Restraint Alternatives and Safe Restraint Use

• Define the key terms and key abbreviations in this chapter.
• Describe the purpose of restraints.
• Identify the risk factors related to restraint use.
• Identify restraint alternatives.
• Explain the legal aspects of restraint use.
• Explain how to use restraints safely.
• Perform the procedure described in this chapter.
• Explain how to promote PRIDE in the person, the family, and yourself.

chemical restraint Any drug used for discipline or convenience and not required to treat medical symptoms

convenience Any action taken to control or manage a person's behavior that requires less effort by the staff; the action is not in the person's best interest

discipline Any action taken by the agency to punish or penalize a patient or resident

enabler A device that limits freedom of movement but is used to promote independence, comfort, or safety

freedom of movement Any change in place or position of the body or any part of the body that the person is able to control

medical symptom An indication or characteristic of a physical or psychological condition

physical restraint Any manual method or physical or mechanical device, material, or equipment attached to or near the person's body that he or she cannot remove easily and that restricts freedom of movement or normal access to one's body

remove easily The manual method, device, material, or equipment used to restrain the person that can be removed intentionally by the person in the same manner it was applied by the staff

Key Abbreviations

CMS	Centers for Medicare & Medicaid Services
FDA	Food and Drug Administration
OBRA	Omnibus Budget Reconciliation Act of 1987
ROM	Range-of-motion
TJC	The Joint Commission

Chapters 13 and 14 have many safety measures. However, some persons need extra protection. They may present dangers to themselves or others (including staff).

The Centers for Medicare & Medicaid Services (CMS) has rules for using restraints. Like the Omnibus Budget Reconciliation Act of 1987 (OBRA), CMS rules protect the person's rights and safety. This includes the right to be free from restraint. Restraints may be used only to treat a medical symptom or for the immediate physical safety of the person or others. Restraints may be used only when less restrictive measures fail to protect the person or others. They must be discontinued as soon as possible.

The CMS uses these terms.

• Physical restraint—any manual method or physical or mechanical device, material, or equipment attached to or near the person's body that he or she cannot remove easily and that restricts freedom of movement or normal access to one's body.
• Chemical restraint—any drug used for discipline or convenience and not required to treat medical symptoms. The drug or dosage is not a standard treatment for the person's condition.
• Freedom of movement—any change in place or position of the body or any part of the body that the person is able to control.
• Convenience—any action taken to control or manage a person's behavior that requires less effort by the staff; the action is not in the person's best interest.
• Discipline—any action taken by the agency to punish or penalize a patient or resident.
• Remove easily—the manual method, device, material, or equipment used to restrain the person that can be removed intentionally by the person in the same manner it was applied by the staff. For example, the person can put bed rails down, untie a knot, or unclasp a buckle.

History of Restraint Use

Restraints were once used to prevent falls. Research shows that restraints cause falls. Falls occur when persons try to get free of the restraints. Injuries are more serious from falls in restrained persons than in those not restrained.

Restraints also were used to prevent wandering or interfering with treatment. They were often used for confusion, poor judgment, or behavior problems. Older persons were restrained more often than younger persons were. Restraints were viewed as necessary devices to protect a person. However, they can cause serious harm, even death. See “Risks From Restraint Use” on p. 203.

Besides the CMS, the Food and Drug Administration (FDA), state agencies, and The Joint Commission (TJC—an accrediting agency) have guidelines for restraint use. They do not forbid restraint use. They require considering or trying all other appropriate alternatives first.

Every agency has policies and procedures for restraints. They include identifying persons at risk for harm, harmful behaviors, restraint alternatives, and proper restraint use. Staff training is required.

Restraint Alternatives

Often there are causes and reasons for harmful behaviors. Knowing and treating the cause can prevent restraint use. This is very important for persons with speech or cognitive problems. The nurse tries to find out what the behavior means.

Restraint alternatives for the person are identified in the care plan (Box 15-1). The care plan is changed as needed. Restraint alternatives may not protect the person. The doctor may need to order restraints.

Box 15-1

Restraint Alternatives

Physical Needs

• Life-long habits and routines are in the care plan. For example, showers before breakfast; reads in the bathroom; walks outside before lunch; watches TV after lunch.
• Pillows, wedge cushions, and posture and positioning devices are used.
• Food, fluid, hygiene, and elimination needs are met.
• The bedpan, urinal, or commode is within the person's reach.
• Back massages are given.
• A calm, quiet setting is provided.
• Exercise programs are provided.
• Outdoor time is planned for nice weather.
• Furniture meets the person's needs (lower bed, reclining chair, rocking chair).
• Observations and visits are made at least every 15 minutes. Or as often as directed by the nurse and the care plan.
• The person is moved to a room close to the nurses' station.
• Light is adjusted to meet the person's needs and preferences.
• Staff assignments are consistent.
• Sleep is not interrupted.
• Noise levels are reduced.

