Applying an Extremity Restraint

Skill 4-4

Applying an Extremity Restraint

Cloth extremity restraints immobilize one or more extremities. They may be indicated after other measures have failed to prevent a patient from removing therapeutic devices, such as intravenous (IV) access devices, endotracheal tubes, oxygen, or other treatment interventions.

Restraints should be used only after less restrictive methods have failed. Ensure compliance with ordering, assessment, and maintenance procedures. Restraints must be applied safely and appropriately to reduce risks of injury.

Federal guidelines reinforce that in all settings, the primary responsibility is to protect and promote patient's rights, and that restraints may only be used to protect the patient, staff, or others (Taylor et al., 2023). They must be discontinued at the earliest possible time (Taylor et al., 2023).

An extremity restraint may be applied to the hands, wrists, or ankles. Review the general guidelines for using restraints in the chapter introduction and in Fundamentals Review 4-2 and Box 4-2 in Skill 4-3. See also Evidence for Practice after Skill 4-3 for best evidence on the topic of interventions to be used as alternatives to the use of restraints, as well as minimizing and eliminating the use of restraints.

Delegation Considerations

After assessment of the patient by the RN, the application of an extremity restraint may be delegated to assistive personnel (AP) as well as to licensed practical/vocational nurses (LPN/LVNs). The decision to delegate must be based on careful analysis of the patient's needs and circumstances as well as the qualifications of the person to whom the task is being delegated. Refer to the Delegation Guidelines in Appendix A.

Equipment

Appropriate cloth restraint for the extremity that is to be immobilized
Padding, if necessary, for bony prominences
PPE, as indicated

Assessment

Assess the patient's physical condition and the potential for injury to self or others. A confused patient who might remove devices needed to sustain life is considered at risk for injury to self and may require the use of restraints. Assess the patient's behavior, including the presence of confusion, agitation, and combativeness as well as the patient's ability to understand and follow directions. Evaluate the appropriateness of the least restrictive restraint device. For example, if the patient has had a stroke and cannot move the left arm, a restraint may be needed only on the right arm. Inspect the extremity where the restraint will be applied. Establish baseline skin condition for comparison at future assessments while the restraint is in place. Consider using another form of restraint if the restraint may cause further injury at the site. Before application, assess for adequate circulation in the extremity to which the restraint is to be applied, including capillary refill and proximal pulses.

Actual or Potential Health Problems and Needs

Many actual or potential health problems or needs may require the use of this skill as part of related interventions. An appropriate health problem or need may include:

Injury risk
Acute confusion

Outcome Identification and Planning

The expected outcome to achieve is that the patient is constrained by the restraint and remains free from injury, and the restraint does not interfere with therapeutic devices. Other outcomes that may be appropriate include the following: the patient does not experience impaired skin integrity, the patient does not sustain injury due to the restraints, and the patient's family/caregivers will demonstrate an understanding about the use of the restraint and their role in the patient's care.

