Applying an Extremity Restraint

Goal: The patient is constrained by the restraint, remains free from injury, and the restraint does not interfere with therapeutic devices.

1. Determine need for restraints. Assess patient’s physical condition, behavior, and mental status. (Refer to Fundamentals Review 3-1, 3-2, 3-3, and 3-4 at the beginning of the chapter.)

2. Confirm agency policy for application of restraints. Secure an order from the primary care provider, or validate that the order has been obtained within the past 24 hours.

3. Perform hand hygiene and put on PPE, if indicated.

4. Identify the patient.

5. Explain reason for restraint use to patient and family. Clarify how care will be given and how needs will be met. Explain that restraint is a temporary measure.

6. Include the patient’s family and/or significant others in the plan of care.

7. Apply restraint according to manufacturer’s directions:
a. Choose the least restrictive type of device that allows the greatest possible degree of mobility.
b. Pad bony prominences.
c. Wrap the restraint around the extremity with the soft part in contact with the skin. If a hand mitt is being used, pull over the hand with cushion to the palmar
aspect of hand. Secure in place with the Velcro straps.

8. Ensure that two fingers can be inserted between the restraint and patient’s wrist or ankle.

9. Maintain restrained extremity in normal anatomic position. Use a quick-release knot to tie the restraint to the bed frame, not side rail. The restraint may also be attached to a chair frame. The site should not be readily accessible to patient.

10. Remove PPE, if used. Perform hand hygiene.

11. Assess the patient at least every hour or according to facility policy. 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.

12. Remove restraint at least every 2 hours, or according to agency policy and patient need. Perform range-of-motion exercises.

13. Evaluate patient for continued need of restraint. Reapply restraint only if continued need is evident and order is still valid.

14. Reassure patient at regular intervals. Provide continued explanation of rationale for interventions, reorientation if necessary, and plan of care. Keep call bell within easy reach.