Safety and Security Needs

• The call light is within reach.
• Call lights are answered promptly.
• The person wanders in safe areas.
• All staff are aware of persons tending to wander. This includes staff in housekeeping, maintenance, the business office, dietary, and so on.
• Knob guards are used on doors.
• Falls and injuries from falls are prevented (Chapter 14).
- • Padded hip protectors are worn under clothing (Fig. 15-1, p. 202).
  
  FIGURE 15-1 Hip protector. (Image courtesy Posey Company, Arcadia, Calif.)
- • Floor cushions are placed next to beds (Chapter 14).
- • Roll guards are attached to the bed frame (Fig. 15-2, p. 202).
  
  FIGURE 15-2 Roll guard. (Image courtesy Posey Company, Arcadia, Calif.)
• Warning alarms are used on beds, chairs, and doors.
• Walls and furniture corners are padded.
• Procedures and care measures are explained.
• Frequent explanations are given about equipment or devices.
• Confused persons are oriented to person, time, and place. Calendars and clocks are provided. See Chapter 49.

Love, Belonging, and Self-Esteem Needs

Safe Restraint Use

Restraints can cause serious injury and even death. CMS, OBRA, FDA, and TJC rules and guidelines are followed. So are state laws. They are part of the agency's policies and procedures for restraint use.

Restraints are not used to discipline a person. They are not used for staff convenience. Restraints are used only when necessary to treat medical symptoms. A medical symptom is an indication or characteristic of a physical or psychological condition. Symptoms may relate to physical, emotional, or behavioral problems. Sometimes restraints are needed to protect the person or others. That is, a person may have violent or aggressive behaviors that are harmful to self or others or that are threatening to others.

See Focus on Surveys: Safe Restraint Use.

Focus on Surveys

Safe Restraint Use

Agencies must have a policy about restraint use. Surveyors will try to learn if restraints were used:

• For discipline or staff convenience
• Only for a certain time for the person's well-being

Surveyors will review medical records and interview staff. Some questions will focus on:

Physical and Chemical Restraints

According to the CMS, a physical restraint includes these points.

• May be any manual method, physical or mechanical device, material, or equipment.
• Is attached to or next to the person's body.
• Cannot be removed easily by the person.
• Restricts freedom of movement or normal access to one's body.

Physical restraints are applied to the chest, waist, elbows, wrists, hands, or ankles. They confine the person to a bed or chair. Or they prevent movement of a body part. Some furniture or barriers also prevent freedom of movement.

• A device used with a chair that the person cannot remove easily. The device prevents the person from rising. Trays, tables, bars, and belts are examples (Fig. 15-3).

FIGURE 15-3 This lap-top tray is a restraint alternative. It is a restraint when used to prevent freedom of movement. (Image courtesy Posey Company, Arcadia, Calif.)
• Any chair that prevents the person from rising.
• Any bed or chair placed so close to the wall that the person cannot get out of the bed or chair.
• Bed rails (Chapter 14) that prevent the person from getting out of bed. For example, 4 half-length bed rails are raised. They are restraints if the person cannot lower them.
• Tucking in or using Velcro (or other device) to hold a sheet, fabric, or clothing so tightly that freedom of movement is restricted.

Drugs or drug dosages are chemical restraints if they:

• Control behavior or restrict movement.
• Are not standard treatment for the person's condition.

Drugs cannot be used for discipline or staff convenience. They cannot be used if they affect physical or mental function.

Sometimes drugs can help persons who are confused or disoriented. They may be anxious, agitated, or aggressive. The doctor may order drugs to control these behaviors. The drugs should not make the person sleepy and unable to function at his or her highest level.

Enablers.

An enabler is a device that limits freedom of movement but is used to promote independence, comfort, or safety. Some devices can be restraints or enablers. When the person can easily remove the device and it helps the person function, it is an enabler. For example:

• A chair or wheelchair with a lap-top tray for meals, writing, and so on (see Fig. 15-3). The chair is an enabler. If used to limit freedom of movement, the chair is a restraint.
• A person chooses to have raised bed rails. The bed rails are used to move in bed and to prevent falling out of bed. The bed rails are enablers, not restraints.

