SAFETY

RESTRAINTS- A protective device used to limit the physical activity of the client or part of the body.

- It is any device, garment, material or object that restricts a person’s freedom from movement or access to one’s body. The restraint must be clinically justified and a part of the prescribed medical treatment and plan of care, and all other less restrictive measures must be employed first.

A physician order is required for the use of restraints and or seclusion. The order must be written or the telephone order countersigned by the ordering or “covering” physician within 24 hours of the order being given. “Restrain p.r.n.” orders are not permitted. Orders must include a time limit not to exceed 24hours. Physicians must review the use of restraints and reissue a medical order every 24 hours.Restrain the patient according to the hospital policy.

Restraints order sheet must have:1. Behaviors requiring restraints:- Confusion- Self harm- Harm to others/ surroundings- Removing medical devices2. Length of time- must not exceed 24

hours3. The type of restraint used4. Additional instruction if any.

Purposes: •To promote safety for client and others

and prevent injury•To allow medical treatment proceed

without client interference

Patients are at risk for falls and possible injury because of several factors:

1. They have an impaired ability to move due to disease, surgery or age.

2. They may be receiving medications that affect their mental status, balance and coordination.

3. They may be disorientated because of a change in their environment or because of a medical condition.

4. They may have impaired hearing or vision.

Classification of Restraints

 1. Physical restraints- are any manual

method or physical or mechanical device, material or equipment attached to the client's body.

2. Chemical restraints-are medications used to control socially disruptive behavior. -neuroleptics, axiolytics, sedatives,psychotropic agents

Alternatives to Restraints

• Design a safer physical environment by removing obstacles that impede movement.

• Assign nurse in pairs to act as “buddies” so that one nurse can observe the client when the other leaves the unit

• Regular attention to toileting and other physical and personal needs.

• Place unstable clients in an area that is constantly or closely supervised.

• Position beds at their lowest level to facilitate getting in and out of bed

Alternatives to Restraints

•Wedge pillows or pads against the sides of wheelchairs to keep clients well positioned

•Use therapeutic touch•Use night light•Involve the family in client's care

Criteria in Selecting Restraints

1. It restricts the client's movement as little as possible. -If a clients needs to have one arm restrained, do not restrain the entire body.

2. It does not interfere with the client's treatment or health problem.-If a client has poor blood circulation to the hands, apply restraint that will not aggravate that circulatory problem.

Criteria in Selecting Restraints3. It is readily changeable.• -Restraints need to be changed

frequently, especially if they become soiled. Keeping other guidelines in mind, choose a restraint that can be changed with minimal disturbance to the client.

4. It is safe for the particular client.-Choose a restraint which the client cannot self-inflict injury.

5. It is least obvious to others.

Kinds of Restraints1. Jacket/ vest restraintsVestlike garment. Front and back of garment should be labeled as such. Apply over clothing or hospital gown

Rationale: restrains client while lying or reclining in bed and while sitting in chair or wheelchair. Proper application prevents suffocation or choking. Clothing or gown prevents friction against skin.

Kinds of Restraints2. Belt restraint•Device that

secures client to bed or stretcher. Avoid placing belt too tightly across client chest or abdomen

Rationale: Restrains center of gravity and prevents client from rolling off stretcher or sitting up while on stretcher or from falling out of bed. Tight application may interfere with ventilation.

Kinds of Restraints

3. Mitt restraint•Thumbless mitten device to restrain

client’s hand•Rationale: Prevents client from dislodging

invasive equipment, removing dressings or scratching .

Mitten restraint

Kinds of Restraints

4. Extremity restraints •Restraint designed to immobilize one or

all extremity.•Rationale: Maintains immobilization of

extremity to protect client from injury from fall or accidental removal of therapeutic device

Extremity restraint

TYING RESTRAINTS without STRAPS

•Quick Release Knot•This is an extremely

useful knot that can be used in any situation that requires a quick release.Also known as the draw hitch.

Steps in tying•Step 1:•Form a loop with the

rope and position it behind post to which your are going to tie the rope.

Steps in tyingStep 2:•Grasp the standing

part and formanother loop at the front of the post.Then push the loop through the backloop.

