Restraint Application
The Centers for Medicare and Medicaid Services (CMS) and The Joint Commission define restraints as devices that immobilize or reduce the ability of a patient to move the arms, legs, body, or head freely, except in situations involving orthopedic devices, surgical bandages, and similar devices required for the patient’s care.
A vest restraint can be used to prevent self–injury from falls or to immobilize a patient to assist medical treatment. It’s applied to a patient’s torso over his hospital gown or clothing. The straps are then secured to the patient’s bed frame or chair.
A limb restraint is a device consisting of a cuff, typically made of padded fabric or foam, that’s applied to a patient’s wrists or ankles, and straps that are secured to the patient’s bed frame or chair. Limb restraints may be used to prevent self-injury or to prevent the removal of therapeutic equipment, such as IV lines, indwelling catheters, and nasogastric tubes.
A mitt restraint is a pocket enclosure that’s applied over a patient’s hand to prevent self-injury or removal of therapeutic equipment, such as IV lines, indwelling catheters, and nasogastric tubes. Mitt restraints may be padded or rigid and may include finger separators or leave the fingers exposed. Optional straps that can be secured to the patient’s bed frame or chair may be included with the device or may need to be ordered separately if indicated. Most mitt restraints can be applied to either hand.
A belt restraint consists of a strip of material—usually cotton fabric or mesh—that’s applied over a patient’s gown or clothing, around the waist or lap, and then secured to the bed frame or chair. The straps are then secured to the patient’s bed frame or chair. Belt restraints can be used to prevent self-injury from falls or to immobilize a patient to assist with medical treatment.
A leather or leather-like restraint is made of leather or a synthetic substitute for leather, such as polyurethane or vinyl, and is applied to a patient’s wrists or ankles and then secured to the bed frame or chair. It can be used to prevent self-injury or injury to others or to immobilize a patient for medical treatment. Although some facilities prefer to use traditional leather restraints because of the perceived strength of the material, synthetic materials offer the advantage of being easier to clean and sanitize.
The CMS and The Joint Commission recognize the rights of patients to be free from restraint or seclusion, of any form, imposed as a means of coercion, discipline, convenience, or retaliation by staff members. Therefore, restraint or seclusion may only be used to ensure the immediate physical safety of the patient, a staff member, or others and should only be used when all other methods have failed to keep the patient from harming himself or others. This standard has been established with the intent of reducing the overall use of restraints. If restraints must be used, the health care provider must choose a restraint that’s the least restrictive to the patient and discontinue restraint use at the earliest possible time.1,2
Only staff members trained in the use of restraints and the use of less restrictive techniques aimed at avoiding restraint are permitted to evaluate the need for restraints, apply restraints, and monitor patients who are restrained. Always check your facility’s policy on restraints before applying them to a patient.1,3
Equipment
Restraint device (vest, limb, mitt, belt, or leather) ▪ key ▪ cuff liners (if recommended by the manufacturer).
Preparation of Equipment
Because there are various types of body restraints, always refer to the manufacturer’s preparation and application instructions. For
example, some vest restraints wrap around the patient with the straps crossing in the front, whereas other types close with a zipper at the patient’s back. Check to see that you have obtained the correct size for the patient’s build and weight. Some devices require that the straps be fed through the cuff before application. Because there are various types of belt restraints, make sure you’ve chosen a restraint that’s appropriate for your patient. For example, a restraint may hold a patient in a stationary position or allow the patient to roll from side to side, may wrap around the pelvis in addition to the waist for additional security when sitting up, or be padded or unpadded. Some belt restraints wrap around the patient with the straps crossing in the back; others have straps that cross in the front.
example, some vest restraints wrap around the patient with the straps crossing in the front, whereas other types close with a zipper at the patient’s back. Check to see that you have obtained the correct size for the patient’s build and weight. Some devices require that the straps be fed through the cuff before application. Because there are various types of belt restraints, make sure you’ve chosen a restraint that’s appropriate for your patient. For example, a restraint may hold a patient in a stationary position or allow the patient to roll from side to side, may wrap around the pelvis in addition to the waist for additional security when sitting up, or be padded or unpadded. Some belt restraints wrap around the patient with the straps crossing in the back; others have straps that cross in the front.
If using leather restraints, make sure the straps are unlocked and the key fits the lock.
Check the device for damage before use; obtain a new device if necessary.
Implementation
Obtain a doctor’s order for the restraint. In an emergency situation, obtain an order as soon as possible after applying the restraints according to your facility’s policy.1,4
Nursing Alert
If the patient is being restrained because of violent or self-destructive behavior that jeopardizes the physical safety of the patient, staff members, or others, the doctor or other licensed independent practitioner responsible for the patient’s care must conduct an in-person evaluation within 1 hour of initiating the restraint. No as-needed or standing orders for restraints can be used.1
Tell the patient that you’re applying a restraint. Assure him that the restraint is being used to protect him from injury rather than to punish him. Emphasize that the restraint will be removed as soon as it is safe to do so, and tell him the criteria you’ll use for discontinuing restraints.
If necessary, obtain the assistance of additional staff members to apply the restraints.
Applying A Vest Restraint
If the patient’s condition permits, assist the patient to a sitting position. If the patient is unable to sit, apply the vest restraint by rolling the patient side to side.
Smooth out the patient’s gown or clothing to remove as many wrinkles as possible.
Slip the vest over the patient’s gown or clothing.
Assist the patient in putting his arms through the armholes.
For a criss-cross vest restraint, check that the V-shape neck is in front. Criss-cross the straps in the front of the vest. Never criss-cross the flaps in the back because doing so may cause the patient to choke if he tries to squirm out of the vest. Feed the straps through the holes in the front of the vest as indicated by manufacturer’s instructions.
For a zipper vest restraint, make sure that the zipper is in the back. Zip up the back of the restraint.
Adjust the vest for a comfortable fit. Make sure the restraint doesn’t compromise breathing or circulation. You should be able to slip an open, flat hand between the vest and the patient.
Applying A Limb Restraint
Position the patient’s wrist or ankle in the soft padded cuff portion of the restraint by slipping the cuff over the patient’s hand or foot. If using a wrap type device, wrap the wrist or ankle so that the fasteners are on the outside of the device.
If indicated, fasten the buckle or Velcro fastener.
Adjust the straps for a snug fit that doesn’t compromise the patient’s circulation. You should be able to slip one or two fingers between the restraint and the patient’s skin. Applying the restraint too tightly may impair circulation distal to the restraint.
Applying A Mitt Restraint
Assess for baseline hand and finger circulation to determine the appropriateness of the device and to determine whether circulatory changes may occur after application.
Insert the patient’s hand into the mitt with his palm facing down according to the manufacturer’s instructions. If finger separators are available in the device, separate each finger into its own slot.
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