Risks From Restraint Use

Box 15-2 lists the risks from restraints. Injuries can occur as the person tries to get free of the restraint. Injuries also occur from using the wrong restraint, applying it wrong, or keeping it on too long. Cuts, bruises, and fractures are common. The most serious risk is death from strangulation.

Restraints are medical devices. The Safe Medical Devices Act applies if a restraint causes illness, injury, or death. Also, CMS requires the reporting of any death that occurs:

• While a person is in a restraint.
• Within 24 hours after a restraint was removed.
• Within 1 week after a restraint was removed. This is done if the restraint may have contributed directly or indirectly to the person's death.

Laws, Rules, and Guidelines

Laws (federal and state) and rules (CMS, FDA) for restraint use are followed. So are accrediting agency (TJC) guidelines. Remember:

• Restraints must protect the person. They are not used for staff convenience or to discipline a person. Using restraints is not easier than properly supervising and observing the person. A restrained person requires more staff time for care, supervision, and observation. A restraint is used only when it is the best safety measure for the person. Restraints are not used to punish or penalize uncooperative persons.
• A doctor's order is required. OBRA, CMS, state laws, FDA warnings, TJC, and other accrediting agencies protect persons from unnecessary restraints. If restraints are needed for medical reasons, a doctor's order is required. The doctor gives the reason for the restraint, what body part to restrain, what to use, and how long to use it. This information is on the care plan and your assignment sheet. In an emergency, the nurse can decide to apply restraints before getting a doctor's order.
• The least restrictive method is used. It allows the greatest amount of movement or body access possible. Some restraints attach to the person's body and to a fixed (non-movable) object. They restrict freedom of movement or body access. Vest, jacket, ankle, wrist, hand, and some belt restraints are examples. Other restraints are near but not directly attached to the person's body (bed rails or wedge cushions). They do not totally restrict freedom of movement and are less restrictive. They allow access to certain body parts.
• Restraints are used only after other measures fail to protect the person (see Box 15-1). Some people can harm themselves or others. The care plan must include measures to protect the person and prevent harm to others. Many fall prevention measures are restraint alternatives (Chapter 14).
• Unnecessary restraint is false imprisonment (Chapter 5). You must clearly understand the reason for the restraint and its risks. If not, politely ask about its use. If you apply an unneeded restraint, you could face false imprisonment charges.
• Informed consent is required. The person must understand the reason for the restraint. The person is told how the restraint will help the planned medical treatment. The person is told about the risks of restraint use. If the person cannot give consent, his or her legal representative is given the information for purposes of giving consent. Consent must be given before a restraint can be used. The doctor or nurse provides needed information and obtains the consent.

Safety Guidelines

The restrained person must be kept safe. Follow the safety measures in Box 15-3. Also remember these key points.

Box 15-3

Safety Measures for Using Restraints

Before Applying Restraints

• Do not use sheets, towels, tape, rope, straps, bandages, Velcro, or other items to restrain a person.
• Apply a restraint only after being instructed about its proper use.
• Demonstrate proper application of the restraint before applying it.
• Use the restraint noted in the care plan. Use the correct size. Small restraints are tight. They cause discomfort and agitation. They also restrict breathing and circulation. Strangulation is a risk from big or loose restraints.
• Use only restraints that have manufacturer's instructions and warning labels.
- • Read the warning labels. Note the front and back of the restraint.
- • Follow the instructions. Some restraints are safe for bed, chair, and wheelchair use. Others are used only with certain equipment.
• Use intact restraints.
- • Look for broken stitches, tears, cuts, or frayed fabric or straps.
- • Look for missing or loose buckles, locks, hooks, loops, or straps or other damage. The restraint must hold securely.
• Test zippers, buckles, locks, hooks, loops, and other fasteners. The device must fasten securely.
• Do not use a restraint near a fire, a flame, or smoking materials.

Applying Restraints

• Follow agency policies and procedures.
• Do not use a restraint to:
- • Position a person on a toilet.
- • Position a person on furniture that does not allow for correct application.
• Position the person in good alignment before applying the restraint (Chapter 17).
- • Semi-Fowler's position (Chapter 20) is usually preferred for a vest, jacket, or belt restraint.
- • When in a chair, position the person so the hips are well to the back of the chair.
• Pad bony areas and the skin as instructed by the nurse. This prevents pressure and injury from the restraint.
• Follow the manufacturer's instructions. A restraint applied wrong or backward may cause serious injury or death. Death may occur from suffocation or strangulation.
- • For a vest restraint, the “V” neck is in front (Fig. 15-4, p. 206).
  
