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 persons freedom from movement or access
to ones 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 devices
2. Length of time- must not exceed 24 hours
3. The type of restraint used
4. 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 Restraints

3. 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 selfinflict injury.
5. It is least obvious to others.

Kinds of Restraints

1. Jacket/ vest
restraints
Vestlike 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 Restraints
2. 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 clients
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 tying
Step 2:
Grasp the standing
part and form
another loop at the
front of the post.
Then push the loop
through the back
loop.

Steps in tying
Step 3:
Pull the rear loop tight
by pulling
on the tag end. Then
bring the
tag end around the
front.

Steps in tying
Step 4:
Grasp the tag end and
form a third
loop. This loop is now
pushed through the
remaining loop.

Steps in tying
Step 5:
Once the final loop
is in place, pull
hard 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 restraint
Maintains 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 restraints

1. 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 Restraints

5. 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

ASSESS
1. 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
clients ability to move freely, the nurse must
make clinical judgments appropriate to the
clients and agency policy. If a nurse restrains a
client a physicians 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/23inch wide
90-120cm/3-4ft long
RATIONALE: Ensures smooth and orderly
procedures

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

Procedure
2. Perform hand hygiene, and observe appropriate
infection control procedures
RATIONALE: Reduces transfer of
microorganisms
3. Place the client in proper alignment
RATIONALE: 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 restraint
RATIONALE: 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

Procedure
10. Restraint should be removed every two hours. Client
should not left unattended at this time.
RATIONALE: Provides opportunity to change clients
position and perform full range of motion.
11. Secure call bell or intercom system within reach
RATIONALE: Allows client, family to obtain assistance
quickly.

Procedure
Document:
Behavior/s Indicating the need for the restraint.
The type of restraint applied, the time it was applied,
the goal for its application.
The clients 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
SEIZURE
1.GENERALIZED
SEIZURE
2.PARTIAL OR FOCAL
SEIZURES

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

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 SEIZURES
2. 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 strip
in the right hemisphere of the brain, affecting first
one
muscle 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 seizures

1. 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 seizures

The 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 seizures

3. 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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