PROCEDURE: RESTRAINT

DEFINITION: Restraint are protective devices used

to limit the physical activity of the client or part of
the body.
OBJECTIVES:
To promote safety and prevent injury
To allow medical or surgical treatment to
proceed without client interference.
ASSESSMENT:
The behavior indicating the possible need for a
restraint.
Underlying caused assessed behaviour.
PLANNING: Review institutional policy for
restraints and seek consultation as appropriate
before independently deciding to apply a restraint.
All other possible interventions that are less
restrictive must have been tried. The primary
practitioner must be notified prior to using a
restraint, unlesss there is a danger to self or
others. In that case the primary practitioner must
be notified within the prescribed time frame per
the agency protocol.
MATERIAL/S: Appropriate type and size of
restraints.

PROCED STEPS RATIONA UNIT/

URE LE POSITI
ON
BELT 1. Introduce self - To - staff
RESTRAI and verify the establish nurse
NT doctors written rapport
order.
2. Explain to the - To give - staff
client and to informatio nurse
his/her family what n on what
you are going to action will
do, why it is be done.
necessary and how And tell
they can the
cooperate. results
that will
be used in
planning
further
care or
any
treatment
 .

3. Allow time for - To - staff

the client to provide nurse
express feeling needed
about the emotional
procedure of being reassuran
restrained. ce that
the
restraints
will be
used only
when
absolutely
necessary
.

4. Perform hand hygiene - To -

observe staff
appropriat nurs
e infection e
control.
5. Provide for client - To gain -
privacy if indicated trust and staff
maintain nurs
the e
dignity of
the
patient.

6. Apply the appropriate - To work -

restraint accordingl staff
y in the nurs
said e
procedure

7. Determine that the - To avoid -

safety belt is in good any staff
condition untoward nurs
happening e
to the
patient

8. If the belt has a long - The long -

portion and shorter attached staff
portion, place the long portion nurs
portion of the belt(under) will then e
the bedridden client and move up
secure it to the movable when the
part of the bed frame. head of
the bed is
elevateda
nd will not
tighten
around
the client.
Place the
shorter
portion of
the belt
around
the
clients
waist,
over the
gown.
There
should a
fingers
width
between
the belt
and the
client.
9. Attach the belt around - Belt -
the clients waist, and restraints staff
fasten it at the back of must be nurs
the chair. Or if the belt is applied to e
attached to a stretcher, all clients
secure the belt firmly on
over the clients hips or stretcher
abdomen. even
when the
side rails
are up.

10. Adjust the plan of - To -

care as required, this maintain staff
includes releasing the skin nurs
restraint, providing skin integrity. e
care, range-of-motion And for
exercises, and attending the
to the clients physical patient
needs by providing not to
fluids, nutrition and acquire
toileting. further
disability.

11. Record on the clients - To -

chart the behaviour(s) provide staff
indicating the need for legal nurs
restraints, all other document e
interventions s or
implemented in an evidence
attempt to avoid the use for the
of restraints and their clients
outcomes, and the time care.
the primary providers
was notified to the need
for restraint. Also
include:
The type of restraint
applied, the time it
was applied, and the
goals for its
application.
The clients response
to the restraint.
The time that the
restraints were
removed and skin
care given.
Any other
assessment and
intervention
Explanation given to
the client and S.O
JACKET 1. Introduce self and - To -
RESTRA verify the doctors establish staff
INT written order. rapport nurs
e
2. Explain to the client - To give -
and to his/her family informatio staff
what you are going to n on what nurs
do, whyit is necessary action will e
and how they can be done.
cooperate. And tell
the
results
that will
be used in
planning
further
care or
any
treatment
.
3. Allow time for the - To -
client to express provide staff
feeling about the needed nurs
procedureof being emotional e
restrained. reassuran
ce that
the
 restraints
will be
used only
when
absolutely
necessary.
4. Perform hand - To -
hygiene observe staff
appropriat nurs
e e
infection
control.