  FIGURE 15-4 The vest restraint criss-crosses in front. The “V” neck is in front. (NOTE: The bed rails are raised after the restraint is applied.)
- • For a jacket restraint, the opening is in the back.
- • For a belt restraint when in a chair—Apply the restraint at a 45-degree angle over the thighs (Fig. 15-5, p. 206).
  
  FIGURE 15-5 The belt restraint is at a 45-degree angle over the thighs. (Image courtesy Posey Company, Arcadia, Calif.)
• Do not criss-cross straps in the back unless required by the manufacturer's instructions (Fig. 15-6, p. 206). Straps may loosen when the person moves and cause serious injury.

FIGURE 15-6 Never criss-cross vest or jacket straps in the back. (Image courtesy Posey Company, Arcadia, Calif.)
• Secure restraints according to agency policy. The policy should follow the manufacturer's instructions and allow for quick release in an emergency. Quick-release buckles or airline-type buckles are used (Fig. 15-7, p. 206). So are quick-release ties (Fig. 15-8, p. 207).

FIGURE 15-7 A, Quick-release buckle. B, Airline-type buckle. (Image courtesy Posey Company, Arcadia, Calif.)

FIGURE 15-8 The Posey quick-release tie. (Image courtesy Posey Company, Arcadia, Calif.)
• Secure straps out of the person's reach.
• Leave 1 to 2 inches of slack in the straps if directed to do so by the nurse. This allows some movement of the part.
• Secure the restraint to the movable part of the bed frame (Fig. 15-9, p. 207). The restraint will not tighten or loosen when the head or foot of the bed is raised or lowered. For chairs, secure straps under the seat of the wheelchair or chair (Fig. 15-10, p. 207).

FIGURE 15-9 The restraint is secured to the movable part of the bed frame.

FIGURE 15-10 The restraint straps are secured to the wheelchair frame. (Image courtesy Posey Company, Arcadia, Calif.)
• Check for snugness after applying the restraint. The restraint should be snug but allow some movement of the restrained part. Follow the manufacturer's instructions. For example:
- • If applied to the chest or waist—Make sure the person can breathe easily. A flat hand should slide between the restraint and the person's body (Fig. 15-11, p. 207). Check with the nurse if you have very small or very large hands. Small or large hands could cause the restraint to be too tight or too loose.
  
  FIGURE 15-11 A flat hand slides between the restraint and the person.
- • For wrist and mitt restraints—You should be able to slide 1 finger under the restraint. Check with the nurse if you have very small or very large fingers. Small or large fingers could cause the restraint to be too tight or too loose.
• Make sure that the straps:
- • Cannot tighten, loosen, slip, or cause too much slack.
- • Will not slide in any direction. If straps slide, they change the restraint's position. The person can get suspended off the mattress or chair (Figs. 15-12 and 15-13, p. 208). Strangulation can result.
  
  FIGURE 15-12 A, A person can get suspended and caught between bed rail bars. B, The person can get suspended and caught between half-length bed rails. (Images courtesy Posey Company, Arcadia, Calif.)
  
  FIGURE 15-13 Strangulation can result if the person slides forward or down because of extra slack in the restraint. (Images courtesy Posey Company, Arcadia, Calif.)
• Never secure restraints to the bed rails. The person can reach bed rails to release knots or buckles. Also, injury to the person is likely when raising or lowering bed rails.
• Use bed rail covers or gap protectors as instructed by the nurse (Fig. 15-14, p. 208). They prevent entrapment between the rails or the bed rail bars (see Fig. 15-12). Entrapment can occur between:

FIGURE 15-14 A, Bed rail protector. B, Guard rail pads. (Images courtesy Posey Company, Arcadia, Calif.)