Steps in tying

Step 3:•Pull the rear loop

tight by pullingon the tag end. Then bring the tag end around the front.

Steps in tying•Step 4:•Grasp the tag end

and form a thirdloop. This loop is now pushed through the remaining loop.

Steps in tying•Step 5:•Once the final

loop is in place, pullhard on the standing part and the knot is complete.

Steps in tying•Step 6:•The completed knot.

To quickly release the knot, pull hard in a downward direction on the tag end.

Half- Bow knot

Kinds of Restraints

Mummy restraintMaintains short term restraint of small child or infant for examination or treatment involving head and neck.

•Rationale: Effectively controls movement of torso and extremities

Steps in Mummy restraints1. Spread out the blanket on a flat surface.

Fold down one corner of the blanket. Position the baby with his shoulder just slightly below the folded section of the blanket.

2. 2a) Place his left arm close to his body, and fold the left side over.

  2b) Tuck in the edge under his back.3) Fold up the bottom, covering the baby's legs and lower body.

Steps in Mummy restraints

4. Place the baby's right arm close to his body before bringing the right edge of the blanket over his body

5) Tuck the right edge securely under the left side of the baby's body.

Kinds of Restraints5. Elbow restraints•Piece of fabric with slots

in which tongue blades are placed so that elbow joint remains rigid

•Rationale: Used with infants and children to prevent elbow flexion when an IV line is in place

ASSESS1. The behavior indicating the possible need

for a restraint.RATIONALE: Restraint are used when other

have failed to prevent interrupted of therapy (traction, IV infusions, NGT,IFC)

2. The underlying cause for the assessed behavior.

RATIONALE: To prevent a confused combative client from self injury

ASSESS

3. The status of the skin to which the restraint is to be applied

4. The circulatory status distal to the restraints, and the extremities

•RATIONALE: Restraints may compress and interfere with functioning of devices or tubes. Provides baseline assessment data regarding skin integrity

Review Institutional policy for restraints, and seek consultation as appropriate before independently deciding to apply restraint.RATIONALE: Because restraints limit the client’s ability to move freely, the nurse must make clinical judgments appropriate to the client’s and agency policy. If a nurse restrains a client a physician’s order must be obtained as soon as possible.

Assemble equipment:

•Appropriate type and size of restraint•Padded dressing•Strip of gauze bandage or cloth tie 5-

8cm/2-3inch wide 90-120cm/3-4ft long

RATIONALE: Ensures smooth and orderly procedures

Procedure

1. Introduce yourself and verify the client’s identity. Explain to the client and family what you are going to do, why is it necessary, and how the client can cooperateRATIONALE: Helps minimize client anxiety during application of the device and helps minimize family concerns during restraint maintenance as to establish rapport.

Procedure2. Perform hand hygiene, and observe

appropriate infection control proceduresRATIONALE: Reduces transfer of microorganisms

3. Place the client in proper alignmentRATIONALE: Proper body alignment should be maintained to prevent contractures and neurovascular injury

4. Pad skin and bony prominences before applying restraints

Procedure

RATIONALE: Padding reduces friction and pressure to skin and underlying tissue

5. Apply appropriate restraint make sure it is not over an IV line or other devices.

RATIONALE: IV lines and other therapeutic devices maybe occluded.

6. Attach restraint to bed frame, which moves when the head of the bed is raised and lowered

Procedure

RATIONALE: Client may be injured if restraint is secured to side rail and it is lowered

7. Secure restraints with a quick release tie or half bow knot.

RATIONALE:Does not tighten or slip when attached end is pulled but unties easily when the loose end is pulled.

8. Insert two fingers under the secured restraintRATIONALE: A tight restraint may cause

constriction and impede circulation

Procedure

9. Every 30 minutes, proper placement of restraint, skin integrity, pulses, temperature, color, and sensation of restrained body should be assessed.

RATIONALE: Frequent assessment prevents complications such as suffocation, skin breakdown and impaired circulation

Procedure10. Restraint should be removed every two hours.

