13. 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).

14. Attach restraint to a fixed location on bed (if necessary),

maintaining the opportunity for quick release and regular vascular checks (safety pin, secure tucking, etc.). Do

not attach restraint to equipment that can be moved

(crib side rails, incubator doors), as injury may occur.

Quick release allows for mobility and access in an

emergency (1,2).

15. Document restraint use and, if required, obtain physician order (see hospital policy and/or regulatory agency

requirement (the Joint Commission, CMS) (1,2).

16. Remove restraint at the earliest time possible.

F. Complications

1. Failure of restraint resulting in self-injury and/or interference with treatment

2. Neurovascular impairment (1)

3. Impairment of skin integrity (i.e., pressure ulcer formation, necrosis) (1)

4. Contractures or positional deformity/paralysis from prolonged immobility (1)

5. 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)

6. Impairment or compromise of medical state, including

oxygenation, musculoskeletal system, and cardiorespiratory conditions (1)

7. Increased agitation or irritability (1)

8. Extravasation injury leading to impairment of skin

integrity, tissue necrosis, infection, and/or nerve and

tendon damage (6)

G. Special Considerations

1. A temporary alternative to restraint usage during procedures is therapeutic holding. This is defined as the “use

of a secure, comfortable, temporary holding position

that provides close physical contact with the parent or

caregiver for 30 minutes or less” (2). Staff must properly

prepare the parent or caregiver and provide proper

supervision throughout the procedure.

2. The American Academy of Pediatrics has outlined recommendations addressing infant sleep positioning to

reduce the risk of sudden infant death syndrome. In

terms of positioning the infant, they should be placed

in a “supine position (wholly on their back)” (7).

Therefore, when returning the patient to a sleep and/

or recovery position following a procedure, health

care professionals should endorse and model this

behavior for parents and caregivers whenever

possible.

References

1. Perry AG, Potter PA. Clinical Nursing Skills and Techniques. 7th

ed. St. Louis: Mosby/Elsevier; 2010.

2. Hockenberry MJ, Wilson D. Wong’s Nursing Care of Infants and

Children. 9th ed. St. Louis: Elsevier Mosby; 2011.

3. Mathur AM, Neil JJ, McKinstry RC, et al. Transport, monitoring,

and successful brain MR imaging in unsedated neonates. Pediatr

Radiol. 2008;38:260.

4. Vergara ER, Bigsby R. Developmental & Therapeutic Interventions

in the NICU. Baltimore: Paul H. Brookes; 2004.

5. The Joint Commission. Comprehensive Accreditation Manual for

Hospitals. Chicago: The Joint Commission; 2012.

6. Ramasethu J. Prevention and management of extravasation injuries in neonates. NeoReviews. 2004;5(11):c491.

7. American Academy of Pediatrics. Policy Statement: The changing

concept of sudden infant death syndrome: diagnostic coding shifts,

controversies regarding the sleeping environment, and new variables to consider in reducing risk. Pediatrics. 2005;116(50):

c1245.