Outcome Identification and Planning
Sample desired outcomes include the following:
- Client experiences no falls or injuries while under nurse's care.
- Client demonstrates intact skin and circulation at and below the site of restraint, with capillary refill less than 3 s and warm skin temperature.
Special Considerations in Planning and Implementation
Because restraints may actually cause injury instead of preventing it, whenever possible use alternative protective measures specific to the problem resulting in the use of restraints (e.g., minimize use of invasive treatments, disguise tubing or keep out of client's view, wrap infusion sites in stockinette or bandage, use abdominal binder for dressings to prevent disruption of lines or wounds). Always obtain a doctor's order before applying restraints, unless an approved protocol or standard is in place. Notify the doctor of the time when restraints were initiated so that a face-to-face evaluation can be performed within 1 hr of restraint use, as required by the Joint Commission and the Centers for Medicare and Medicaid Services (CMMS). Learn standards and protocols and agency policy regarding use of restraints (e.g., some agencies require that restraints be used in certain situations, such as presence of an endotracheal tube).
Note that Joint Commission standards limit restraint use to emergent dangerous client actions, addictive disorders, as an adjunct to planned care, and as a component of an approved protocol, or in some cases as part of standard practice. While a client is in restraints, perform assessments every 15 min; in some agencies, one-on-one supervision of the client is required for the entire period.
When possible, use mittens instead of wrist restraints because mittens are less restrictive and permit growth and development activities. Consider that some parents may be conflicted about the use of physical restraints. Take the time to provide explanations to parents if any type of restraint device is necessary.
Restrain elderly clients with linen or soft restraints applied loosely, as their skin is often very sensitive and the blood vessels easily collapse. Check the client's circulation frequently. Remove restraints frequently to check the skin underneath.
Suggest using sheets to help secure a client to a bed or chair to prevent falls.
Cost-Cutting Tip Use socks or other soft pieces of cloth to make wrist restraints; mittens made with socks or gauze restraints may be used to prevent pulling of tubes. However, commercial restraints may be cost-effective due to decreased friction on skin.
Train unlicensed assistive personnel before they are allowed to apply restraints. Training focuses on appropriate application and client monitoring. However, monitoring the client's physical status remains the primary responsibility of the nurse.