Restraints are the measures used to limit the child’s ability to move around freely or reach normal body parts.
Types of Restraints
- Environmental
- Physical
- Mechanical
- Chemical
Environmental:
Environmental restraint limits the area where the child can move freely and may refer to a time-out or seclusion.
Physical:
Physical restraint involves having one or more persons restraining the child through body contact alone.
Mechanical:
Mechanical restraint refers to the use of devices placed on the wrists, ankles, or chest, for example, arm boards and cloth boards.
Chemical: Any medicines that help child to calm down and relax.
Indications
- When child’s behavior is out of control and puts himself or others in danger, for example, drug use, head injury, or mental disorder
- While doing the procedures, for example, venipuncture
- After surgery, for example, wrist restraints to prevent the child from pulling out tubes or other medical devices
Principles
- The institution should have the policy in place to satisfy the reason for restraint.
- When determining the need for restraining a child, the nurse needs to consider the child’s growth and developmental level, mental status, and significant others self.
- Apply the principle of atraumatic care, the nurse uses a restraint only when necessary and for the short duration of time as possible.
- Use of at least one alternative method for restriction before using a restraint.
- Various restraints to facilitate examination or maintain safety are essential in the care and treatment of pediatric patients.
- Restraints are used only when necessary.
- Improperly applied restraints can cause skin irritation and can impair circulation.
- Free movement facilitates growth and development.
Guidelines for Use of Restraints
- At least two caregivers are needed to physically restrain the child.
- Physical restraint should be used in a quiet environment away from other children.
- Mechanical restraints to be used must be easy to remove in the case of an emergency.
Types of Mechanical Restraints
1.Clove Hitch Restraint
Purpose
Wrist or ankle restraint to prevent the range of motion of extremities.
Nurse’s responsibilities
- Check wrist or ankle for any sign of circulatory or neurologic compromise. The ends of the restraints are never tied to the side rails and should be tied on the bed frame.
- The part must be padded to prevent undue pressure, constriction, or tissue injury.
2.Elbow Restraints
Made up of a piece of muslin long enough to reach comfortably from just below the axilla to the wrist, with a number of vertical pockets into which tongue blades are inserted.
The restraint is wrapped around the arm and secured with tapes or pins. Pin the top of the restraint under the shirt sleeve to prevent restraint from slipping.
Purpose
- To prevent the child from the reaching the head or face (e.g., after lip surgery, scalp vein infusion).
- To prevent scratching in the case of skin disorders.
Nurse’s responsibilities
- Position the restraint so it does not rub against axilla.
- Check pulse, temperature, and capillary refill of the extremity.
3.Mummy Restraint
A blanket or sheet is opened on the bed with one corner folded to the center. The infant is placed on the blanket with shoulders at the fold and feet toward the opposite corner with infant’s right arm straight down against the body. The right side of the blanket is pulled firmly across the right shoulder and chest and secured beneath the left side of the body. The left arm is placed straight against the infant’s side and the left side of the blanket is brought across the shoulder and chest and tucked beneath the infant’s body of the right side. The lower corner is folded and brought over the body and fastened securely with safety pins
Purpose
- Short-term restraint of infant for examination or treatment that involves the head and neck, for example, venipuncture, throat examination, and gavage feeding.
Nurse’s responsibilities
- Ensure that all extremities are secured within the sheets.
- For chest examination, the folded edge of the blanket is brought over each arm and under the back, after which the loose edge is folded over and secured at chest.
4.Jacket (Vest Restraint)
The jacket is put on the child with the ties in the back so that the child is unable to manipulate them.
The long tapes are secured to the under-structure of the crib or chair (See Picture).
Purpose
Used to keep the child flat in the bed, in situations such as after surgery or safe in chair.
Nurse’s responsibilities
- Ensure that the child can turn the head to side and that at the head-end, the bed is elevated.
- Place the ties in the back so the child cannot manipulate.
5.Crib Top Bubble Restraint
Placing clean plastic cover over the bed
Purpose
To prevent infants or young children from falling out of bed
Nurse’s responsibility
Ensure that there are no tears or loose plastic.