Implementation

Action	Rationale
1. Determine the need for restraints. Assess the patient's physical condition, behavior, and mental status. (Refer to Fundamentals Review 4-2 and Box 4-2 in Skill 4-3.)	Restraints should be used only as a last resort when alternative measures have failed, and the patient is at increased risk for harming self or others.
2. Confirm facility policy for the application of restraints. Secure an order from the physician or other licensed practitioner who is permitted to order restraint or seclusion in that health care facility, or validate that the order has been obtained within the required time frame (CMS, 2020a).	Policy protects the patient and the nurse and specifies guidelines for application as well as the type of restraint and duration. Each order for restraint or seclusion used for the management of violent or self-destructive behavior that jeopardizes the immediate physical safety of the patient, a staff member, or others may only be renewed in accordance with the following limits for up to a total of 24 hours: (A) 4 hours for adults 18 years of age or older, (B) 2 hours for children and adolescents 9 to 17 years of age, or (C) 1 hour for children under 9 years of age. After 24 hours, before writing a new order for the use of restraint or seclusion for the management of violent or self-destructive behavior, a physician or other licensed practitioner who is permitted to order restraint or seclusion in that health care facility and responsible for the care of the patient must see and assess the patient (CMS, 2006).
3. Perform hand hygiene and put on PPE, if indicated.	Hand hygiene and PPE prevent the spread of microorganisms. PPE is required based on transmission precautions.
4. Identify the patient.	Identifying the patient ensures the right patient receives the intervention and helps prevent errors.
5. Explain the reason for restraint use to patient and family/caregivers. Clarify how care will be given and how needs will be met. Explain that restraint is a temporary measure.	Explanation to the patient and family/caregivers may lessen confusion and anger and provide reassurance. A clearly stated facility policy on the application of restraints should be available for the patient and family/caregivers to read. In a long-term care facility, the family/caregivers must give consent before a restraint is applied.
6. Include the patient's family and/or caregivers in the plan of care.	Promotes person-centered, individualized care and engagement, continuity of care and understanding.
7. Inspect the restraint before use. Do not use a restraint that is soiled or damaged (TIDI Products, 2018a).	Always inspect the device before each use, checking for broken stitches or parts, torn, cut or frayed material; or locks, buckles or hook-and-loop fasteners that do not hold securely. Do not use soiled or damaged restraints to prevent injury or death (TIDI Products, 2018a).
8. Apply restraint according to the manufacturer's directions:	Proper application reduces the risk for injury.
a. Choose the least restrictive type of device that allows the greatest possible degree of mobility.	This provides minimal restriction.
b. Pad bony prominences.	Padding helps prevent skin injury.
c. Wrap the restraint around the extremity with the soft part in contact with the skin (Figure 1). If a hand mitt is being used, pull over the hand with cushion to the palmar aspect of the hand (Figure 2).	Prevents excess pressure on the extremity.
9. Secure in place with the hook-and-loop fastener straps or other mechanism, depending on specific restraint device (Figure 3). Depending on the characteristics of the specific restraint, close the quick-release buckle on the cuff.	Proper application secures the restraint and ensures that there is no interference with the patient's circulation and potential alteration in neurovascular status.
10. Ensure that one to two fingers can be inserted between the restraint and patient's extremity (Figure 4).	The restraint must be snug, but not compromise circulation (TIDI Products, 2018b). Proper application ensures that nothing interferes with the patient's circulation and potential alteration in the neurovascular status.
11. Maintain restrained extremity in normal anatomic position. Use a quick-release knot to tie the restraint to the bed frame that moves with the patient, not side rail, bed rail, mattress, or head/footboard (Figure 5). The restraint may also be attached to a chair frame. The site should not be readily accessible to the patient.	Maintaining a normal position lessens the possibility of an injury. A quick-release knot ensures that the restraint will not tighten when pulled and can be removed quickly in an emergency. Securing the restraint to a side rail may injure the patient when the side rail is lowered. Tying the restraint out of the patient's reach promotes security.
12. Remove PPE, if used. Perform hand hygiene.	Proper removal of PPE reduces the risk for infection transmission and contamination of other items. Hand hygiene prevents transmission of microorganisms.
13. Assess the patient according to facility policy, or more often, based on the individual patient circumstances and nursing judgment. Assessment should include the placement of the restraint, neurovascular assessment of the affected extremity, and skin integrity. In addition, assess for signs of sensory deprivation, such as increased sleeping, daydreaming, anxiety, panic, and hallucinations. Monitor the patient's vital signs.	The condition of the restrained patient must be continually assessed, monitored, and reevaluated (CMS, 2006). The frequency of monitoring should be made on an individual basis, which includes a rationale that reflects consideration of the individual patient's medical needs and health status (CMS, 2006). Improperly applied restraints may cause skin tears, abrasions, or bruises. Decreased circulation may result in paleness, coolness, decreased sensation, tingling, numbness, or pain in extremity. The use of restraints may decrease environmental stimulation and result in sensory deprivation. Monitoring vital signs provides information about the status of the patient.
14. Remove restraint at least every 2 hours or according to facility policy, individual patient circumstances, and nursing judgment. Remove the restraint at least every 2 hours for children 9 to 17 years of age and at least every 1 hour for children under 9 years of age, or according to facility policy, individual patient circumstances, and nursing judgment. Perform range-of-motion (ROM) exercises. Provide for hydration, nutritional, and elimination needs.	Removal allows you to assess the patient and reevaluate the need for a restraint. It also allows interventions for toileting, provision of nutrition and liquids, exercise, and change of position. Exercise increases circulation in the restrained extremity.
15. Evaluate the patient for continued need of restraint. Reapply restraint only if continued need is evident and order is still valid.	Continued need must be documented for reapplication.
16. Reassure the patient at regular intervals. Provide continued explanation of rationale for interventions, reorientation if necessary, and plan of care. Keep the call bell within the patient's easy reach.	Reassurance demonstrates caring and provides an opportunity for sensory stimulation as well as ongoing assessment and evaluation. The patient can use the call bell to summon assistance quickly.

