Applying Restraint Nursing Skill

SKILL: APPLYING RESTRAINT
LEGEND:
1. Task not accomplished as required 2. Accomplished task adequately 3. Fully accomplished task with art
and dexterity
ASSESSMENT 1 2 3 COMMENTS
1. The behavior indicating the possible need for a restraint.
 The underlying cause for the assessed behavior.
 What other protective measures might be implemented before
applying a restraint.
 The status of the skin to which the restraint is to be applied.
 The circulatory status distal to the restraints, and of the
extremities.
 The effectiveness of other available safety precautions.
2. Review institutional policy for restraints, and seek consultation as

appropriate before independently deciding to apply a restraint.
3.Assemble equipment:
 Appropriate type and size of restraint
Implementation
4. Introduce yourself, and verify the client's identity. Explain to the client
what you are going to do, why it is necessary, and how the client can
cooperate.
5. Perform hand hygiene, and observe appropriate infection control
procedures.
6. Provide for client privacy.
7. Apply the selected restraint
Belt Restraint (Safety Belt)
 Determine that the safety belt is in good order. If a Velcro safety
belt is to be used, make sure that both pieces of Velcro are intact.
 If the belt has a long and a shorter portion, place the long
portion of the belt behind (under) the bedridden client, and
secure it to the movable part of the bed frame.
 Place the shorter portion of the belt around the client's waist,
over the gown. There should be a finger's width between the
belt and the client; Or
 Attach the belt around the client's waist, and fasten it at the back
of the chair; or Attach the belt around the client's waist, and
fasten it at the back of the chair; or If the belt is attached to a
stretcher, secure the belt firmly aver the client's hips or abdomen.
Jacket Restraint
 Place the vest on the client, with the opening at the front or the
back, depending on the type of vest.
 Pull the tie on the end of the vest lap across the chest, and place
it through the slit in the opposite side of the chest.
 Repeat for the other tie.
 Use a half-bow knot to secure each tie around the movable bed
frame or behind the chair to a chair leg; or Fasten the ties
together behind the chair using a slip or quick release knot.
 Ensure that the client is positioned appropriately to enable
maximum chest expansion for breathing.
Mitt Restraint
 Apply the commercial thumb less mitt to the hand to be
restrained. Make sure the fingers can be slightly flexed and are
not caught under the hand.
 Follow the manufacturer's directions for securing the mitt at
regular intervals per agency protocol. Wash and exercise the
client's hand, then reapply the mitt.
 If a mitt is to be worn for several days, remove it Assess the
client's circulation to the hands shortly after the mitt is applied,
and at regular intervals.
Wrist or Ankle Restraint
 Pad bony prominences on the wrist or ankle, if needed, to
prevent skin breakdown.
 Apply the padded portion of the restraint around the ankle or
wrist.
 Pull the tie of the restraint through the slit in the wrist portion or
through the buckle.
 Using a half-bow knot (quick-release knot), attach the other end
of the restraint to the movable portion of the bed frame.
8. Adjust the plan of care as required.
9. Document:
 Behavior(s) indicating the need for the restraint.
 All other interventions implemented in the attempt to avoid the
use of restraints, and their outcomes.
 The time the primary care providers were notified of the need
for restraint.
10. Also record;

 The type of restraint applied, the time it was applied, the goal
for its application.
 The client's response to the restraint.
 The times that the restraints were removed and skin care given.
 Any other assessments and interventions.
 Explanations given to the client and significant others.

Applying Restraint Nursing Skill

Uploaded by

Document Information

Original Description:

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

Applying Restraint Nursing Skill

Uploaded by

Copyright:

Available Formats

SKILL: APPLYING RESTRAINT

2. Review institutional policy for restraints, and seek consultation as

10. Also record;

You might also like