A physical restraint is any manual method, physical or mechanical device, material, or equipment that immobilizes or reduces the ability of a patient to move his or her extremities, body, or head freely.
A drug may be considered a chemical restraint when it is given to manage behavior or restrict freedom of movement and is not part of the standard treatment for a patient’s condition (NAPHS, 2007). Physical or chemical restraints should be the last resort and used only when reasonable alternatives fail.
Restraints are most commonly used in hospitals to prevent the disruption of therapy, such as pulling out intravenous (IV) tubes or removing urinary catheters. Restraint use is more common in critical care settings, where nurses are concerned that disruption of therapy can significantly injure patients (Mion, 2008).
The use of physical restraints is no longer a safe strategy, yet many nurses
still believe that they are needed to control behavioral symptoms and prevent falls in older adults with dementia.
It requires that a restraint be used only under the following circumstances:
(1) to ensure the immediate physical safety of the patient, a staff member, or others;
(2) when less restrictive interventions have been ineffective;
(3) in accordance with a written modification to the patient’s plan of care;
(4) when it is the least restrictive intervention that will be effective to protect the patient, staff member, or others from harm;
(5) in accordance with safe and appropriate restraint techniques as determined by hospital policies; and
(6) it is discontinued at the earliest possible time.
Restraints are a temporary means to maintain patient safety. However, there is no evidence that they prevent falls, reduce wandering, or prevent medical devices from being pulled out. Research has shown that patients suffer fewer injuries if left unrestrained.
The use of mechanical or physical restraints requires a licensed health care
provider’s order and must be based on a face-to-face patient assessment.
The order must be current, specifying the type of restraint and the duration and circumstances or patient behaviors under which the restraint is to be used. Orders should be renewed according to agency policy (usually every calendar day) and based on reassessment and reevaluation of the restrained patient. A patient’s or family member’s informed consent is necessary in the long-term care setting.
The use of restraints is associated with serious complications, including pressure ulcers, hypostatic pneumonia, constipation, incontinence, and death. The Food and Drug Administration (FDA) regulates restraints as medical devices and requires manufacturers to label them “prescription only.” Most patient deaths in the past have resulted from strangulation from a vest or jacket restraint. Numerous agencies no longer use vest restraints. For these reasons this text does not describe their use.
Delegation and Collaboration
The skills of assessing a patient’s behavior and level of orientation, the need for restraints, the appropriate restraint type, and the ongoing assessments required while a restraint is in place cannot be delegated to nursing assistive personnel (NAP). Applying and routinely checking a restraint can be delegated to NAP.
The nurse directs the NAP by:
• Reviewing correct placement of the restraint and how to routinely check the patient’s circulation, skin condition, and breathing.
• Reviewing when and how to change a patient’s position and provide range-of-motion (ROM) exercises, toileting, and skin care.
• Instructing NAP to notify nurse immediately if there is a change in level of patient agitation, skin integrity, circulation of extremities, or patient’s breathing.
Equipment
❏ Proper restraint (e.g., belt, wrist, mitten)
❏ Padding (if needed)
IMPLEMENTATION
1 Gather equipment and perform hand hygiene. Promotes organization and reduces transmission of microorganisms.
2 Use calm approach and introduce yourself to patient, including both name and title or role. Reduces patient anxiety and uncertainty.
3 Identify patient using two identifiers (i.e., name and birthday or name and account number) according to agency policy. Compare indentifiers with information on patient’s identification bracelet. Ensures correct patient.
4 Provide privacy. Explain to patient and family purpose of restraint. Be sure that patient is comfortable and in correct anatomic position. May promote cooperation. Positioning prevents contractures and neurovascular impairment.
5 Adjust bed to proper height and lower side rail on side of patient contact. Allows you to use proper body mechanics and prevent injury.
6 Pad skin and bony prominences (as necessary) that will be covered by restraint. Reduces friction and pressure from restraint to skin and underlying tissue.
7 Apply proper-size restraint: Follow manufacturer directions.
a Belt restraint:
Have patient in sitting position. Apply belt over clothes, gown, or pajamas. Make sure to place restraint at waist, not chest or abdomen. Remove wrinkles or creases in clothing. Bring ties through slots in belt. Help patient lie down if in bed. Avoid applying belt too tightly.
Restrains center of gravity and prevents patient from rolling off stretcher, sitting up while on stretcher, or falling out of bed. Tight application or misplacement can interfere with ventilation. This type of restraint may be contraindicated in patient who had abdominal surgery.
B, Properly applied belt restraint allows patient to turn in bed.
b Extremity (ankle or wrist) restraint:
Commercially available limb restraints are made of sheepskin with foam padding. Wrap limb restraint around wrist or ankle with soft part toward skin and secure snugly (not tightly) in place by Velcro straps. Insert two fingers under secured restraint (see illustration).
Restraint immobilizes one or all extremities to protect patient from fall or accidental removal of therapeutic device (e.g., IV tube, Foley catheter).
Tight application interferes with circulation and causes neurovascular injury.
under restraint.
c Mitten restraint:
Thumbless mitten device restrains patient’s hands. Place hand in mitten, being sure that Velcro strap(s) are around wrist and not forearm (see illustration).
Prevents patients from dislodging invasive equipment, removing dressings, or scratching; yet allows greater movement than wrist restraint.
d Elbow restraint (freedom splint):
Restraint consists of rigidly padded fabric that wraps around arm and is closed with Velcro. Upper end has a clamp that hooks to patient’s gown sleeve (see illustration).
Insert patient’s arm so elbow joint rests against padded area, keeping joint rigid. Commonly used with infants and children to prevent elbow flexion
(e.g., when IV line placed in antecubital fossa). May also be used for adults.
8 Attach restraint straps to portion of bedframe that moves when raising or lowering head of bed. Be sure that straps are secure. Do not attach to side rails. Restraints can be attached to frame of chair or wheelchair as long as ties are out of patient’s reach. Patient will be injured if restraint is secured to side rail and bed is then lowered.
9 Secure restraints with quick-release tie (see illustrations), buckle, or adjustable seat belt–like locking device. Do not tie in a knot. Allows for quick release in emergency.
10 Double-check and insert two fingers under secured restraint. Checking for constriction prevents neurovascular injury.
11 Assess proper placement of restraint, including skin integrity, pulses, temperature, color, and sensation of restrained body part. Provides baseline to later evaluate if injury develops from restraint
use.
12 Remove restraints at least every 2 hours (TJC, 2012a) or according to agency policy and assess patient each time. If patient is violent or noncompliant, remove one restraint at a time and/or have staff assist while removing restraints. Removal provides opportunity to change patient’s position, offer nutrients, perform full ROM, toilet and exercise patient.
13 Secure call light or intercom system within reach. Allows patient, family, or caregiver to obtain assistance quickly.
14 Leave bed or chair with wheels locked. Keep bed in lowest position. Locked wheels prevent bed or chair from moving if patient tries to
get out. Placing bed in lowest position reduces chance of injury if patient falls out of bed.
15 Perform hand hygiene. Reduces transmission of microorganisms.
Book references:
- Mosby’s Pocket Guide to Nursing Skills & Procedures ( PDFDrive )
- Taylor’s Clinical Nursing Skills_ A Nursing Process Approach, Third Edition ( PDFDrive )
- Essential Procedures for Practitioners in Emergency, Urgent, and Primary Care Settings A Clinical Companion ( PDFDrive )
- Clinical Nursing Skills and Techniques ( PDFDrive )
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