Client should not left unattended at this time.RATIONALE: Provides opportunity to change client’s

position and perform full range of motion.11. Secure call bell or intercom system within reachRATIONALE: Allows client, family to obtain assistance

quickly.

ProcedureDocument:•Behavior/s Indicating the need for the restraint.•The type of restraint applied, the time it was

applied, the goal for its application.•The client’s response to 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.

SEIZURES

•Generally refers to a disturbance of usual neurological functioning of relatively abrupt onset that is due to transient disturbance of CNS activity.

•It is a sudden, excessive, disorderly electrical discahrges of the neurons.

•The most common type is GRAND MAL SEIZURE

CAUSES

•Idiopathic-genetic •Acquired•hypoxemia•vascular insufficiency•fever•head injury•Central nervous system infections

CLASSIFICATION OF SEIZURE1.GENERALIZED

SEIZURE2.PARTIAL OR FOCAL

SEIZURES

A. GENERALIZED SEIZURES

1. Generalized convulsive (“grand mal” or generalized tonic-clonic): Also known as Grand Mal seizure or tonic clonic seizure is characterized by an aura. Aura may be flashing lights, smells, spots before the eyes and dizziness.

 

The “whole brain” is affected at once; both hemispheres electrically disturbed. The key (essential) clinical feature is LOSS OF CONSCIOUSNESS!

GENERALIZED SEIZURE

Generalized Convulsion/ Grand Mal

Characteristics:•sudden, immediate loss of consciousness • initial generalized tonic contraction and

posture (causing fall and epileptic cry)•slowing of the frequency of the convulsive

movements•typically lasts 1-3 minutes•post-ictal exhaustion, sleep, disorientation

GENERALIZED SEIZURES2. Absence: CHARACTERISTICS• sudden, immediate loss of consciousness

without warning• no loss of postural tone• no or minimal motor manifestations (only

minor twitching of eyelids or other)• interrupts activity or function• typically lasts less than 15 seconds• no post-ictal phase

An absence seizure. In (a) the child is eating normally. In (b) the seizure has affected his whole awareness; his eyes have rolled back in his head and he is briefly immobilized. In (c) he is immediately awake and aware again.

 

B. Partial (focal) Seizures:Only part of the brain (the focus) is affected.Consciousness is not lost

1. Simple partial/ Petit Mal seizures/ little sickness- only one part of one hemisphere of the cerebral cortex affected -CONSCIOUSNESS IS NOT AFFECTED.- symptoms depend on the part affected: motor, sensory, auditory, visual ..-duration is variable: seconds to minutes to hours or even days; usually seconds to minutes.-There is no post-ictal alteration of consciousness

SIMPLE PARTIAL SEIZURE

•A simple partial seizure with motor symptoms.Here the neuronal discharge begins in the motor stripin the right hemisphere of the brain, affecting first onemuscle then another on the left side of the body as it spreads.In (a) first the fingers then the hand and arm are jerking.In (b) it has spread to the upper shoulder.In (c) the woman's head is drawn towards her shoulder.In (d) the leg is drawn up. The woman remains conscious but unable to prevent her muscles' response to the excessive stimulation they are receiving from her brain.

2. Complex partial Seizure•There is ALTERATION of

consciousness during part of the seizure•Duration is usually more than 30

seconds•There is post-ictal confusion,

disorientation or fatigue

Other types of seizures1. Psychomotor Seizure- it has a psychiatric

component. Aura is present (hallucinations/ illusions). It is characterized by mental clouding (being out of touch with the environment).

The client appears intoxicated.During the time of loss of consciousness, there

are on going physical activities. It is manifested by amnesia, confusion and need

for sleep.

Other types of seizuresThe client may commit violent or antisocial

acts like going naked in public, running amok during the time of loss of consciousness.

2. Febrile Seizures- This is common among children under 5 years old of age when temperature is rising.

Other types of seizures3. STATUS EPILEPTICUS- A type of seizure

occurring in rapid succession and full conscousness is not regained between seizures. Brain damage may occur secondary to prolonged hypoxia and exhaustion. The client is often in coma for 12-24 hours or longer, during which time recurring seizures occur. The attack is usually related to failure to take anticonvulsants.

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