After Applying Restraints

• Keep full bed rails up when using a vest, jacket, or belt restraint. Also use bed rail covers or gap protectors. Otherwise the person could fall off the bed and strangle on the restraint. Or the person can get caught between half-length bed rails.
• Do not use back cushions when a person is restrained in a chair. If the cushion moves out of place, slack occurs in the straps. Strangulation is a risk if the person slides forward or down from the extra slack.
• Do not cover the person with a sheet, blanket, bedspread, or other covering. The restraint must be within plain view at all times.
• Check the person at least every 15 minutes for safety, comfort, and signs of injury. Or check the person as often as directed by the nurse and the care plan.
• Monitor persons in the supine (back-lying) position constantly. Aspiration is a great risk if vomiting occurs (Chapter 27). Call for the nurse at once.
• Check the person's circulation at least every 15 minutes or as often as directed by the nurse and the care plan.
- • For mitt, wrist, or ankle restraints—You should feel a pulse at a pulse site below the restraint. Fingers or toes should be warm and pink. Tell the nurse at once if:
- • For a belt, jacket, or vest restraint—The person should be able to breathe easily. Also check the position of the restraint, especially in the front and back.
• Keep scissors in your pocket. In an emergency, cutting the tie may be faster than untying a knot. Never leave scissors where the person can reach them. Make sure the person cannot reach the scissors in your pocket.
• Remove or release the restraint and re-position the person every 2 hours or as often as noted in the care plan. The restraint is removed or released for at least 10 minutes. Meet the person's basic needs. You need to:
• Keep the call light and other needed items within the person's reach. Chart that this was done.
• Complete a safety check before leaving the room. (See the inside of the front cover.)
• Report to the nurse every time you checked the person and removed or released the restraint. Report your observations and the care given (Fig. 15-15, p. 209). Follow agency policy for recording.

FIGURE 15-15 Charting sample.

• Observe for increased confusion and agitation. Restraints can increase confusion and agitation. Whether confused or alert, people are aware of restricted movements. They may try to get out of the restraint or struggle to pull at it. Some restrained persons beg others to free or to help release them. These behaviors often are viewed as signs of confusion. Some people become more confused because they do not understand what is happening to them. Restrained persons need repeated explanations and reassurance. Spending time with them has a calming effect.
• Protect the person's quality of life. Restraints are used for as short a time as possible. The care plan must show how to reduce restraint use. The person's needs are met with as little restraint as possible. You must meet the person's physical, emotional, and social needs. Visit with the person and explain the reason for the restraint.
• Follow the manufacturer's instructions. They explain how to safely apply and secure the restraint. The restraint must be snug and firm but not tight. Tight restraints affect circulation and breathing. The person must be comfortable and able to move the restrained part to a limited and safe extent. You could be negligent if you do not apply or secure a restraint properly.
• Apply restraints with enough help to protect the person and staff from injury. Persons in immediate danger of harming themselves or others are restrained quickly. Combative and agitated people can hurt themselves and the staff when restraints are applied. Enough staff members are needed to complete the task safely and quickly.
• Observe the person at least every 15 minutes or as often as directed by the nurse and the care plan. Restraints are dangerous. Injuries and deaths can result from improper restraint use and poor observation. Prevent complications. Breathing and circulation problems are examples.
• Remove or release the restraint, re-position the person, and meet basic needs at least every 2 hours. Or do so as often as noted in the care plan.

See Focus on Communication: Safety Guidelines, p. 208.

See Teamwork and Time Management: Safety Guidelines, p. 209.

Focus on Communication

Safety Guidelines

Restraints can increase confusion. Remind the person of the reason for the restraint and to call for help when it is needed. Repeat the following as often as needed.

• “Dr. Monroe ordered this restraint so you don't hurt yourself. If you need to get up, please call for help. I'll check on you every 15 minutes. Other staff will check on you too.”
• “How does the restraint feel? Is it too tight? Is it too loose?”
• “Please put your call light on. I want to make sure that you can reach and use it with the restraint on.”
• “Please call for help right away if the restraint is too tight.”
• “Please call for help right away if you feel pain in your fingers or hands. Also call for me if you feel numbness or tingling.”
• “Please call for help right away if you are having problems breathing.”

Teamwork and Time Management

Safety Guidelines

You may not be assigned to a restrained person. However, make sure you know who is restrained on your unit. When you walk past the person or the person's room, check if the person is safe and comfortable. Answer the person's call light promptly.

Belt Restraints.

A belt restraint (Fig. 15-18) may be used when injuries from falls are risks or for positioning during a medical treatment. The person cannot get out of bed or out of a chair. However, a roll belt allows the person to turn from side to side or to sit up in bed.

FIGURE 15-18 Belt restraint. (NOTE: The bed rails are raised after the restraint is applied.)

The belt is applied around the waist and secured to the bed or chair (lap belt). It is applied over a garment. The person can release the quick-release type. It is less restrictive than those that only staff can release.

Vest Restraints and Jacket Restraints.

