CARE, SAFETY, & COMFORT
University of Iowa Hospitals and Clinics
Department of Nursing
Childrenís and Womenís Services
SUBJECT:†††† Restraints in Neonatal and Pediatric Patients
PURPOSE:†††† To provide criteria for the use of the
Clinical Care protocol in order to promote maintenance of essential therapy and
DEFINITION:†† Restraint is the involuntary restriction of the movement of the whole or a portion of a patientís body as a means of controlling their physical activities in order to protect themselves or others from injury.† Restraint may incorporate the use of a physical force (physical restraint) or the administration of medication (chemical restraint).† Physical force may be human or mechanical.† Restraint is defined by intent rather than the type of device employed or medication administered.
1.†††††††† Restraint for the purpose of behavior management (e.g., patients who exhibit unanticipated aggressive or destructive behavior that places the patient or others in immediate danger) refer to Department of Nursing Practice Policy, Restraints, Use of (2.170).
a.†††††††† Devices that are usual, customary, and integral parts of medical, dental, and surgical diagnostic and therapeutic procedures for infants and children are considered immobilization/protection devices.† These do not need to be treated as restraints.
1)†††††††† IV devices - Infants or children who have IVs may have immobilization devices applied to arms and/or legs as necessary.† Devices would include IV arm boards, IV protection covers, expandable net covering, arm cuffs, mitts, and swaddling devices.† If these devices are fastened down (e.g., clipped to the bed), they become a restraint.
2)†††††††† Seats - Infants or young children placed in an infant seat, bouncy seat, high chair, swing, or other similar equipment will be secured with a seat belt.† This should fit properly and be fastened securely.† The patient will be supervised at all times, unless the patient is positioned in an infant seat and placed in a crib with the side rails up.
3)†††††††† Positioning - Infants or young children requiring special positioning due to condition or treatment may have immobilization devices applied to arms and/or legs or may require immobilization with such devices as halter vests, orthopaedic devices, swaddling devices, or bendable positioning devices.
4)†††††††† Protective devices - Safety devices such as helmets, bed rails, or bubble tops will be used to protect the patient.
1.†††††††† Restraint Applied Under Clinical Care Protocol - Maintaining essential tubes and lines is considered an integral part of therapy in pediatric and neonatal patient populations.† These patients will be evaluated for restraint needs based upon the safety and developmental needs of the patient.† The RN/LPN will assess the need for restraint including utilization of alternatives to restraint.† If alternatives to restraint are not effective, the physician/Licensed Independent Provider (LIP) must be notified, and an order obtained to initiate restraint per Clinical Care Protocol.† Criteria for implementation of the Clinical Care protocol include:
a.†††††††† Infants or children with an IV, central line, percutaneous line, pressure monitoring line, nasogastric tube, transpyloric tube, endotracheal tube, chest tube, mediastinal tube, peritoneal dialysis catheter, hemodialysis catheter, ECMO circuit, other tube appliance, or dressing that should not be removed may have devices that limit freedom of movement of a body part applied to arms and/or legs to prevent the tube from being dislodged (e.g., soft blue foam devices).† Maintaining these lines and tubes is a part of essential therapy.
b.†††††††† Infants or children receiving continuous vasoactive IV drip medications and/or mechanical ventilation to maintain cardiac and respiratory stability (e.g., soft blue foam devices).
c.†††††††† Infants or children whose therapy requires specialized body positioning with the intent of limiting freedom of movement (e.g., sandbags across the head).
d.†††††††† Infants or children whose cognitive and/or developmental abilities do not allow them to understand that tube displacement could be life-threatening, be detrimental to their care, and require replacement.
e.†††††††† Children whose unlimited freedom of movement may result in disruption of therapies (e.g., attempting to climb out of bed that may result in dislodging or displacing invasive devices).
2.††††††† Restraints will be used only when alternative measures are not sufficient.† Alternatives to restraint may include distraction, parental involvement in direct care and monitoring of patient behavior, and Child Life activities.
