Definition
Applying restraint is a last-resort intervention used to protect patients from harming themselves or others when all other alternatives have failed. It must be done ethically, legally, and with the utmost care.
Purposes
- To provide safety.
- To facilitate examination.
- To carry out diagnostic and therapeutic procedures.
- To keep the child in desired position
Articles
- Draw sheet or baby blanket for babies (Newbon).
- Elbow restraint-cloth with 5-6 pockets in which spatulas are kept (children).
- Clove hitch knot-4″ bandage, cotton pads, knitted bandage.
- Padding to protect bony prominences.
Procedure
| Nursing action | Rationale | |
| 1 | Identify patient in need of restraints, eg, confused or disoriented patients requiring immobilization of extremity, and children requiring immobilization of elbow joint to prevent dislodgment of therapeutic equipment. | Restrains are used to reduce risk of patient falling from/out of bed, chair or wheelchair. Prevents interruption of therapy, such as traction and IV infusion. |
| 2 | Check physician’s order and assess type of restraint needed. | Nursing assessment and institutional policies aid in determining what type of restraints are used. Physician order is necessary to apply restraints. |
| 3 | Explain to patient and family about the importance of restraint, type of restraint selected and anticipated duration of use | Restraint can increase confusion or combativeness in patient, Family may express anger about restraint. Explanation and reinforcement can reduce or prevent negative perceptions. |
| 4 | During procedure Wash hands. | Reduces transmission of microorganisms. |
| 5 | Apply selected restraints Jacket restraint: Vest like garment that usually crosses in front of patient Belt restraints; Device that secures patient on stretcher or chair. Avoid placing belt too tightly across patient’s chest or abdomen. Extremity restraints: (ankle of wrist restraints) Restraints designed to immobilize one or all extremities. Commercially available limb restraints are composed of sheep skin and foam pads that come contact with skin. Modification of commercial restraints can be devised by making clove-hitch restraints (Strips of cloth that does not tighten if patient pulls against It). Make figure of eight with the strip of cloth and then pick up loops before attaching restraints to patient’s limbs. Place gauze or padding around extremity to be restrained and then place loops of clove hitch directly over padded surface. Mitten restraint: Thumbless mitten devices to restrain patient’s hand Elbow restraint: Piece of fabric with slots in which wooden spatula is placed so that elbow joint flexion is prevented. Swaddle wrap; Blanket or sheet opened on bed or crib with one corner folded toward center. baby is placed on blanket with shoulders at fold and feet towards opposite corner. With baby’s right arm straight down against the body, right side of the blanket is pulled firmly across the right shoulder and chest and secured beneath left side of the body. Left arm is placed straight against side and left side of the blanket is brought across shoulder and chest and locked beneath baby’s body and tucked or fastened securely with safety pins . | Restrains patient while lying or reclining in bed and while sitting in chair or wheelchair Restraints prevent from falling out chair or stretcher. Maintain s immobilization of extremity to protect patient from injury or accidental removal of therapeutic device (e.g iv tube or foley catheter.) Prevents patient from dislodging, invasive equipment, removing dressing or scratching Used for infants and children to prevent elbow flexion. Maintains short-term restraint of small child or infant for examination. Or treatment involving head and neck Swaddle wrapping device effectively controls movement of baby’s torso and extremities |
| 6 | After procedure Wash hand | Reduces transmission of micrograms. |
| 7 | Record type of restraints, assessment and appropriate interventions (risk of injury) before and after application of restraints, patient’s level of orientation, patient response to the restraint, skin integrity and status of musculoskeletal system | Ensures patient’s physical safety and prompt management of risk of injury. |
Special Considerations
1. If patient is violent and noncompliant, remove one restraint at a time or have staff assistance while removing restraints.
2. Special attention should be given towards safety of patients who are immobilized, emaciated, and for patients with fever, chronic illness and impaired skin integrity since they are at risk of developing musculoskeletal injury.
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
- Adrianne Dill Linton, Medical-Surgical Nursing, 8th Edition, 2023, Elsevier Publications, ISBN: 978-0323826716
- Donna Ignatavicius, Medical-Surgical Nursing: Concepts for Clinical Judgment and Collaborative Care, 11th Edition ,2024, Elsevier Publications, ISBN: 978-0323878265
- Lewis’s Medical-Surgical Nursing, 12th Edition,2024, Elsevier Publications, ISBN: 978-0323789615
- AACN Essentials of Critical Care Nursing, 5th Ed. Sarah. Delgado, 2023, Published by American Association of Critical-Care Nurses ISBN: 978-1264269884.
- Ernstmeyer K, Christman E, editors. Nursing Fundamentals [Internet]. 2nd edition. Eau Claire (WI): Chippewa Valley Technical College; 2024. PART IV, NURSING PROCESS. Available from: https://www.ncbi.nlm.nih.gov/books/NBK610818/
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