Vest and jacket restraints are applied to the chest. They have the same purpose as belt restraints. The person cannot turn in bed or get out of a chair.

A jacket restraint is applied with the opening in the back. For a vest restraint, the “V” neck is in front and the vest crosses in the front (see Fig. 15-4). Vest and jacket restraints are never worn backward. Strangulation or other injuries are risks if the person slides down in the bed or chair. The restraint is always applied over a garment. (NOTE: The straps of vest and jacket restraints cross in the front. A vest or jacket restraint may have a positioning slot in the back [Fig. 15-19]. Criss-cross straps following the manufacturer's instructions.)

FIGURE 15-19 Jacket restraint. (NOTE: The bed rails are raised after the restraint is applied.)

Vest and jacket restraints have life-threatening risks. Death can occur from strangulation. If caught in the restraint, it can become so tight that the person's chest cannot expand to inhale air. The person quickly suffocates and dies. Correct application is critical. You are advised to only assist the nurse in applying them. The nurse should assume full responsibility for applying a vest or jacket restraint.

See Focus on Communication: Applying Restraints.

See Focus on Children and Older Persons: Applying Restraints, p. 212.

See Delegation Guidelines: Applying Restraints, p. 212.

See Promoting Safety and Comfort: Applying Restraints, p. 212.

See procedure: Applying Restraints, p. 213.

Focus on Communication

Applying Restraints

If you do not know how to apply a certain restraint, do not do so. Ask the nurse to show you the correct way. You can say: “I've never applied a restraint like this before. Would you please show me how and then watch me apply it?” Thank the nurse for helping you.

When applying a restraint, explain to the person what you are going to do. Then tell the person what you are doing step-by-step. Always check for safety and comfort. You can ask: “How does the restraint feel? Is it too tight? Is it too loose?”

Make sure the person can communicate with you after leaving the room. Place the call light within reach. Make sure the person can use it with the restraint on. Remind the person to call if uncomfortable or if anything is needed.

Focus on Children and Older Persons

Applying Restraints

Children

Elbow splints limit arm movements. They prevent infants and children from bending their elbows (Fig. 15-20). They are used to prevent scratching and touching incisions or pulling out tubes. Both arms are restrained to achieve the desired effect.

FIGURE 15-20 Elbow splints. (Image courtesy Posey Company, Arcadia, Calif.)

Older Persons

Restraints may increase confusion and agitation in persons with dementia. They do not understand what you are doing. They may resist your efforts to apply a restraint. They may try to get free from the restraint. Serious injury and death are risks.

Never use force to apply a restraint. If a person is confused or agitated, ask a co-worker to help apply the restraint. Report problems to the nurse at once.

Delegation Guidelines

Applying Restraints

Before applying a restraint, you need this information from the nurse and the care plan.

Promoting Safety and Comfort

Applying Restraints

Safety

Restraints can cause serious harm, even death. Always follow the manufacturer's instructions. The instructions for 1 restraint may not apply to another. Also, the manufacturer may have instructions for applying restraints on persons who are agitated.

Never use force. Ask a co-worker to help if a person is confused and agitated. Report problems to the nurse at once.

Check the person at least every 15 minutes or as often as directed by the nurse and the care plan. Make sure the call light is within reach. Ask the person to use the call light at the first sign of problems or discomfort.

Never use a restraint as a seat belt in a car or other vehicle.

Mitt Restraints

Mitt restraints prevent finger use. Often they are not secured to the bed or chair. Therefore the person can raise the mitt to his or her mouth. Observe the person closely to make sure that he or she does not:

• Use the teeth to remove or damage the device.
• Ingest any mitt material.

Persons with mitt restraints may be able to walk about. Falls are a risk. Practice safety measures to prevent falls (Chapter 14).

Belt, Vest, and Jacket Restraints

If a belt, vest, or jacket restraint is ordered, monitor the person to make sure that he or she cannot:

• Slide forward or down in the chair or bed and become suspended or entrapped.
• Fall off the chair or mattress and become suspended or entrapped.

Comfort

The person's comfort is always important when restraints are used. Restraints limit movement. This affects position changes and reaching needed items. Position the person in good alignment before applying a restraint (Chapter 17). Also make sure the person can reach needed items—call light, water mug, tissues, phone, bed controls, and so on.

Applying Restraints

Quality of Life

• Knock before entering the person's room.
• Address the person by name.
• Introduce yourself by name and title.
• Explain the procedure before starting and during the procedure.
• Protect the person's rights during the procedure.
• Handle the person gently during the procedure.