3.††††††† A physician/LIP order to initiate restraint per Clinical Care Protocol is required prior to initiation of restraint.† In emergency life-threatening situations, e.g. self-extubation, restraint may be initiated before a physician/LIP order is present.† A physician/LIP order must be obtained immediately after the life-threatening situation is resolved.† After initiation, the restraint episode may be maintained without additional physician/LIP orders.† If the patient is transferred to another unit, a new order must be obtained.
4.††††††† The least restrictive device will be used.
5.††††††† The use of restraint requires a written modification to the patientís plan of care.
6.††††††† Continued need for restraint and alternatives tried will be assessed and documented at least every 2 hours.
†7.†††††† The use of restraint will be discontinued when assessment of the patientís behavior indicates that restraint is not needed.† Restraints will not be used for convenience or punishment of patient behavior.
†8.†††††† The patientís rights, dignity, and well-being will be protected during restraint.
†9.†††††† The patient, when applicable, and patientís family will be informed as to why the use of immobilization devices and/or restraints are needed to protect the patient or others from injury.
10.††††† Restraints will be initiated and maintained by competent staff.† Staff will complete annual restraint competency review.
11.††††† Protocols for application of restraints by nursing staff in neonatal and pediatric populations will be approved by the medical staff (Clinical Affairs Committee), as listed in the following procedure.
Clinical Care Protocol:† Assessment, Monitoring, and Documentation Requirements
†1.††††††† Care of the restrained patient will include:
a.†††††††† Provision of enough slack in the restraint device to assure circulation is not impaired.
b.†††††††† Assessment of restrained limbs for positioning and circulation every two hours and to provide for movement, comfort measures, and skin care.
c.†††††††† Provision of age appropriate sensory stimulation for the patient.
†2.††††††† Monitoring and documentation requirements.
a.†††††††† When initiated, document the following:
1)†††††††† A description of the patientís behavior that indicates the need for restraint.
2)†††††††† Alternative measures implemented before the use of restraint.
3)†††††††† The type of restraint utilized and the body area to which it is applied.
4)†††††††† Explanation to the patient/family when appropriate.
b.†††††††† During episode of restraint, the following must be assessed and documented at least every 2 hours:
1)†††††††† Neurocirculatory and skin integrity checks of the restrained extremity
2)†††††††† Restraint system integrity and effectiveness
3)†††††††† Patient needs addressed (e.g., hygiene, elimination, hydration, nutrition, position change, comfort)
4)†††††††† Release of restraint for provision of motion (while awake)
5) Respiratory status
6) Assessment of the patientís behavior and use of alternative measures indicating criteria present for release of the restraint, use of a less restrictive method of restraint, or to continue the episode of restraint
c.†††††††† At conclusion of restraint episode, document the following:
1)†††††††† Assessment of patientís behavior indicating absence of need to continue restraint.
2)†††††††† Document the time restraint was discontinued.
PRECAUTIONS, CONSIDERATIONS, AND OBSERVATIONS:
1.†††††††† Immobilization devices/restraints should be secured to a bed frame or crib frame behind the side rails so that the side rails/crib sides can be raised and lowered safely.
2.†††††††† For infants in incubators or on warmer beds, restraints should be clipped to the sheet with a hemostat.
3.†††††††† The mattress should never be punctured with pins as this increases the potential for pathogen growth by making it permeable.
RELATED STANDARD OF PRACTICES:
Department of Nursing Practice Policy, Restraints, Use of (2.170).
Department of Nursing Practice Policy, Safety Precautions for the Pediatric Patient (2.210).
Approved:† Clinical Affairs, 6/97, 9/01
††††††††††††††††††† Frank H. Morriss, Jr., MD ††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††
††††††††††††††††††† Pediatric Nursing Advisory Council, 9/01
††††††††††††††††††† Jody Kurtt, RN, MA ††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††
††††††††††††††††††† Associate Director, Childrenís & Womenís Services
Revised:†††† 2/87; 4/89; 4/90; 7/91; 10/93; 7/95; 1/97; 5/98; 7/00; 9/01; 2/02