Restraint Use

Definition

A restraint, or physical restraint, is a piece of equipment or device that restricts a patient's ability to move. Restraints may keep a patient from getting out of bed or moving arms and legs excessively.

Purpose

Restraints are used to control a patient who is in danger of harming him/herself or others. It is sometimes necessary to restrain children, who may not be capable of remaining still when they are frightened or in pain during some procedures. The use of physical restraints in the health care arena should be used as a last-resort option.

Precautions

Many safety measures should be considered before applying restraints. According to federal law, first and foremost is the need to try other methods to promote safety and avoid the use of physical restraints. Some examples of alternative methods are patient reorientation to physical surroundings, discussion with family and friends about staying with patient, moving the patient's room nearer to staff members, teaching relaxation techniques in order to decrease anxiety and fear, and decreasing overstimulation. Documentation of these methods is extremely important.

Description

Several types of medical manufacturers have different names for the same types of physical restraints. The most common names and types of physical restraints are:

• soft wrist and ankle restraints
• strap fastening vest (posey jacket)

• seat belt with buckle (restraint belt)
• mittens (restraint mitts)
• leather wrist and ankle restraints

The most common reasons for the use of physical restraints are:

• When a confused patient roams through the health care facility endangering him/herself.
• When a confused patient tries to remove medically necessary tubes, intravenous lines, or protective dressings.
• When a patient has an unsteady gait (walk) and is at risk for falls.
• When a patient needs to be kept from inflicting self-harm or injury (suicidal).
• When a patient needs to be kept from inflicting harm on health care workers, other patients, and/or visitors (homicidal).
• When a professional is performing minor surgical procedures on a child who is not able to remain still.

Preparation

Before restraint application, the health care provider should be familiar with the restraint device that will be used. Also, if a patient is violent, a five-person team is optimal for the restraining process. Each person will be responsible for one extremity, with the fifth person supervising and positioning the patient's head.

Each restraint device will have different directions for application. However, there are some universal standards for proper application. When using any type of restraining device, it is extremely important to tie or lock the restraint to the bed frame and not the bed rails, thus allowing for proper movement. With soft restraints, posey jackets, and restraint belts, a quick-release slipknot should be used to allow immediate release if needed. When leather restraints are used and applied to both arms and legs, one arm should be positioned above the patient's head while the other is positioned by the patient's side. This will decrease the possibility of the patient's rocking or tipping over the bed.

Aftercare

The nurse has to reassess restraints at least every 30 minutes. Neurovascular assessment (circulation to hands, fingers, feet, toes); skin assessment (bruising of restrained area); and meeting a patient's activities of daily living such as toileting, eating, and drinking are all aspects of restraint reassessment and care. Documentation of these interventions must be clearly identified on the patient's chart.

Complications

Most common restraint complications include:

• accidental or intentional removal of restraints by patient, family, or staff, resulting in possible removal of tubes, intravenous lines, or injury to patient or others
• injury to restrained extremity (arm or leg)
• fracture or muscle strains during application with violent patient
• dislocation or contusion of extremity
• exposure to blood or body fluid while restraining violent patient (biting, spitting, urinating, etc.)
• numbness and/or tingling in restrained extremity

Results

The end results of using physical restraints are the maintenance of safety to the patient and others and the administration of medically necessary interventions.

Health care team roles

The registered nurse (RN) or licensed practical nurse (LPN) has a tremendous responsibility when caring for a patient in physical restraints. Many times restraints are needed immediately and violent attacks on health care workers can happen. The emphasis on proper documentation of alternative methods is an absolute must. Obtaining a physician's order for physical restraints is a top priority as well. Rationale for the application of restraints must be discussed with the patient and family. Adequate explanation of the interference with medical treatment or the diversion of suicidal or homicidal acts is important. Reassessment of proper restraint positioning and re-evaluation of the patient's continued need for physical restraints are also aspects of complete nursing care.

Paramedics and emergency medical technicians (EMTs) are confronted with the need to use physical restraints in the field (outside the hospital). In these cases, they are allowed to use a "reasonable amount of force" in order to manage a combative patient during transport to the health care facility. Physical restraints utilized by paramedics and EMTs are plastic bound straps (zip straps), vests, and blankets. When physical restraints are necessary, law enforcement is usually involved.

KEY TERMS

Extremity— A term referring to an arm or leg.

Gait— A characteristic pace of a person's walk.

Neurovascular— Referring to the combined status of the neurological and circulatory systems.

Physical restraint— A piece of equipment or device that restricts a patient's ability to move.

Resources

BOOKS

Bledsoe, Bryan E., Robert S. Porter, and Richard S. Cherry. "Medical/Legal Aspects of Advanced Prehospital Care." In Paramedic Care: Principles & Practice: Introduction to Advanced Prehospital Care. Upper Saddle River, NJ: Prentice-Hall, 2000, pp. 108-137.

Mulryan, Kathleen. "Designing a Restraint-Free Environment." In Clinical Nursing Skills & Techniques, 4th ed. Edited by Susan R. Epstein. St. Louis: Mosby-Year Book, 1998, pp.74-78.

Mulryan, Kathleen. "Applying Restraints." In Clinical Nursing Skills & Techniques, 4th ed. Edited by Susan R. Epstein. St. Louis: Mosby-Year Book, 1998, pp.78-84.

PERIODICALS

Karlsson, Stig. "Restraint Use in Elder Care: Decision Making Among Registered Nurses." Journal of Clinical Nursing 9, no. 6 (November, 2000): 842-850.

ORGANIZATIONS

National Association of Psychiatric Health Systems. 325 Seventh Street, N.W., Suite 625, Washington, D.C. 20004-2802. (202) 393-6700. 〈http://www.haphs.org/News/guidingprinc.html〉.

OTHER

Wigder, Herbert N. "Restraints from Emergency Medicine/Legal Aspects of Emergency Medicine." emedicine.com January 200l. 〈http://www.emedicine.com/emerg/topic776.htm〉.