Pre-Procedure

1 Follow Delegation Guidelines: Applying Restraints. See Promoting Safety and Comfort: Applying Restraints.
2 Collect the following as instructed by the nurse.
3 Practice hand hygiene.
4 Identify the person. Check the ID (identification) bracelet against the assignment sheet. Use 2 identifiers (Chapter 13). Also call the person by name.
5 Provide for privacy.

Procedure

6 Position the person for comfort and good alignment.
7 Put the bed rail pads or gap protectors (if needed) on the bed if the person is in bed. Follow the manufacturer's instructions.
8 Pad bony areas. Follow the nurse's instructions and the care plan.
9 Read the manufacturer's instructions. Note the front and back of the restraint.
10 For wrist restraints:
- a Apply the restraint following the manufacturer's instructions. Place the soft or foam part toward the skin.
- b Secure the restraint so it is snug but not tight. Make sure you can slide 1 finger under the restraint (see Fig. 15-16). Follow the manufacturer's instructions. Adjust the straps if the restraint is too loose or too tight. Check for snugness again.
- c Secure the straps to the movable part of the bed frame out of the person's reach. Use the buckle or a quick-release tie.
- d Repeat step 10, a–c for the other wrist.
11 For mitt restraints:
12 For a belt restraint:
13 For a vest restraint:
14 For a jacket restraint:
15 For elbow splints:

Post-Procedure

16 Position the person as the nurse directs.
17 Provide for comfort. (See the inside of the front cover.)
18 Place the call light and other needed items within the person's reach.
19 Raise or lower bed rails. Follow the care plan and the manufacturer's instructions for the restraint.
20 Unscreen the person.
21 Complete a safety check of the room. (See the inside of the front cover.)
22 Practice hand hygiene.
23 Check the person and the restraint at least every 15 minutes or as often as directed by the nurse and the care plan. Report and record your observations.
- a For wrist or mitt restraints or elbow splints: check the pulse, color, and temperature of the restrained parts.
- b For a vest, jacket, or belt restraint: check the person's breathing. Call for the nurse at once if the person is not breathing or is having problems breathing. Make sure the restraint is properly positioned in the front and back.
24 Do the following at least every 2 hours for at least 10 minutes.
25 Complete a safety check of the room. (See the inside of the front cover.)
26 Practice hand hygiene.
27 Report and record your observations and the care given.

Focus on Pride

The Person, Family, and Yourself

Personal and Professional Responsibility

Restraints have many risks. See Box 15-2. Therefore restraint use brings many responsibilities. You must:

• Monitor the person for safety.
• Apply the restraint properly.
• Promote comfort.
• Observe the person closely.
• Meet basic needs.
• Report any concerns to the nurse.

If you do not know how to apply a restraint, do not do so. Ask the nurse to show you. To use restraints safely and responsibly, follow the guidelines in Box 15-3.

Rights and Respect

Every person has the right to freedom from restraint. Restraints are used only as a last resort to protect the person or others from harm. Other methods must be tried before restraints are used. You may be asked to assist with restraint alternatives (see Box 15-1). Make a genuine effort. Be honest. Do not tell the nurse you tried if you really did not. Do your best to allow the person the right to freedom from restraint.

Independence and Social Interaction

All restraints limit movement. Independence is restricted. To promote independence:

• Keep the call light within reach at all times. Make sure the person can use it. Tell the person to signal for you if anything is needed. Answer the call light and meet the person's needs promptly.
• Keep needed items within reach. This is most important with restraints that allow hand and arm use. Belt, vest, and jacket restraints and elbow splints are examples.
• Check the person at least every 15 minutes or as often as directed by the nurse and the care plan.
• Remove or release the restraint at least every 2 hours.
• Meet food, fluid, hygiene, and elimination needs.
• Assist the person with walks or ROM exercises.
• Allow choice. For example, let the person choose where to walk or what to eat and drink.
• Let the person do as much for himself or herself as safely possible.

Personal choice and freedom of movement promote independence, dignity, and self-esteem. Provide care that gives restrained persons the independence they deserve.

Delegation and Teamwork

Care conferences are held to meet the person's safety needs. The health team reviews and updates the person's care plan. Every attempt is made to protect the person without restraints.

You are an important member of the health team. Your input has value. Share your observations and ideas. For example, Mrs. Garner does not try to get out of her chair when she looks through her photo albums or reads a book. You share this with the team. They include diversion activities in her care plan.

Ethics and Laws

Imagine the following.