5. Provide for client - To gain -

privacy if indicated trust and staff
maintain nurs
the e
dignity of
the
patient.

6. Apply the - To work -

appropriate restraint accordingl staff
y in the nurs
said e
procedure
7. Place vest on the - -
client with opening at staff
the front or the back nurs
depending on the e
type.
8. Pull the tie on the - To -
end of the vest flap tighten up staff
across the chest and the the nurs
place it through the slit restraint e
in the opposite side of and to
the chest. chest.

9. Repeat for the other - For -

side. equal staff
tightness nurs
of the e
restraints
that is
applied
10. Fasten the ties - A half -
together behind the bow knot staff
chair using a slip quick does not nurs
release knot. tighten or e
slip when
the
attached
end is
 pulled but
unties
easily
when the
end is
pulled.
11. Adjust the plan of - To
care as required, this maintain
includes releasing the skin
restraint, providing integrity.
skin care, range-of- And for
motion exercises, and the
attending to the patient
clients physical needs not to
by providing fluids, acquire
nutrition and toileting. further
disability.

12. Record on the - To

clients chart the provide
behaviour(s) indicating legal
the need for restraints, document
all other interventions s or
implemented in an evidence
attempt to avoid the for the
use of restraints and clients
their outcomes, and care.
 the time the primary
providers was notified
to the need for
restraint. Also include:
The type of
restraint applied,
the time it was
applied, and the
goals for its
application.
The clients
response to the
restraint.
The time that the
restraints were
removed and skin
care given.
Any other
assessment and
intervention
Explanation given
to the client and
S.O

MITT 1. Perform hand hygiene - To -

REST observe staff
RAIN appropriat nurs
T e infection e
control.

2. Explain to the client - To give -

and to his/her family informatio staff
what you are going to do, n on what nurs
whyit is necessary and action will e
how they can cooperate. be done.
And tell
the results
that will
be used in
planning
further
care or
any
treatment.
3. Allow time for the - To -
client to express feeling provide staff
about the procedureof needed nurs
being restrained. emotional e
reassuran
ce that
the
restraints
will be
 used only
when
absolutely
necessary.
4. Apply the appropriate - To work -
restraint accordingl staff
y in the nurs
5. Apply the commercial said e
thumbless mitt. To the procedure -
hand to be restrained. - If the staff
Make sure the fingers ties are nurs
can be slightly flexed and attached e
are not caught under the to the
hand. movable
portion,
the wrist
or ankle
will not be
pulled
when the
bed
position is
changed.

6. Follow the - To avoid -

manufacturers direction further staff
for securing the mitt. damage nurs
 or e
problem.
7. If a mitt is to be worn - To -
for several days, remove maintain staff
it at regular intervals per skin nurs
agency protocol. Wash, integrity. e
exercise the clients And for
hands and then reapply the
the mitt. patient
not to
acquire
further
disability.
8. Assess the patient - Client -
circulation to the hands complaint staff
shortly after mitt is s of nurs
applied and at regular numbness e
intervals. ,
discomfort
or inability
to move
the
fingers
could
indicate
impaired
circulation
 to the
hand.
9. Adjust the plan of care - To -
as required, this includes maintain staff
releasing the restraint, skin nurs
providing skin care, integrity. e
range-of-motion And for
exercises, and attending the
to the clients physical patient
needs by providing not to
fluids, nutrition and acquire
toileting. further
disability.

