Atlas of Procedures in Neonatology, 4th Edition

Preparation and Support

3

Methods of Restraint

Margaret Mary Kuczkowski

Physical restraints are required for proper positioning for certain procedures. Infants may also need to be restrained to prevent accidental injury or interference with treatment (i.e., removal of feeding tubes, catheters, etc.). Select the least restrictive but most appropriate restraint for the individual patient.

  1. Definitions
  2. Physical Restraint: “any device, garment, material, or object that restricts a person's freedom of movement or access to one's body” (1)
  3. Indications

Restraints should be utilized:

  1. When procedures require proper positioning to maintain asepsis and facilitate access to patient (IV placement, lumbar punctures, radiographs, etc.) (1)
  2. To reduce the risk of interference with treatment (removal of feeding tubes, IV access, mechanical ventilation, etc.) (2)
  3. To prevent accidental injury
  4. Contraindications

Restraints should not be utilized:

  1. When close observation of the patient could protect against potential injury or potential interference with treatment (3)
  2. When a change in treatment or medication regimen could protect against potential injury or interference with treatment (3)
  3. When modification of the patient's environment (decreased stimuli, appropriate developmental positioning, reduced noise) could protect against potential injury or interference with treatment (3)
  4. When use of a restraint could compromise patient care, procedures, or emergency access (1)
  5. Techniques

Restraints for Procedures/Positioning

  1. Mummy Restraint
  2. Purpose:Safe temporary method for restraining young children for treatment or examination; allows for unimpeded access to head and scalp; individual extremities can be released for access for examination or treatment (1)
  3. Equipment:
  4. Commercially available restraint (“papoose board”) for larger infants

OR

  1. Clean blanket or small sheet
  2. Safety pins or other device for securing final blanket fold
  3. Procedure (1):
  4. Open blanket or sheet.
  5. Fold one corner toward the center.
  6. Place infant on blanket with shoulders at fold and feet toward opposite corner (Fig. 3.1 A).
  7. With infant's right arm flexed and midline, tuck right side of blanket across trunk and under left side of body (Fig. 3.1 B).
  8. Fold lower corner up toward head and tuck under left shoulder (Fig. 3.1 C).
  9. With infant's left arm flexed and midline, tuck left side of blanket across trunk and under right side of body. Be sure to secure arms under blanket (Fig. 3.1 D).
  10. Extremity Restraint (wrist or ankle) (Fig. 3.2.)
  11. Purpose:Immobilization of one or more extremities; protects infant from interfering with or removing treatment regimens (IV access, feeding tube, mechanical ventilation, etc.)
  12. Equipment:
  13. Commercially available restraint (sheepskin and/or foam padding) for larger infants

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OR

  1. Roll of gauze or gauze pads
  2. Adhesive tape
  3. Safety pins or other securing device
  4. Procedure
  5. Open gauze and fold in half lengthwise to reinforce material.
  6. Wrap wrist or ankle with gauze at least three times to create secure restraint. Caution: Do not wrap gauze too tight; this might interfere with distal circulation.
  7. Use adhesive tape to ensure that gauze does not unravel.
  8. Secure restraint to mattress, blanket, or light sandbag with safety pin.
 

FIG. 3.1. A: Mummy restraint: steps (1)–(3). B: Mummy restraint: step (4). C: Mummy restraint: step (5). D: Mummy restraint: step (6).

  1. Mitten Restraint
  2. Purpose:Thumbless device to restrain or cover hand; eliminate infant's ability to grasp and possibly dislodge necessary treatment regimens (IV access, feeding tube, mechanical ventilation, etc.); prevent infant from scratching self or removing dressings, interfering with maintenance of skin integrity
  3. Equipment:
  4. Commercial mittens

OR

  1. Stockinette material (cut to fit individual infant)

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  1. Adhesive tape
  2. Safety pins or other securing device (optional)
 

FIG. 3.2. Extremity restraint (wrist).