• Your nose itches. But your wrists are restrained. You cannot scratch your nose.
• You need to use the bathroom. Your arms are restrained with wrist restraints. You cannot get up. You cannot reach your call light. You soil yourself with urine or a bowel movement.
• Your phone is ringing. You cannot answer it.
• You are wearing mitt restraints. You cannot reach your eyeglasses or put them on. You cannot see who is coming into and going out of your room. And you cannot speak because of a stroke.
• You are uncomfortable. You have a vest restraint. You cannot move or turn in bed.
• You are thirsty. Your wrists are restrained. You cannot reach the water mug.
• You hear the fire alarm. You have on a restraint. You cannot get up to move to a safe place. You must wait until someone rescues you.

What would you do? Would you calmly lie or sit there? Would you try to get free from the restraint? Would you yell for help? Would the staff think that you are uncomfortable? Or would they think that you are agitated and uncooperative? Would you feel angry, embarrassed, or humiliated?

Ethics deals with how others are treated. Restraints lessen the person's dignity and freedom. A person should not be treated in this way. That is why restraints are a last resort. Put yourself in the person's situation. Then you can better understand how the person feels. Treat the person like you would want to be treated—with kindness, caring, respect, and dignity.

Focus on Pride: Application

Your input has value. Do not be afraid to share your thoughts, observations, and ideas with the nurse. Describe 3 scenarios involving behavior that is dangerous or that interferes with treatment. List ideas for managing the behavior without using restraints.

Review Questions

Circle T if the statement is TRUE or F if it is FALSE.

1. T F Restraint alternatives fail to protect a person. You can apply a restraint.

2. T F A restraint restricts a person's freedom of movement.

3. T F Some drugs are restraints.

4. T F Restraints can be used for staff convenience.

5. T F A device is a restraint only if it is attached to the person's body.

6. T F Bed rails are restraints if the person cannot lower them.

7. T F Restraints are used only for a person's specific medical symptom.

8. T F Unnecessary restraint is false imprisonment.

9. T F You can apply restraints when you think they are needed.

10. T F You can use a vest restraint to position a person on the toilet.

11. T F Restraints are removed or released at least every 2 hours.

12. T F Restraints are tied to bed rails.

13. T F Wrist restraints are used to prevent falls.

14. T F A vest restraint crosses in front.

15. T F Bed rails are left down when a vest restraint is used.

Circle the BEST answer.

16. Which is a restraint alternative?

a Positioning the person's chair close to the wall

b Raising all bed rails

c Giving a drug that restricts movement

d Padding walls and corners of furniture

17. Physical restraints

a Can be removed easily by the person

b Are not allowed by OBRA

c Require a doctor's order

d Are safer than chemical restraints

18. The following can occur because of restraints. Which is the most serious?

a Fractures

b Strangulation

c Pressure ulcers

d Urinary tract infections

19. A belt restraint is applied to a person in bed. Where should you secure the straps?

a To the bed rails

b To the head-board

c To the movable part of the bed frame

d To the foot-board

20. A person has a restraint. You should check the person and the position of the restraint at least every

21. A person has mitt restraints. Which will you report to the nurse at once?

a The hands are clean, warm, and dry.

b The person has numbness in the hands.

c You removed the restraints for 10 minutes.

d You felt a pulse in both arms.

22. When applying restraints, you should

a Know when to apply and release them

b Use force if the person is agitated

c Allow plenty of slack in the straps

d Apply a restraint you have not used before

23. A person has a vest restraint. To check for snugness, slide

a A fist between the vest and the person

b 1 finger between the vest and the person

c An open hand between the vest and the person

d 2 fingers between the vest and the person

24. The correct way to apply any restraint is to follow the

a Nurse's directions

b Doctor's orders

c Care plan

d Manufacturer's instructions

See Review Question Answers at the back of the text.

Focus on Practice

Problem Solving

Mrs. Lopez has confusion and weakness in her legs. She uses a wheelchair and often tries to get up without help. What are some alternatives to restraints that may be tried? If a restraint is needed, how will you provide for her basic needs?

Key Abbreviations

History of Restraint Use

Restraint Alternatives

Safe Restraint Use

Physical and Chemical Restraints

Enablers.

Risks From Restraint Use

Laws, Rules, and Guidelines

Safety Guidelines

Reporting and Recording

Applying Restraints

Wrist Restraints.

Mitt Restraints.

Belt Restraints.

Vest Restraints and Jacket Restraints.

Review Questions