Use of Restraints and safety devices

A nurse in a long-term care facility recognizes the need to place wrist restraints on a client, but the client does not want the restraints applied. The appropriate nursing action would be to: A.Contact the physician B.Apply the restraints anyway C.Medicate the client with a sedative, then apply the restraints Compromise with the client and use only one wrist restraint instead of two

Contact the physician Rationale: The use of restraints must be avoided if possible. If it is determined that a restraint is necessary, the nurse should discuss the issue with the family and obtain a prescription from the physician. The nurse should explain carefully to the client and family the reasons that the restraint is necessary, the type of restraint that has been selected, and the anticipated duration of use of the restraint. If a client refuses restraints, the nurse must contact the physician. Therefore the other options are incorrect.

Seclusion and/or restraint must never be used for:

Convenience of the staff Punishment for the client

Ordering & Using Restraints

Need a physician's prescription Prescription should be renewed in accordance with the policy of the agency. PRN prescriptions for restraints are not allowed. May be apply in an emergency situation = but the nurse must obtain physician's prescription ASAP. Informed Consent is required = either by the client or proxy if client is unable to consent = otherwise False Imprisonment.

Nurse's Responsibilities during restraint

Ensure that the call bell is within the client's reach. Assess restraints and client's circulatory status (circulation, sensation, mobility), and skin integrity every 30 minutes Offer food and fluid. Provide means for hygiene and elimination. Monitor vital signs. Offer range of motion of extremities = release every 2 hours to facilitate inspection of the skin, help ensure good circulation, and permit movement of the joint through its range of motion.

To ensure it fits properly...

Ensure that two fingers can be inserted under the secured restraint. Ensure it is loose enough for range of motion.

Complications of Restraints

Entanglement, which may result in asphyxiation or strangulation Pressure ulcers Constipation Respiratory infections Urinary and fecal incontinence Contractures Nerve damage Circulatory impairment Humiliation or loss of self-esteem Fear Anger

Frequency of client assessments in regard to

Food Fluids Comfort Safety

The physician orders a vest restraint for a patient. What should the nurse do first when applying this restraint? A.Ensure that the back of the vest is positioned on the patient's back B.Permit four fingers to slide between the patient and the restraint C.Inspect the patient's skin where the restraint is to be placed D.Secure the restraint to the bed frame using a slipknot

Inspect the patient's skin where the restraint is to be placed Rationale: Even when applied correctly, restraints can cause pressure and friction. A baseline assessment of the skin under the restraint should be made. In addition, the presence of a dressing, pacemaker, or subclavian catheter may influence the type of restraint to use.

A patient consistently tries to pull out a urinary retention catheter. As a last resort to maintain integrity of the catheter and patient safety, the nurse obtains an order for a restraint. Which type of restraint is most appropriate in this situation? A.Mummy restraint B.Elbow restraint C.Jacket restraint Mitt restraint

Mitt restraint Rationale: A mitt restraint covers the hand to prevent the fingers from grasping and pulling out tubes. A mummy restraint is used to immobilize an infant or very young child during a procedure. An elbow restraint is used to prevent flexion of the elbow in an infant or young child to prevent the pulling out of tubes. A jacket restraint is used to keep a person from falling out of bed while not immobilizing the extremities.

Legal & Ethical Guidelines Restraints

Nurses must know and follow federal/state/facility policies that govern the use of restraints: Only for a limited time Only for emergency = when less restrictive measures are not sufficient. For the physical protection of the client or the protection of other clients or staff. Never interfere with treatment

Documentation Points

Precipitating events and behavior of the client prior to seclusion or restraint = Reason for the restraint Alternative actions taken to avoid seclusion or restraint The time restraints were applied and removed. Type of restraint used and location Client's behavior while restrained Type and frequency of care (range of motion, neurosensory checks, removal, integumentary checks) Condition of restrained body part = assessment of circulatory, neurovascular, and skin integrity. Client's response when the restraint is removed The duration of use of the restraint Medication administered.

Which of the following points should the nurse include when documenting information about a client who is wearing wrist restraints? Select all that apply. A.The client's temperature B.The client's 24-hour urine output C.Skin integrity of the restrained body part D.The procedure used in applying the restraint E.The date and time of application of the restraint F.Circulatory and neurovascular status of the restrained extremities

Skin integrity of the restrained body part The procedure used in applying the restraint The date and time of application of the restraint Circulatory and neurovascular status of the restrained extremities Rationale: The nurse is responsible for documenting specific information about the client who is wearing any type of restraint. The points that must be included in such documentation are the reason for the restraint; alternatives to the restraint that were used; the method of restraint; the procedure used in applying the restraint; date and time of application of the restraint; client's response to application of the restraint; condition of the restrained body part; assessment of circulatory, neurovascular, and skin integrity; periodic release from restraint with movement or range-of-motion exercise; assessment of the need for continued use of the restraint; the duration of use of the restraint; and the client's response on removal of the restraint.

A staff nurse caring for a client with a head injury notes that the client is restless and pulling at the intravenous (IV) line. The client's physician does not want to prescribe sedation, and the family has requested that the client not be restrained. Which action by the nurse is appropriate? A.Asking a family member to sit with the client B.Asking a nursing assistant to monitor the client C.Staying with the client and consulting with the nurse manager about the situation D.Telling the family that the application of wrist restraints is critical in preventing injury to the client

Staying with the client and consulting with the nurse manager about the situation Rationale: The nurse must stay with the client and consult with the nurse manager about the situation. It may be necessary for the nurse manager to call the supervisor to request an additional staff member to care for the client. Because the client has a head injury, the development of increased intracranial pressure (ICP) is a major concern. A nursing assistant is not trained to monitor the client for increased ICP. It is inappropriate to ask a family member to sit with the client. The application of restraints may agitate the client, causing further restlessness and thus increasing ICP.

