2. Restraints Presented by, Mrs.T.L. DIVYA, Asst. Professor, Pediatric Nursing Department, Annammal College Of Nursing, Kuzhithurai.

3.  Adults may need to be restrained for some diagnostic procedures, therapeutic procedures or during the physical examination and sometimes to protect from an injury  An appropriate safe and comfortable restraint should be selected. The restraint may be provided manually with help of some device INTRODUCTION

4.  Restraints are protective devices used to limit the physical activity of a client or to immobilize a client or extremity. Restraints are used to protect the client, allow for treatment in a safe environment, and reduce the risk of injury to others. Definition

5.  Physical restraints reduce the client’s movement through the application of a device. Most states require a physician’s order for the application of physical restraints.  Chemical restraints are medications used to control the client’s behavior. Commonly used chemical restraints are anxiolytics and sedatives.  Seclusion is defined as the involuntary confinement of a person in a room or an area where he or she is physically prevented from leaving. Types Of Restraints

6.  To carry out the physical examination  To provide the safety to patient  To protect the patient from injury  To complete the diagnostic and therapeutic procedures  To maintain the patient in prescribed position  To reduce the discomfort of patient during some tests and procedures like specimen collection Use of Restraints

7.  Restraints are used only when necessary and not as a substitutes for punishment.  Improperly applied can cause skin irritation and impaired circulation.  Restraints should not be too tight not too loose.  Careful observation and periodic checking is essential to prevent complication (every 15 mins).  Proper explanation is essential before the application of restraints. Principles

8.  Behavioral Restraint (Almost exclusively in ER)  Used for the control of aggressive/violent behavior or behavior that is dangerous to self or others.  Medical/Surgical Restraint (Most common on units)  Used for care management for a patient who is exhibiting behavior that is interfering with treatment (e.g. pulling on IV, Foley, or dressings). Two major types of restraints

9. 1. Medical surgical restraints  Mummy restraint  Elbow restraint  Arm boards  Jacket restraint  Orthopedic appliances  Helmets 2. Behavioral restraints  Elbow restraint  Jacket restraint  seclusion Types of restraints

10. Equipment needed

11. Baby Blanket

12. Clove hitch knot rope

13. Cotton pads

14. Restraint cloths with pocket and spatulas

15. Jacket for jacket restraint

16. Adhesive tape to fix the bandage

17. Purposes  To immobilze the arms and legs of an infant.  When the child’s head and neck to be examined.  When the jugular puncture is to be done  When the scalp vein needle is to be inserted  When a gastric lavage is to be done  While bathing to provide warmth of the body.  While passing Ryle’s Tube.  Checking weight. Mummy Restraint

19. Procedure  Take the blanket or draw sheet and spread it over the bed or table.  Place the baby on backside  Keep the one hand of baby near the body and wrap the baby’s body by holding the corner of the sheet and tuck it under the body in opposite side.  Now place another hand near the body and wrap the child’s body by holding another corner of sheet and tuck it.  Now take the rounded sheet at bottom near the leg and fold it towards the chest and tuck it at upper level of sheet or we can pin it at lower level of sheet. Mummy Restraint

20. Purpose  To examine the chest and abdomen Modified Mummy Restraint

21.  This is used to hold the elbow in an extended position so that the patient cannot reach the face. Purposes  When the patient has had surgery on face or head  When the patient has eczema or other skin disorders on face and head  When the scalp vein needle is in place. Elbow Restraint

23. Procedure  The elbow restraint is made up of double piece of clothe or other strong material, with pockets sewn into which tongue blades are inserted.  The tongue blades should be strong enough to reach from the axilla to the wrist, so that the elbow cannot be bent when the restraint is applied around the arm. Elbow Restraint

24. Purpose  To prevent the patient falling from a highchair and wheel chair Jacket Restraint

26. Procedure  The jacket is put on with the strings in the back so that the patient cannot reach them.  Secure ties of jacket to a non movable part of the bed frame or wheelchair.  Use the knot that cannot be quickly released.  Reposition the patient release immmobilizing restraints and perform range of motion every 1-2 hours. Jacket Restraint

27. Danger of jacket restraint  Jacket restraint is that of strangulation through pressure of the restraint that has slipped out of place and encircled a patient’s neck. Jacket Restraint

28.  This restraint is used to hold the patient in a supine position on the bed.  Abdominal restraint should not be too tight, so that it cannot interfere with respiration and bowel movement.  For this restraint, use wide size wooden strips.  Place the cotton pad approximately to provide the proper comfort. Abdominal Restraint

29.  It is used to immobilize the extremities Extremity restraint (Ankle or Wrist)

30.  The material for clove hitch can be soft cloth, crepe bandage and 2 inch wide gauze bandage.  First apply the cotton pad over the wrist, ankle to prevent discomfort.  Prepare figure of eight by the bandage and place it in the wrist or in the ankle.  Tie the bandage by knot. Knot should not be too tight or too loose.  Patient can remove the knot if it is too loose. Too tight knot can interfere in blood circulation.  The fingers and toes should be checked for discoloration or any skin rash etc. Clove hitch knot restraint

31. Finger Restraint

32.  It can be completed by making mitten.  The mitten covers all the fingers of a hand and restrict the movements of the fingers.  The hand can be wrapped by gauze or hand can be put in a bag like pouch and tie it properly at the wrist of the patient.  Finger restraints are used in case of facial surgeries, burns, IV infusions, any eczema of face and body parts.  Keep the mittens soft and it should not interfere with the circulation. Finger Restraint

