01.07 Restraints

Overview

1. Purpose
   1. Restraints are used to protect clients from self harm or injury
      1. See Restraints lesson
   2. Restraints should be placed with proper technique in order to prevent injury caused by the restraints themselves

Nursing Points

General

1. Supplies
   1. Soft wrist restraints
   2. Mittens
   3. Posey vest
2. Remember that the LEAST invasive method should always be attempted before applying restraints
3. Restraints should be used for patient safety ONLY – they are NOT for nurse convenience

Nursing Concepts

1. Applying Soft Mittens
   1. Explain purpose of restraints to patient
   2. Explain criteria for removal to patient
   3. Insert patient’s hands into mittens
   4. Spread fingers into finger-holes within mittens
      1. Ensure you are applying per manufacturer’s instructions
   5. Ensure soft padding around wrist, then tighten strap
      1. Should be able to fit 2 fingers snugly under strap
   6. Every 2 hours (or per facility policy) and as needed, check skin and circulation on wrist and hands
   7. Continually monitor for need
2. Applying Soft Wrist restraints
   1. Explain purpose of restraints to patient
   2. Explain criteria for removal to patient
   3. Wrap soft pad around patient’s wrist
   4. Secure with buckle or velcro
      1. Should be able to fit 2 fingers snugly under strap
   5. Secure the end of the tie to a non-movable part of the bed (typically there’s a place on the bedframe)
   6. Secure with a QUICK-release knot
      1. Some have buckles
      2. Otherwise use a slip knot
   7. The patient should have a very small range of motion (not be 100% restricted – that could cause strain on joints)
      1. Ensure that they cannot reach any essential tubes or lines – cover or move them as needed
   8. Every 2 hours (or per facility policy) assess and intervene as needed for the following:
      1. Elimination needs
      2. Food/fluid needs
      3. Skin under restraint
         1. Must REMOVE cuff to assess!
      4. Circulation distal to restraint
      5. Patient’s LOC/mental status
      6. Patient’s current behavior
   9. Continually monitor for the need for restraints – remove when no longer indicated
3. Posey Vest
   1. Explain purpose of restraints to patient
   2. Explain criteria for removal to patient
   3. Slip patient’s arms into the vest with the opening to the back
      1. Ensure the vest is not riding too high on their neck
      2. Make sure you have the right size
   4. Roll the patient side to side to pull the vest and straps around the back to the opposite side
   5. Secure straps to a non movable part of the bed
      1. Should be able to fit 2 fingers snugly under straps
   6. Monitor skin integrity under vest, especially at location of straps
   7. Keep in mind, the patient could still move up and down in bed, even though they can’t get out.
      1. This could cause a suffocation risk – continue to monitor them closely even with the posey vest
   8. Continually monitor for need

Patient Education

1. Patients and their family members should understand the purpose for restraints and the criteria for having them removed
2. Physician order is renewed every 24 hours
3. Need for restraints are continually monitored by the nurse
4. Patient’s physical needs will continue to be met