APPLICATION OF RESTRAINTS Definition:Restraints protective devices used to limit the physical activity of a client or to immobilize an extremity or the client

himself or herself. Types: 1. physical restraints- devices applied to reduce the patients movement. 2. chemical restraints- are medications used to control the patients behavior. Indications: To limit activities of patients who are: a. confused b. combative or hostile c. high risk for falling when left unattended Special Precaution: The reasons for the use of restraints are to be clearly stated; a. The use of restraints must be part of the patients medical treatment as ordered by the physician. b. All other restrictive interventions must be tried first. c. Supporting documentation must be provided. Key Elements of Restraint Documentation Reason for restraint Method of restraints Application: Date, Time, and patients response Safety release from restraints for blood circulation and skin integrity Assessment of the continued need for restraints Patient outcome

Equipment: 1. Restraints 2. Pads

Procedure Action 1. Explain the rationale for application of Restraints. cooperation. Repeatedly reinforce the rationale. Secure consent if applicable. 2. Prepare for restraints. efficient time 3. Assess the skin for irritation or other skin problems. assessment. 4. Apply restraints to patient assuring some movement circulation and mobility. of body parts. One or two fingers should slide to release. between restraints and patients skin. Tie the straps securely with clove hitch. To make a clove hitch: Make a figure of eight; pick up the loops; put the limb through the loops and secure. Put a pad on bony prominence. 5. Secure restraints to bed frame. Do not tie the straps Prevents accidental injury to patient from to the side rails. moving side rails decreases patients ability to untie restraints. 6. Assess restraints and skin integrity every thirty minutes. Permits exercise and Rationale Explanation facilitates

Organization promotes management. Provides baseline

Maintains

adequate

Patient should be easy

and

muscle

Release restraints at least every 2 hours. every two hours. 7. Document the procedure noting the time of members of the application and condition of the patient. contributes to the legal for restraints.

promotes

circulation

Communicates to the health team and

record by documenting the need