33. Crib-net Restraint

34.  In this a net is used to cover the patient’s cot. Net is attached to the cot frame.  This net restraint is used to prevent the patients climbing over the side rails of cot.  In this net when side rails are up, the patient can stand but cannot climb over the side rails of cot.  Inside the crib net, the patient is totally free to move, no movement is restricted.  It mainly prevents the patient to climb and fall from the side rails of cot. Crib-net Restraint

35. Safety belts

36.  These are made up of electrically nonconductive materials.  These belts are used on stretcher and operation tables to prevent the patient from falling.  These belts go around the patient’s waist and tied to the frame of bed under the mattress. Safety belts

37. Side rails

38.  These are available especially in patients cot.  The rails are made up of iron or steel.  These can be raised when ever need arises and can be decreased as per convenience.  The main purpose of side rails are to prevent from fall.  These are used for patients with convulsive disorder also. Side rails

39. 39 RESTRAINTS MONITORING  Observe every 15 minutes for behaviors and physical conditions and document on BehavioralRestraint/Seclusion Flowsheet  Offer liquid, nutrition, comfort, and bathroom every 2 hours  Remove restraints every 2 hour for no less than 5 minutes for range of motion and skin care. BEHAVIORALMEDICAL/SURGICAL Observe every 2 hours for behaviors and physical conditions and document Offer liquid, nutrition, comfort, and bathroom every 2 hours Remove restraints every 2 hours for no less than 10 minutes for range of motion and skin care. Use Prevention Management of Aggressive Behavior (PMAB) interventions for escalating behaviors in all clinical settings.

40. Why has the practice of using physical restraints become so regulated and monitored?

41. Due to enforced immobilization: Physical  – Increased weakness & falls  – New pressure ulcers  – New onset incontinence  – Joint contractures Adverse Consequences of Physical Restraint

42. Psychological/Mental Impact  – Independent predictor of delirium  – Increased agitation  – Depression  – Demoralization Adverse Consequences (cont.)

43. Indirect: death Direct effects  – Death  – Anoxic encephalopathy  – Brachial nerve damage  – Wrist fractures Adverse Consequences (cont.)

44.  Reason for the restraint.  Method of restraint.  Application: Date, time, and client’s response  Duration.  Frequency of observation and client’s response.  Safety: Release from restraints with periodic, routine exercise and assessment for circulation and skin integrity.  Assessment of the continued need for restraint.  Client outcome. Key elements of restraint documentation

45.  Free all restraints at least every 2 to 4 hours, and provide range-of-motion exercise and skin care  Instantly report to the nurse in charge and record on the client’s chart any constant reddened or broken skin areas under the restraint  At the first sign of cyanosis or pallor, coldness of a skin area, or a client’s complaint of a tingling feeling, pain, or numbness, release the restraint and exercise the limb,  If there is any bruises do dressing as per doctors order.  Lubricate dry skin with moisturizing creams or ointments Skin Care

46.  Restraints are never used as the first alternative to manage these types of situations. There are other measures that can be taken by the family or staff to try to prevent restraint use. These are some of the things you can do to help your child  Talk to your healthcare providers about your patient and let us know if he/she has any special needs. Tell us what works best to calm your patient.  Speak to your patient about medical procedures or equipment in a manner he/she can understand.  If at all possible, stay with your patient to provide comfort and to reduce anxiety. If you are not able to stay around the clock, ask a close adult family member or friend to visit when you cannot stay with your patient. Alternatives to restraints

47.  Provide your child’s favorite play activities like toys, games, video games, videotapes, and music to distract attention away from his/her medical devices or condition.  Please tell us if your patient is in pain. We want to do everything we can to control your patients’s pain.  Reduce the amount of noise, light, and/or visitors in your child’s room to help decrease excitement.  Your nurse can contact a Child Life Specialist if your child is having difficulty coping with hospitalization. Alternatives to restraints

48.  The reason for applying the restraints must be explained to both the child and the parents.  The consent should be taken from the patient before applying restraints.  While applying the restraint and periodically during the period of restraint, the nurse should talk soothingly to the child to provide stimulation and diversion.  When restraints are applied, they should be put on effectively, yet as loosely as possible to prevent interferences with respiration and circulation and so that the child can move safely, to some degree.  Sufficient padding must be used under extremity restraints to prevent skin irritation Nursing Management

49.  The ties on restraints should be attached to the crib frame instead of the crib rails to prevent traction on the restraint or injury to the child when the crib rail is raised and lowered  Restraints should be checked every 15 to 30 minutes to determine whether they are constricting the respiration or circulation in any way.  Periodically, at least every 2 hours, the child should be removed from the restraints, held if possible and played with, to increase body contact and sensory input.  Before the restraints are reapplied, the child’s position should be changed to improve physiological functioning Nursing Management

50.  A restraint or seclusion should be applied by health care prescriber or Licensed Independent Practitioner.  If the child’s behavior is threat to others the RN can do restraint. But with in 1 hour she has to get verbal or written order from the physician.  Children with following conditions are contraindications for chemical restraints Abnormal airway Raised ICP Depressed conscious level History of sleep apnea Respiratory failure Cardiac failure Neuromuscular disease Points to remember

51.  Restraints and seclusions should not be used as punishments.  Children should never be left alone while in behavioral restraint or secluded.  The use of side rails, safety belts, protective nets, helmets and postural support devices used to promote good body alignment are not restraints.  Verbal or written orders for restraint and seclusion are limited to 4 hours for patients 18 years of age and older 2 hours for children 9 to 17 years of age 1 hour for children younger than 9 years of age Seclusion and restraints should not be ordered on a PRN basis. Points to remember