Figure 30.2 Promoting safety (e.g.

, place hot pots on back burners with handles turned inward) is required to
keep children from injury.
Figure 30.4 Placement of a bed exit monitoring device.
Courtesy of J.T. Posey Company.
Figure 30.5 Padding a bed for seizure precautions.
Figure 30.6 (A) Padded tongue blade and (B) oral airway.
Figure 30.11 Securing a jacket restraint to the back of a wheelchair.
Figure 30.12 A belt restraint.
Figure 30.13 A mitt restraint.
Figure 30.16 A quick-release knot.
Figure 30.18 Make sure that two fingers can be inserted between the restraint and the wrist or ankle.
Figure 30.19 An elbow restraint.
Figure 30.19 Making a mummy restraint.
 SAFETY FACTORS AFFECTING SAFETY
1. Age and Development
2. Lifestyle
3. Mobility and Health Status
4. Sensory-Perceptual Alterations
5. Cognitive Awareness
6. Emotional State
7. Ability to Communicate
8. Safety Awareness
9. Environmental factors
RESTRAINTS – are devices use to limit the physical
activity of the client or a part of the body.

Purpose: to prevent the client from injuring self or others.

Classification of Restraint
1. PHYSICAL RESTRAINTS
- are any manual method or physical or mechanical device,
material, or equipment attached to the client’s body.
they cannot be removed easily and they restrict the client’s
movement.
2. CHEMICAL RESTRAINTS
- are medications such as neuroleptics, anxiolytics, sedatives, and
psychotropic agents used to control socially disruptive behavior.
TWO STANDARDS Legal Implications of Restraints
1. Behavior Management Standard
•Client is danger to self or others
•The nurse may apply restraints but the physician or other licensed
independent health practitioner must see the client within 1 hour for
evaluation.
•A written restraint order for adult, following evaluation, is valid only for
4 hours.
•If the client must be restrained and secluded, there must be continual
visual and audio monitoring of the client’s status.
2. Acute Medical and Surgical Care Standard
•Permits up to 12 hour for obtaining the physician’s written order for the
restraint. All orders must be renewed daily
 SEIZURE
- a sudden onset of convulsion or
other
paroxysmal motor or sensory activity.

GRAND-MAL (TONIC-CLONIC) seizure

– seizure that involve the entire body.

SEIZURE PRECAUTION
– are safety measures taken by the
nurse to protect clients from injury
should they have a seizure.