NSS II: Physical Restraints

Physical restraints are devices that are attached to a person's body that

• can be easily removed

• cannot be easily removed

• allows freedom of movement

• restrict freedom of movement

State the 4 types of physical restraints

Answer explanation

Limb Restraint

Mitts restraint

Vest restraint

Belt restraint

State 5 potential complications of physical restraints.

Answer explanation

Any 5 of the following:

• - Increased agitation

• - Abrasion at restraint site

• - Anger

• - Bruising

• - Aspiration

• - Falls causing injury

• - Dehydration from lack of access to fluid

• - Loss of appetite

• - Death

• - Asphysia (insufficient oxygen in body)

• - Strangulation

• - Deconditioning

• - Increased dependency

• - Faecal impaction

• - Pressure ulcers

• - Decreased muscle mass

• - Loss of autonomy

State 3 purposes of applying restrainers.

Answer explanation

• - To restrict the movement of one or more extremities

• - To restrict the patient's use of fingers on one or both hands

• - To restrict total body movement, patient can still move their limbs and turn from side to side

Outline 5 health education for physical restraints with rationale.

Answer explanation

1) Check neurovascular status/ circulation over the restraint limb to make sure that the restraint are not cutting off blood flow

2) Explain to patient clearly on the use of restrainers to gain trust and allay anxiety

3) Ensure that self-care needs are met for the patient to promote good hygiene

4)Ensure that restrainers are used only for to protect patients from self harm and remove when it is safe to protect patients right

5) Reinforce that restraints are used for safety reasons and not as punishment to allay anxiety

Which restrainer should a nurse use first to prevent the stroke patient from pulling out his Nasogastric tube.

• Limb

• Hand Mitts

• Belts

• Vests

Choose the correct hospital guidelines when using physical restraints.

• Least restrictive form of restraint must be used

• Must be ordered by the physician

• To be used for the nurse convenience

• Must be used at the last resort.

• Patient's family must be informed

The nurse should use a _____ _______ knot when applying physical restraint.

To check blood circulation to the restraint area, the nurse should release the site of restraint at least every

• 2 hours

• 4 hours

• 8 hours

• 24 hours

State 5 potential complications of physical restraints.

Answer explanation

Any 5 of the following:

• - Increased agitation

• - Abrasion at restraint site

• - Anger

• - Bruising

• - Aspiration

• - Falls causing injury

• - Dehydration from lack of access to fluid

• - Loss of appetite

• - Death

• - Asphysia (insufficient oxygen in body)

• - Strangulation

• - Deconditioning

• - Increased dependency

• - Faecal impaction

• - Pressure ulcers

• - Decreased muscle mass

• - Loss of autonomy