Defintion of Restraints

1. Defintion:

1. Restraints are physical or chemical devices used to limit a client’s mevement (Taylor, 1997).
2. Restraints is the use of mechanical or manual devices to limit the physical mobility of the patient (Stuart & Sundeen, 1995).

2. Theory:

Safety and security are basic human needs. Safety is a paramount concern that underlies all nursing care, and it is the responbility of all health care providers. The focus on safety encompasses all health care facilities as well as the home, work places, and community. There are universal safety concerns common to all age groups as well as unique safety considerations for each (Taylor, 1997).

Restraint involve the use of mechanical or manual devices to limit the physical mobility of teh patient. Such an intervention may be indicated to protect the patient or others from injury, particulary if less restrictive intervention such as enviromental change and behavioral strategies have failed (Stuart & Sundeen, 1995).

The JCAHO guidelines clearly state that restraints should only be applied when less-restrictive or alternative measures have proved ineffective in protecting the client (Corr & Corr cit. Taylor, 1997). Nurse consistently cite the risk of injury from falls as the primary reason for applying restraints (Varone et all., 1992; Werner et all., 1994; Hardin et all., 1994) (Taylor, 1997).

APA has outlined the following give criteria for the appropriate use of physical intervention, seclusion, and restraint (Stuart & Sundeen, 1995):

1. To prevent imminent harm to the patient or other persons when other means of control are ineffective or inappropiate.
2. To preclude serious disruption of the treatment program or significant damage to the physical enviromnet.
3. To maintain treatment as part of an ongoing plan of behavioral theraphy.
4. To comply with a patient’s own request.

The primarily indication for restraints is the control of violent behavior, either self-directed or directed toward others, that cannot be controlled by medication or psychosocial tecniques. Patient who benefit from the use of this tecnique include those whose physical condition prevents or limits the use of medication (Stuart & Sundeen, 1995).

Other indications for the use of restraints include hyperactivity, insomnia, decreased food and fluid intake, and grossly impaired judgment. Restraints may also be used to reduce disruptive effects of excessive stimulation that gave resulted in increased agitation and confusion (Stuart & Sundeen, 1995).

The following are physiologic hazards associated with use of restraints (Taylor, 1997):

1. Danger of suffocation from improperly applied vests
2. Impaired circulaation
3. Altered skin integrity (eg abrasions, skin tears, bruises)
4. Pressure ulcers and bone mass
5. Fractures
6. Altered nutrition and hydration
7. Aspiration and breathing difficulties
8. Incontinence

Despite all efforts, restraints may be the only solution in some situations. It is important to expalin to the client and his or her family that restraints are being applied as a protective device, not as punishment measure (Taylor, 1997).

A physician’s order ordinarily is required to apply restraints, but some agencies allow nurses to apply them in certain emergencies provided verbal or written time-limited physician’s order is obtained. Constant re-evaluation of the need for the restraints is vital. Stundent nurses, from their earlinest clinical experiences, need help to identify and assess the cause of a client’s behavior and not just the behavior itself (Schott-Baer, Lusis, & Beauregard cit Taylor, 1997).

3. Types of Restraints:

Side rails, geriatric chairs with attached trays, and appliances tied at the wrist, ankle or waist, are types of physical restaints. Chemical or farmacological agents, such as sleeping pills, sedatives and tranquilizeres, also may either intensionally or inadvertently restrain activity and behavior. Older clients are more likely to be restrained than younger clients (Taylor, 1997).

The type of restraints avaiable include wrist and ankle restraints and camisoles. Make sure the wrist and ankle restraints are properly padded to safeguard the integrity of the skin. Restraints should be released at least every 2 hours to allow for freedom of movement and to check the condition of the skin. Also check that good body positioning is maintained when restraints are used (Barry, 1998).

a. Physical Restraints For Elderly

Physical restraints include of devices such as mitts, posey vests, and geri chairs applied with physician’s order. Although such devices may assist ataff to protect gerophychiatric patients, they limit freedom of choice and movement, as well as threaten dignity.

b. Restraints For Child

Some method of restraints frequently is needed to ensure a child’s safety or comfort, to facilitate examination, or to carry out prosedures. Restraints can be accomplished with the hand or with physical devices. Restraining the child with the hand provides as an element of human contact that is lacking in restraint by mechanical means. The use of physical devices may require a physician’s order, although it is the nurse’s responsibility to decide when mechanical restraints are needed. Mechanical restraint are never used as punishment or as asubtitute for observation. When a child must be restrained, the child and parents need a simple explanation. Restraints must be checked and documened every 1-2 hours. This ensures that restraints are accopmlishing their purpose, that they are applied correctly, and that they do not impair circulation, sensation or skin integrity (Whaley and Wong’s, 1995).

1. Mummy Restraints

When an infant or small child requires short-term restraint for examination or treatment that involves the head and neck (eg. Venipuncture, throat examination, gavage feeding) (Whaley and Wong’s, 1995).

2. Jacket Restraints

A jacket restraints is sometimes used as an alternative to the crib to prevent the child from climbing out of the crib on the child with the ties in back so that the child is unable to manipulate them. The longs tapes, secured to the under structure of the crib, keep the child inside the crib. The jacket restraints is also useful as a means to maintain the child in a desired horizontal positition. A posey belt scaled to fit the child is an alternative divice (Whaley and Wong’s, 1995).

3. Arm and Leg Restraints

Several commercial restraining devices are available, including disposible wrist and ankle restraints, or a restraints can be fashioned from gauze tape, muslin strips, or a length of narrow stockinette. When this type of restraint is used, it must be appropriate to the child’s size, it must be padded to prevent undue pressure, constriction, or tissue injury, and the extremity must be observed frequently for signs of irritation or impaired circulation. The ends of the restraints are never tied to the side rails, since lowering of the rail will distrub the extremity, frequently with a jerk that may hurt or injury the child (Whaley and Wong’s, 1995).

4. Elbow Restraints

Sometimes it is important to prevent the child from reaching the head or face, for exanple, after lip surgery, when the scalp vein infusion in a place, or to prevent scratching in skin disorder. The most common form of elbow restrain consists of a piece of muslin long enough to reach comfortably from just below the axilla to the wrist, with a number of vertical pockets into wihich tongue depressor are inserted. The restraint is wrapped around the arm and secured with tapes or pins. It may be necessary to pin the top of the restraint to the undershirt sleeve to prevent the restraint from slipping. Similar restraint can be made from readily available items (Whaley and Wong’s, 1995).

c. Restraint For Addult (Spesifically Violence Behavior)

Review the behavior that precipiteted the intervention and patient’s current capacity to exercise control over their behavior are key factors. Patients should be told which behaviors their need to exhibit and which behaviors are impulses they need to control before the intervention can be discontinue. Communication and careful documentation are critical in making accurate asssessment of a patient’s level of control (Stuart & Sundeen, 1995).

Padding of cuff restraints helps to prevent skin breakdown. For the same reason, the patient should be positioned in anatomical alignment. Physical needs must be included in the nursing care plan. Vital sign should be checked, and regular observation in the extremitas is necessary. Fluid should be offered regulary and opportunities for elimination provided. Skin care also essential (Stuart & Sundeen, 1995).