10. Record on the - To -

clients chart the provide staff
behaviour(s) indicating legal nurs
the need for restraints, document e
all other interventions s or
implemented in an evidence
attempt to avoid the use for the
of restraints and their clients
outcomes, and the time care.
the primary providers
was notified to the need
for restraint. Also
include:
 The type of restraint
applied, the time it
was applied, and the
goals for its
application.
The clients response
to the restraint.
The time that the
restraints were
removed and skin
care given.
Any other
assessment and
intervention
Explanation given to
the client and S.O

WRIS 1. Pad bony prominences - To -

T OR on the wrist or ankle if prevent staff
ANKL needed skin nurs
E breakdow e
REST n.
RAINI
NG
2. Apply the padded - To -
portion of the restraint prevent staff
around the ankle or wrist skin nurs
 breakdow e
n.
3. Pull the tie of the - if the -
restraint through the slit ties are staff
in the wrist portion or attached nurs
through the buckle to the e
movable
portion
the wrist
or ankle
will not be
pulled
when the
bed
position
changed
4. Using the half bow - When -
knot attach the other end the staff
of the restraint to the attached nurs
portion of the bed frame. end is e
pulled but
unties
easily
when the
loosened
is pulled.
5. Adjust the plan of care - To -
as required, this includes maintain staff
releasing the restraint, skin nurs
providing skin care, integrity. e
range-of-motion And for
exercises, and attending the
to the clients physical patient
needs by providing not to
fluids, nutrition and acquire
toileting. further
disability.

6. Record on the clients - To -

chart the behaviour(s) provide staff
indicating the need for legal nurs
restraints, all other document e
interventions s or
implemented in an evidence
attempt to avoid the use for the
of restraints and their clients
outcomes, and the time care.
the primary providers
was notified to the need
for restraint. Also
include:
The type of restraint
applied, the time it
was applied, and the
 goals for its
application.
The clients response
to the restraint.
The time that the
restraints were
removed and skin
care given.
Any other
assessment and
intervention
Explanation given to
the client and S.O

MUMMY 1. Introduce self and - To -

RESTRAI verify the doctors establish Staff
NT written order. rapport Nurs
e
2. Explain to the - To give -
client and to his / her informatio Staff
family what you are n on what Nurs
going to do, why it is action will e
necessary and how be done.
they can cooperate. And tell
the results
that will
 be used in
planning
further
care or
any
treatment.
3. Allow time for the - To -
client to express provide Staff
feeling about the needed Nurs
procedure of being emotional e
restrained. reassuran
ce that
the
restraints
will be
used only
when
absolutely
necessary
4. Perform hand - To -
hygiene observe Staff
appropriat Nurs
e infection e
control
5. Provide for client - To gain -
privacy if indicated. trust and Staff
maintain Nurs
 the dignity e
of the
patient
6. Obtain a blanket or - So that -
sheet large enough the Staff
distance Nurs
between e
opposite
corners is
about
twice the
length of
the
infants
body.
7. Fold down one -
corner and place the Staff
baby on it in the Nurs
supine position. e
8. Fold the right side -
of the blanket over Staff
the infants body, Nurs
leaving the left arm e
free.
9. Fold the excess -
blanket at the Staff
bottom up under the Nurs
infant. e
10. With the left arm
in a natural position
at the babys side
fold the left side of
the blanket over the
infant including the
arm and tuck the
blanket under the
body.
11. Remain with the - To -
infant whop is in a ensure Staff
mummy restraint safety of Nurs
until the specific the client e
procedure in
completed.
12. Adjust the plan of - To -
care as required, this maintain Staff
includes releasing skin Nurs
the restraint, integrity. e
providing skin care, And for
range- of- motion the
exercises and patient
attending to the not to
clients physical acquire
needs by providing further
fluids, nutrition and disablity.
toileting.
13. Record on the - To -
clients chart the provide Staff
behaviour(s) legal Nurs
indicating the need document e
for the restraints all s for the
other interventions clients
implemented in an care.
attempt to avoid the
use of restraints and
their outcomes, and
the time the primary
providers was
notified to the need
for restraint. Also
include:
The type of
restraint applied
the time it was
applied, and the
goals for its
application.
The clients
response to the
restraint.
The times that
the restraints
 were removed
and skin care
given.
Any other
assessment and
intervention.
Explain given to
the client and
S.O.