  1. Procedure
  2. Place infant's hand inside stockinette
  3. Secure stockinette by applying tape to stockinette material and fastening around infant's wrist. Caution:Do not wrap tape too tight; this might interfere with distal circulation.
  4. Tie end of stockinette in order to isolate fingers inside the stockinette material.
  5. Secure restraint to mattress, blanket, or light sandbag with safety pin (optional).
  6. Elbow Restraint (Freedom Splint) (Fig. 3.3)
  7. Purpose:Reduces ability of infant to flex elbow
  8. Equipment:
  9. Commercially available restraints (sheepskin and/or foam padding) for larger infants

OR

  1. Foam-padded armboard
  2. Adhesive tape
  3. Additional padding material, i.e., cotton balls, gauze pads
  4. Procedure:
  5. Cut four pieces of tape (appropriate size; tape should not completely encircle extremity).
  6. Extend upper extremity.
  7. Place armboard under elbow in order to eliminate ability to flex joint.
  8. Tape extremity securely to armboard. Tape should be applied above and below elbow joint.
  9. Pad bony prominences with cotton as needed.
 

FIG. 3.3. Elbow restraint.

Restraints for Vascular Access

Restraints can be used to secure IV access and prevent accidental dislodgement.

  1. Equipment
  2. Restraint device, i.e., armboard. Armboards vary in size; a larger infant may require an armboard that is 1 to 2 cm wider than the hand/foot and extend from the proximal joint to the distal joint. However, to maintain functional position and natural curvature of the hand at rest for long-term restraint, the armboard can be shorter in length to allow for curvature of fingers around the end of the board.
  3. Adhesive tape. Transparent tape is recommended for visualization of IV site especially during continuous infusion.
  4. Additional padding material, i.e., cotton balls, gauze pads

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FIG. 3.4. Prone positioning during procedures and at rest provides for improved breathing and sleep, lower expenditure of energy, and more stable physiologic functioning (4). Care must be taken to create positioning support of the trunk and hips.

  1. Procedure
  2. Ensure that the infant is in a correct and functional position.
  3. Rationale: Prevention of contractures and supports self-calming techniques of neonates (prone, side-lying) (Figs. 3.4 and 3.5) (4)
  4. Assess skin integrity where restraint is to be applied.
  5. Apply restraint board using transparent tape. Do not allow tape to encircle extremity. Three pieces of tape should sufficiently restrain extremity and allow for visualization of the tips of fingers (Fig. 3.6) or toes (Fig. 3.7). The sequence of tape allows for functional positioning of thumb and ankle.
  6. Pad bony prominences and maintain natural curvature of extremities (especially the hand and fingers).
 

FIG. 3.5. Side-lying positioning is the best alternative to prone for procedures and sleeping. This position allows for more midline positioning of the upper and lower extremities. Nesting support increases postural stability and decreases arching of the back (4).

 

FIG. 3.6. Restraint for vascular access—wrist and forearm. Tape is applied in order, 1 through 3, as shown.

  1. Precautions
  2. Restraints should be a last resort after other reasonable alternatives have failed including close observation, treatment and/or medication change, modification of environment, etc. (3).
  3. Family education regarding the need, procedure, and time frame for the use of the restraint is required. Provide opportunity for collaboration with the family. If possible, remove the restraints when the family is visiting (1).
  4. For restraints during procedures, proper techniques for analgesia, sedation, and distraction (pacifier,

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touch, sound, etc.) are necessary in addition to the restraint.

