Applying Restraints

Written by Hollie Finders, RN
Hollie Finders is a registered nurse with years of experience working in the health care field. She has degrees in both biochemistry and nursing. After working with patients of all ages, Hollie now specializes in pediatric intensive care nursing. Hollie’s LinkedIn

Procedure

Equipment needed: restraints.

Attempt restraint alternatives.
Check with the nurse to ensure use of restraints is necessary in this situation, and that an order for the restraints is being obtained.
Perform hand hygiene.
Explain the procedure to the patient.
Obtain and apply the restraint (see below for specific procedures).
Perform hand hygiene.
Document the procedure in the patient’s chart and report any changes in the patient’s condition to the nurse.

Safety Belt Restraint

Apply the belt over the patient’s clothing at the waist.
Cross the ties around the back of the patient and slip the ties through the corresponding loops on each side.
If the patient is sitting in a chair, correctly fasten the belt using a slipknot around the back of the chair.
If the patient is in bed, tie the restraints to the bed frame on the corresponding side of the bed or stretcher using a slipknot.
Ensure one finger can fit between the patient and the belt.

Vest Restraint

Slip the vest on the patient over his or her clothes. Follow the manufacturer’s protocol to determine if the opening of the vest goes in the front or the back.
Cross the restraint ties by pulling one tie through the slit on the opposite side of the vest.
Tie the restraint around the back of the chair using a slipknot, or tie the restraints to the bed frame on the corresponding side of the bed or stretcher using a slipknot.
Ensure the restraint is not too tight and that the patient’s breathing is not restricted.

Mitt Restraint

Place hand into restraint.
Secure the mitt at the wrist.
Ensure fingers have range of motion and that the restraint is not too tight.

Wrist/Ankle Restraint

Apply padded restraint to wrist or ankle.
Ensure two fingers can fit between the restraint and the patient.
Fasten the straps through the loops on the restraint.
Secure restraint ties to the bed frame using a slipknot.

Important Information

Restraints have very strict guidelines for use due to the number of complications that can result. Use of restraints is associated with increased physical and psychosocial health issues [1]. Restraints are only considered necessary when restraint-free alternatives have failed and the patient or others are at risk of harm without the restraints [1]. It is illegal to use restraints for the staff’s convenience or to punish the patient [2].

Always follow the facility’s policy when using restraints. Nurses are responsible for assessing and monitoring a patient in restraints; however, the nurse may ask the nurse’s aide to assist in releasing restraints and repositioning the patient. Remember to always use a quick release slipknot when securing the restraint. This allows for an easy and immediate removal of the restraint in emergencies. Also, when used in bed, be sure to tie the restraint to the bed frame and never to a bed’s side rail.

References

1. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2564468/

2. https://www.medicare.gov/what-medicare-covers/part-a/rights-in-snf.html

More Resources

Transferring the Resident from a Bed with a Mechanical Lift

A mechanical lift is used to transfer residents who cannot support their own weight. When used properly, mechanical lifts prevent injuries for both residents and health care workers. It is important that a nurse’s assistant be trained to use the mechanical lift before attempting to operate it. Most facilities require at least two health care workers to assist when using a mechanical lift.

Perineal Care of the Male Resident

Perineal care should be performed during a bath, after using the bedpan, and/or after incontinence. Special care should be used when performing perineal care on an uncircumcised male. Failure to retract and wash the area under the foreskin can result in infection. Failure to return the foreskin to its normal position can result in paraphimosis.

Making an Occupied Bed

If a patient is bedridden or on bedrest, the bed linens will need to be changed while the patient is in the bed. For safety reasons, the nurse’s aid should avoid making an occupied bed if the patient is able to get out of bed. Bed linens should be changed according to the facility’s policy or anytime they are wet or soiled.

Measuring Blood Pressure

Many factors can interfere with obtaining an accurate blood pressure. The most common mistakes that lead to inaccurate blood pressures are a result of improper technique, including: not supporting the patient’s arm, using the wrong sized cuff, positioning the cuff too low on the patient’s arm, improper positioning of the cuff’s artery marker, and attempting to measure blood pressure through clothing.

Removing Personal Protective Equipment

It is important to follow the correct procedure while removing personal protective equipment to avoid contaminating your skin or clothing. The most common source of contamination in this process stems from improper removal of gloves. Gloves are often the most soiled piece of equipment. To avoid contaminating your skin or the other equipment worn, gloves should always be removed first. Then remove the goggles, gown, and mask, in that order.

Prone Position

Prone position is not used as commonly as other patient positions. This position allows for full extension of the hips and the knees and gives many bony prominences a break from continuous pressure. However, placing patients in prone position does not come without the risks of pressure ulcers.