A nurse provides instruction to a new nursing assistant regarding the application of a restraint to a client. The nurse watches as the nursing assistant applies the restraint. What observation tells the nurse that the nursing assistant is using correct procedure? A.The assistant applies a tie knot in the restraint strap. B.The assistant attaches the restraint straps securely to the siderails. C.The assistant applies the restraint so that the strap does not tighten when force is applied against it. D.The assistant secures the restraint in such a way that it is impossible to slip a finger between the restraint and the client's skin.

The assistant applies the restraint so that the strap does not tighten when force is applied against it. Rationale: A half-bow safety knot should be used to apply a restraint, because it does not tighten when force is applied against it and because it allows quick, easy removal of the restraint in the event of an emergency. The restraint strap is secured to the bed frame, never to the side rails, to help prevent accidental injury in the event that the siderail is released. A restraint should be secured in such a way that one or two fingers can be easily slipped between the restraint and the client's skin.

After discussing the use of restraints with a client and family, a physician has written a prescription for wrist restraints to be applied to a client. The nurse instructs the nursing assistant to apply the restraints. Which of the following observations by the nurse indicates that the nursing assistant is using the restraints safely and correctly? Select all that apply. A.The restraints are applied tightly. B.The restraints are being released every 2 hours. C.A safety knot has been used to secure the restraints. D.The restraints have been tied to the siderails of the bed. The call light has been placed within reach of the client

The restraints are being released every 2 hours. A safety knot has been used to secure the restraints. The call light has been placed within reach of the client. Rationale: Restraints should never be applied tightly, because this could impair circulation. They should be tied to the bed frame (not the siderail) with the use of a safety knot. The client could sustain injury if the siderail were lowered with a restraint attached to it. A safety knot is used because it can easily be released in an emergency. Restraints must be released every 2 hours to facilitate inspection of the skin, help ensure good circulation, and permit movement of the joint through its range of motion. The call light must always be within reach of the client in case he or she needs assistance.

The nurse is planning care for a patient with a wrist restraint. The restraint should be removed, the area massaged, and the joints moved through their full range every: A.Shift B.Hour C.Two hours Four hours

Two hours ● Rationale: Restraints should be removed every 2 hours. The extremities must be moved through their full range of motion to prevent muscle shortening and contractures. The area must be massaged to promote circulation and prevent pressure injuries.

Belt Restraint

This belt-like device, which is wrapped around the client's waist, is used to secure a client to bed or stretcher. Ensure that the device is not secured too tightly across the chest or abdomen. Tie the belt to the bed frame or hook it under the bed, rather than to the side rails, to prevent injury when the side rail is raised or lowered.

Elbow Restraint

This device consists of a fabric arm wrap with slots into which tongue blades are inserted. The elbow restraint is used in children to prevent flexion of the joint. The device may be used when an intravenous line is in place.

Mummy Restraint

This device is used to restrain an infant or small child during examination or treatment of the head or neck. A blanket or sheet may be used to fashion a mummy restraint. Some types of mummy restraints secure the child to a board with an attached Velcro device.

Extremity (Wrist or Ankle) Restraint

This device is wrapped around the wrist or ankle to immobilize the extremity. Extremity restraints are used to protect the client from a fall or to keep him or her from pulling at or removing a tube or other equipment. The soft part of the device is placed against the skin before the restraint is secured in place.

Mitten Restraint

This device, resembling a mitten, is placed over the hand. In addition to serving as a covering for the hand, the mitten restraint prevents the client from pulling on equipment, removing dressings, or scratching him- or herself. The mitten restraint allows a greater degree of movement than does a wrist restraint

Devices That Allow Free Movement

This device, worn on the leg, signals when the leg is moved into a dependent position. The Ambularm is used for clients at risk for falling who climb out of bed. Devices that may be attached to a bed or chair or to the client's mattress or nightgown are also available. Alarmed Armband This device, worn by the client, signals when the client wanders outside the safe confines of the nursing facility.

Situations for Temporary Use of Restraints

When less restrictive measures are not successful To ensure the physical safety of the client and reduce the risk of injury (e.g., in falls) Reduce the risk of injury to others by the client who engages in disruptive or agitated behavior Prevent the confused or combative client from interrupting therapy (e.g., pulling on tubes)

Attach to what? using a.....

bed frame using a quick-release tie or knot.

Alternatives to Restraints

üMaintain orientation of the client to his or her surroundings. üExplain procedures and treatments to the client and family to help alleviate anxiety. üEncourage a family member or friend to stay with the client; use ONLY agency personnel (a sitter) for clients who need supervision. üEvaluate all medications that the client is taking; some can cause altered mental status and adverse behavior. üLimit environmental stimuli for the client who is confused or agitated. üAssign confused or disoriented clients to rooms near the nurses' station. üProvide appropriate visual and auditory stimuli (e.g., clocks, calendars, television, radio, familiar objects such as family pictures) to the client. üMaintain toileting routines to help prevent restlessness. üUse relaxation techniques with the client. üExercise and ambulate the client as the client's condition allows. üIf possible, avoid treatments and procedures that will agitate the client.