Table of Contents:
1. Restraints
3. Home Safety
2. Fall
4. Environmental Safety
Prevention
Safety
1. Restraints
Restraints are a last resort and Restraints are only used as a last resort if
FIGURE 1. SOFT EXTREMITY RESTRAINTS
are only used when the following there is risk for harm and only after less
criteria have been met: restrictive measures have failed.
1. Client poses a threat to self
or others (pulling at IV lines or
urinary catheter, violent
behavior).
2. Less restrictive measures
have failed (distraction,
reorientation, increased
supervision).
Restraint types:
Physical restraints: Vest,
mittens, soft extremity
(FIGURE 1)
Chemical restraints:
Sedatives, hypnotic
medications
Restraint selection:
Choose the least restrictive
restraint, restricting only
necessary body parts.
Restraint should not interfere with
treatment or worsen health
problems (no extremity
restraints on an ischemic limb).
Restraint use:
Requires an HCP order
Cannot be a PRN or standing order
Discontinue as soon as possible.
Secure restraint using a quick-release knot for
rapid removal in an emergency (see FIGURE 1).
Secure to bed frame (not bed rails) (see FIGURE
1).
, Assess client and remove restraints at least
every 2 hours to:
Ensure 2 fingers can be inserted
between restraint and skin (see FIGURE 1).
Assess neurovascular status distal to
restraint (skin color, temperature, pulse).
Prevent complications like suffocation
and skin breakdown.
Perform ROM exercises, feeding, and
toileting.
Document client’s response to restraint.
@ For clients in restraints, perform neurovascular
assessments every 2 hours, checking skin
color,
temperature, and pulse. Ensure you can fit
the restraint.
1. Restraints
3. Home Safety
2. Fall
4. Environmental Safety
Prevention
Safety
1. Restraints
Restraints are a last resort and Restraints are only used as a last resort if
FIGURE 1. SOFT EXTREMITY RESTRAINTS
are only used when the following there is risk for harm and only after less
criteria have been met: restrictive measures have failed.
1. Client poses a threat to self
or others (pulling at IV lines or
urinary catheter, violent
behavior).
2. Less restrictive measures
have failed (distraction,
reorientation, increased
supervision).
Restraint types:
Physical restraints: Vest,
mittens, soft extremity
(FIGURE 1)
Chemical restraints:
Sedatives, hypnotic
medications
Restraint selection:
Choose the least restrictive
restraint, restricting only
necessary body parts.
Restraint should not interfere with
treatment or worsen health
problems (no extremity
restraints on an ischemic limb).
Restraint use:
Requires an HCP order
Cannot be a PRN or standing order
Discontinue as soon as possible.
Secure restraint using a quick-release knot for
rapid removal in an emergency (see FIGURE 1).
Secure to bed frame (not bed rails) (see FIGURE
1).
, Assess client and remove restraints at least
every 2 hours to:
Ensure 2 fingers can be inserted
between restraint and skin (see FIGURE 1).
Assess neurovascular status distal to
restraint (skin color, temperature, pulse).
Prevent complications like suffocation
and skin breakdown.
Perform ROM exercises, feeding, and
toileting.
Document client’s response to restraint.
@ For clients in restraints, perform neurovascular
assessments every 2 hours, checking skin
color,
temperature, and pulse. Ensure you can fit
the restraint.
