Nursing & Healthcare Programs

Applying Restraints

person wearing orange and white silicone band

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.

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

Safety Belt Restraint

  1. Apply the belt over the patient’s clothing at the waist.
  2. Cross the ties around the back of the patient and slip the ties through the corresponding loops on each side.
  3. If the patient is sitting in a chair, correctly fasten the belt using a slipknot around the back of the chair.
  4. 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.
  5. Ensure one finger can fit between the patient and the belt.

Vest Restraint

  1. 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.
  2. Cross the restraint ties by pulling one tie through the slit on the opposite side of the vest.
  3. 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.
  4. Ensure the restraint is not too tight and that the patient’s breathing is not restricted.

Mitt Restraint

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

Wrist/Ankle Restraint

  1. Apply padded restraint to wrist or ankle.
  2. Ensure two fingers can fit between the restraint and the patient.
  3. Fasten the straps through the loops on the restraint.
  4. 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

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.

Dressing and Undressing a Patient

Patients who have suffered a stroke or have weakness or injury to one side of their body may struggle with dressing and undressing. In order to help these patients regain their strength and independence, it is important that the nurse’s aide only assist them as needed. The nurse’s aide may need to teach patients how to dress and undress safely with their limitations.

Passive Range of Motion Exercises

Range of motion exercises are used to help prevent or decrease contractures, improve flexibility of joints, and improve strength [1]. Bedridden patients as well as those with reduced mobility may greatly benefit from passive range of motion exercises. However, do not perform these exercises without an order to do so, as it may be contraindicated in certain situations.

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.

Offering the Bedpan

When a resident is bed-bound, they must use a bedpan to urinate and defecate. This can be embarrassing for the resident, so it should be done with sensitivity to the resident’s privacy and dignity. There are two types of bedpans. A regular bedpan is the deeper and more rounded of the two. A fracture pan has a relatively flat upper end with a trough at the lower end. Fracture pans are used for residents who have difficulty, or restrictions against, moving their hips and/or backs.

Applying a Condom Catheter

Condom catheters are used for men who are incontinent. These catheters are external and are meant to be used short-term and changed daily.