Fig. 4.6. 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.

weights of common restraint materials in use when

weighing infants for monitoring daily growth.

6. Evaluate the patient and proper use, placement, and position of restraint according to patient need, hospital policy,

and regulatory agency requirement. Regulatory agencies

such as the Joint Commission, the U.S. Food and Drug

Administration (FDA), and the Centers for Medicare and

Medicaid Services (CMS) publish standards of medical

care regarding the safe use and legal requirements for

restraint implementation and maintenance (1,4,5).

7. Ensure that the infant is in a proper and functional

position that promotes flexion and midline positioning

of upper and lower extremities.

a. Rationale: Prevention of contractures and support of

self-calming techniques of neonates (prone, sidelying) (Figs. 4.7 and 4.8) (4).

8. Pad bony prominences and maintain natural curvature

of extremities (especially the hand and fingers)

32 Section I ■ Preparation and Support

a. Rationale: Prevents contractures and neurovascular

injury; preserves skin integrity; reduces friction and

pressure to skin from restraint material (1)

9. 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, as it may impede

circulation. Tips of all digits should remain visible for

assessment.

10. Restraints on the upper or lower extremities need to be

assessed at least hourly (and/or according to hospital

policy and regulatory agency requirement (the Joint

Commission, CMS) for

a. Skin Integrity, including excoriation, erythema, and

edema

b. Pulses

c. Temperature

d. Color

e. Capillary Refill

f. Range of Motion (ROM) (1)

11. Check for possible constriction by inserting a finger

between infant’s skin and the secured restraint (2).

a. Rationale: Constriction from a tight restraint can

cause neurovascular injury and impede circulation.

12. Specific assessments related to oxygenation, musculoskeletal system, and cardiorespiratory conditions need to

be performed in relation to the restraint device and its

usage (1).