Evaluation

The expected outcomes have been met when the patient has remained free from injury to self or others, circulation to extremity remained adequate, skin integrity was not impaired under the restraint, and the patient and family/caregivers were aware of rationale for restraints.

Documentation

Guidelines

Document alternative measures attempted before application of the restraint and that less restrictive interventions have been determined to be ineffective. Document patient assessment before application. Record patient and family/caregiver education and understanding regarding restraint use. Document family/caregiver consent, if necessary, according to facility policy. Document reason for restraining patient, date and time of application, type of restraint, times when removed, and frequency and result of nursing assessments.

Sample Documentation

Developing Clinical Reasoning and Clinical Judgment

Unexpected Situations and Associated Interventions

Patient has an IV catheter in the right wrist and is trying to remove a drain from a wound: The left wrist may have a cloth restraint applied. Due to the IV in the right wrist, alternative forms of restraints could be tried, such as a cloth mitt or an elbow restraint.
Patient cannot move left arm: Do not apply the restraint to an extremity that is immobile. If the patient cannot move the extremity, there is no need to apply a restraint. Restraint may be applied to right arm after obtaining an order from the physician or other licensed practitioner who is permitted to order restraint or seclusion in that health care facility and is responsible for the care of the patient.

Special Considerations

General Considerations

Do not position patient with wrist restraints flat in a supine position due to an increased risk for aspiration (Springer, 2015). If supine position is necessary, be aware that constant monitoring may be required to reduce risk for complications for those at risk of vomiting while restrained (TIDI Products, 2018a).
Check restraint for correct size before applying. Extremity restraints are available in different sizes. If restraint is too large, patient may free the extremity. If restraint is too small, circulation may be affected.
Avoid use on an extremity restraint on a limb with a dislocation or fracture (TIDI Products, 2018b).
Do not use on an extremity with an IV or wound site that could be compromised by the device (TIDI Products, 2018b).
Always inspect the device before each use, checking for broken stitches or parts, torn, cut or frayed material; or locks, buckles or hook-and-loop fasteners that do not hold securely. Do not use soiled or damaged restraints (TIDI Products, 2018a).

Community-Based Care Considerations

In long-term care facilities, patients have the right to be free from physical or chemical restraint not required to treat the resident's medical symptoms. When the use of restraints is indicated, the facility must use the least restrictive alternative for the least amount of time and document ongoing reevaluation of the need for restraints (CMS, 2020b).

EVIDENCE FOR PRACTICE
Minimizing Restraint Use Several resources provide current best evidence on the topic of interventions to be used as alternatives to the use of restraints, as well as minimizing and eliminating the use of restraints. Refer to the Evidence for Practice in Skill 4-3.

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Skill 4-4

EVIDENCE FOR PRACTICE