inspect the area to which the restraint will be applied. Note any tubes or devices. Assess the patient's skin integrity, sensation, circulation, and range of motion. Pad the patient's skin and bony prominences that will be covered by the restraint as necessary.
supplies
Proper restraint, such as a belt, wrist, or hand mitt restraint Padding if needed
finishing steps
Reminder: Attach the restraint straps to the stationary part of the bed frame. Be sure the straps are secure. Do not attach the straps to the side rails. Restraints can be attached to the frame of a chair or a wheelchair as long as the ties are out of the patient's reach. Secure the restraints with a quick-release tie, a buckle, or an adjustable seat belt-like locking device. Do not tie the straps of the restraint into a knot. Double-check to make sure you can insert one finger under any secured restraint. Remove the restraints at least every 2 hours or according to your organization's policy for time specifications for restraint removal, and assess the patient each time. Assess the proper placement of the restraint, including the patient's skin integrity, pulses, temperature, color, and sensation of the restrained body part. If the patient is violent or noncompliant, remove one restraint at a time, and/or have other health care team members assist you as you remove the restraints. To ensure the patient's safety, secure the call light or intercom system within reach and lock the wheels on the patient's bed or chair. Keep the bed in the lowest position, and raise the appropriate number of side rails. Dispose of used supplies and equipment. Leave the patient's room tidy. Remove and dispose of gloves, if used. Perform hand hygiene. Document and report the patient's response and expected or unexpected outcomes. Document the type of restraint, time applied, and reason for restraint.