  1. Weigh equipment required for restraints (i.e., armboards) prior to use. If possible, maintain a list of the weights of common restraint materials in use when weighing infants for monitoring daily growth.
  2. Evaluate proper use, placement, and position of restraint at least every 2 hours or sooner according to patient need, hospital policy, and regulatory agency requirement. Regulatory agencies such as the Joint Commission on Accreditation of Healthcare Organizations (JCAHO), the U.S. Food and Drug Administration (FDA), and the Centers for Medicaid and Medicare Services publish standards of medical care regarding the safe use and legal requirements for restraint implementation and maintenance (1).
  3. Ensure that the infant is in a proper and functional position that promotes flexion and midline positioning of upper and lower extremities.
  4. Rationale:Prevention of contractures and supports self-calming techniques of neonates (prone, side-lying) (Figs. 3.4 and 3.5) (4)
  5. Pad bony prominences and maintain natural curvature of extremities (especially the hand and fingers)
  6. Rationale:Prevents contractures and neurovascular injury; preserves skin integrity; reduces friction and pressure to skin from restraint material (1)
  7. When utilizing tape for securing an extremity to a board, use transparent tape when possible to allow for careful and complete assessment of the underlying skin. Do not apply tape too securely or impede circulation. Tips of the digits should remain visible for assessment.
  8. Restraints on the upper or lower extremities need to be assessed at least hourly for:
  9. Skin Integrity, including excoriation, erythema, and edema
  10. Pulses
  11. Temperature
  12. Color
  13. Capillary Refill
  14. Range of Motion (ROM) (1)
  15. Check for vascular circulation by inserting two fingers between infant's skin and the secured restraint (1).
  16. Rationale:Constriction from a tight restraint can cause neurovascular injury and impede circulation.
  17. Reassess and remove restraint at least every 2 hours and with patient care (or according to individual hospital policy).
  18. Rationale:Regular assessments of circulation and skin integrity and passive ROM of the joint reduce the risk of neurovascular injury and skin impairment.
  19. Specific assessments related to oxygenation, musculoskeletal system, and cardiorespiratory conditions need to be performed in relation to the restraint device and its usage (1).
  20. Observe any treatment equipment for proper positioning and patency, especially in close proximity to the restraint device (kinked IV access, dislodgement of catheters, etc.) (1).
 

FIG. 3.7. A: Restraint for vascular access—foot and ankle. Tape is applied in order 1 through 3, as shown. B: Foot and ankle restraint for vascular access on premature infant.

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  1. Attach restraint to fixed location on bed (if necessary), maintaining opportunity for quick release and regular vascular checks (safety pin, secure tucking, etc.). Do not attach restraint to equipment that can be moved in such a way as to create injury or pressure to restrained joint or skin surface (crib side rails, isolette doors). Quick release allows for mobility and access in an emergency.
  2. Document restraint use and, if required, obtain physician order (see hospital policy).
  3. Rationale:Documentation of location, time, and specific assessments maintains a record of the intervention and specific assessments that were performed. Regulatory agencies, e.g., JCAHO, FDA, and Centers for Medicaid and Medicare Services, have published standards of care addressing the documentation of patient restraints (1).
  4. Remove restraint at the earliest time possible.
  5. Complications
  6. Failure of restraint resulting in self-injury and/or interference with treatment
  7. Neurovascular impairment (1)
  8. Impairment of skin integrity (i.e., pressure ulcer formation, necrosis) (1)
  9. Contractures or positional deformity/paralysis from prolonged immobility (1)
  10. Limb injury (fracture or dislocation) from movement of infant without release of secured restraint or from securing restraint to movable object (e.g., crib side rails, isolette doors) (1)
  11. Impairment or compromise of medical state, including oxygenation, musculoskeletal system, and cardiorespiratory conditions (1)
  12. Increased agitation or irritability (3)
  13. Extravasation injury leading to impairment of skin integrity, tissue necrosis, infection, and/or nerve and tendon damage (5)

References

  1. Perry AG, Potter PA.Clinical Nursing Skills and Techniques. 6th ed. St. Louis, MO: Elsevier Mosby; 2006.
  2. Ofoegbu BN, Playfor SD.The use of physical restraints of paediatric intensive care units. Pediatr Anesth. 2005;15:407–411.
  3. McBeth S.Get a firmer grasp on restraints. Nursing Manage. 2004;35(10):20,22.
  4. Vergara ER, Bigsby R.Developmental & Therapeutic Interventions in the NICU. Baltimore: Paul H. Brookes; 2004.
  5. Ramasethu J.Prevention and management of extravasation injuries in neonates. NeoReviews. 2004;5(11):c491–c497.