6.Abdominal Restraint
This is used to hold the infant in a supine position on the bed, by using abdominal binder or belt and the strips are tied with the side of the cot
7.Crib Net Restraint
This is a net or dome used to cover the child’s cot.
It is used to prevent the child from climbing the side rails of the cot.
8.Safety Belts
These are made up of electrically non-conductive materials. These belts are used on stretchers and operation tables to prevent the children from falling. These belts go around
the child’s wrist and head to the frame of the bed under the mattress.
9.Side Rails
It is to prevent children falling from bed and can be used along restraints.
10.Mitten
The hand is inserted in a bag-like pouch (mitten) and tied properly around the wrist. The mitten covers the hand and restricts the movement of the fingers
Purpose
It is used in the case of facial surgeries, burns, IV infusion, and any skin lesion of the face and body parts to avoid scratching.
11.Splints
Splints are made up of cardboard, plastic, cotton, and gauze pad to restrict the movement of the extremity.
Hazards of Restraints
- If restraint is too tight, it can cause obstruction in blood circulation, tissue damage, redness, scar formation, discoloration of the skin, etc.
- Nerve damage
- Psychological disturbance
- Alteration in body image
- Disturbance in normal development
- Accidental or intentional removal of restraints may result in possible removal of tubes, IV lines, injury, etc.
- Injury to restrained extremity
- Fracture or muscle strains during application with violent patient
- Dislocation or contusion of extremity
- Numbness and tingling in restrained extremity
Nurse’s Responsibilities in Restraining a Child
- The reason for applying restraints must be explained to both the child and the parents.
- While applying the restraint and periodically during the period of restraining, the nurse should talk smoothly to the child to provide stimulation and diversion. Such interaction increases the child’s sensory input and tends to relieve the sense of helplessness and loneliness.
- When restraints are applied, they should be put on effectively yet as loosely as possible to prevent interference with restraints and circulation so that the child can move safely to some degree.
- Sufficient padding must be used under the extremities restraints to prevent skin irritation.
- The ties on restraints should be attached to crib frame instead of side rail to prevent the traction on the restraint or injury to the child when the side rail is raised or lowered.
- Restraints must be checked every 15-30 minutes to determine whether they are achieving their purpose and whether constricting the respirations 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. If it is impossible to release all the extremities from restraints at a time, remove one at a time and reapply so that the child can gain some degree of activity.
- Before the restraints are reapplied the child’s position should be changed to improve the physiologic functioning.
In the Case of Chemical Restraints
- Check the medicines the child currently takes. Make sure that these medicines are safe to take along with medicines used for
chemical restraint. - Medicines used for chemical restraint are commonly offered to the child in pill form first. If the child refuses, medicines may be given as a shot or in an IV.
- After the medicine is given, the child should be constantly monitored. Vital signs should be checked often until the medicine wears off.
In the Case of Environmental Restraints
- Make sure that the room used for seclusion is calm and safe. There should be windows with unbreakable glass so that the caregivers can monitor the child. There should be no exposed wiring, nails, or screws that may be used as weapons.
- The child must be observed constantly by caregivers. This may be done in person or
- with a video camera.
- Caregivers have to review the need for seclusion every 2 hours. Seclusion will end as soon the child behaves as caregivers have requested. This may include stopping violent behavior that puts others at risk.
REFERENCES
- Annamma Jacob, Rekha, Jhadav Sonali Tarachand: Clinical Nursing Procedures: The Art of Nursing Practice, 5th Edition, March 2023, Jaypee Publishers, ISBN-13: 978-9356961845 ISBN-10: 9356961840
- Omayalachi CON, Manual of Nursing Procedures and Practice, Vol 1, 3 Edition 2023, Published by Wolters Kluwer’s, ISBN: 978-9393553294
- Sandra Nettina, Lippincott Manual of Nursing Practice, 11th Edition, January 2019, Published by Wolters Kluwer’s, ISBN-13:978-9388313285
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