restraints nursing

When should restraints be used?

Only as a last resort after less-restrictive alternatives have failed and only to prevent injury or harm to the client or others

What are the three types of restraints?

1. Physical 2. Environmental 3. Chemical

Which client is an appropriate candidate for restraints?

A client attempting to remove an essential medical device (ETT, IV line, catheter) or posing a threat of injury to self or others

Which client should NOT be restrained?

A client who is yelling, wandering, or confused without posing a danger to self or others.

What is the nurse's first action before applying restraints?

Try least restrictive alternatives first

Name four alternatives to restraints.

Meet basic care needs (toileting, feeding, routine schedule),

pain management,

diversion (TV/music/games),

supervision (sitter/nurse's station),

bed/chair alarms,

family presence

What basic care needs should be checked before restraints are used?

Toileting, feeding, and maintaining a routine schedule.

Why are medical/physical restraints commonly used?

To prevent interference with necessary medical care, such as pulling out tubes, drains, catheters, or IV lines.

Are all four side rails considered a restraint?

Yes. Exception: They are not considered a restraint when used for seizure precautions.

What is considered an environmental restraint?

Using room equipment (positioning furniture, tightly tucked sheets, special chairs) to limit movement.

Name four examples of physical restraints.

Soft wrist restraints,

soft ankle restraints,

vest/jacket restraints,

mittens,

leather restraints.

What is a chemical restraint?

A medication used to control behavior that is not part of the client's standard treatment.

What is seclusion?

Isolation of a client in a room, primarily used in psychiatric settings.

What are the requirements of a mitten restraint?

Immobilizes hands/fingers, significantly impairs hand use, cannot be intentionally removed by the client, must be removed for hand hygiene and range of motion

What is the primary purpose of a limb restraint?

To immobilize an arm or leg to prevent removal of essential medical devices or prevent harm.

What is the purpose of a vest restraint?

Prevents the client from getting out of bed; commonly used for confused clients that are high risk for falls.

When is a provider order required for restraints?

Before application, except during emergencies. If used in an emergency, obtain the provider order as soon as possible afterward.

Where should restraints be secured?

To the bed frame, never to the side rails.

What type of knot should be used when applying restraints?

A quick-release knot for rapid removal during emergencies.

What is the two-finger rule?

The restraint should be snug but allow insertion of two fingers between the restraint and the client's skin to prevent circulation impairment

What five items must every restraint order include?

Date/time,

type of restraint,

location,

reason for use

duration.

What documentation is required after applying restraints?

Reason for use,

alternatives attempted,

application/removal times,

restraint type/location,

assessment findings/interventions,

provider order details.

How often should all restrained clients be checked?

At least every 15 minutes.

How often should restraints be removed?

Every 2 hours to assess skin, circulation, neurological status, and provide care.

How soon must a restrained child under 9 years receive a face-to-face medical evaluation?

Within 1 hour.

How often is a new provider order required for a restrained child under 9 years?

Every 2 hours.

How soon must a restrained adult receive a face-to-face medical evaluation?

Within 4 hours.

How often is a new provider order required for restrained adults?

Every 24 hours.

Do the 1-hour/4-hour evaluations and 2-hour/24-hour provider order rules apply to all restraints?

No. According to the lecture, these intervals apply to behavioral (violent or self-destructive) restraints. Routine medical restraints follow facility policy

Place the nurse's actions in order before applying restraints.

Try least restrictive alternatives.

2. Verify indication (danger/interference with medical care).

3. Obtain provider order (unless emergency).

4. Apply least restrictive restraint.

5. Secure to bed frame with a quick-release knot using the two-finger rule.

6. Monitor every 15 minutes and remove every 2 hours for assessment and care