Restraints and Alternatives
Applying Restraints
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Safety
- Place the patient in the lateral position, or elevate the head of the bed. The patient with extremity restraints is at risk for aspiration if placed in the supine position.
- Use a quick release tie to secure the restraint.
- Ensure that the restraint does not interfere with equipment, such as an IV, and is not placed over an access device, such as an arteriovenous shunt.
- Do not attach the straps of a restraint to the side rails of the bed.
- Do not tie the straps of a restraint into a knot.
- Check the skin under the restraint for abrasions.
- Change wet or soiled restraints to prevent skin breakdown.
- Remove a restraint immediately if the patient has an alteration in neurovascular status of an extremity, such as cyanosis, pallor, or coldness of the skin, or if the patient complains of tingling, pain, or numbness in the restrained extremity.
Equipment
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Wrist Restraint
Mitten Restraint
Belt Restraint
Elbow Restraint
PrintableDelegation
The skills of assessing a patient’s behavior and level of orientation, determining the need for restraints, selecting the appropriate restraint type, and performing the ongoing assessments required while a restraint is in place cannot be delegated to NAP.
The application and routine checking of a restraint, however, can be delegated to NAP. The Joint Commission (TJC, 2009a) requires that anyone who monitors a restrained patient, including NAP, be trained in first aid. Be sure to inform NAP of the following:
- Correct placement of the restraint and how to routinely check the patient’s circulation, skin condition, and breathing
- When and how to change a patient’s position or provide range-of-motion exercises, toileting, and skin care
- To notify you immediately if there is a change in the level of the patient’s agitation, skin integrity, circulation of the extremities, or breathing
Preparation
- Assess the patient’s behavior for confusion; disorientation; agitation; restlessness; combativeness; repeated removal of tubing or other therapeutic devices; and inability to follow directions.
- Follow your agency’s policies regarding restraints. Check the health care provider’s order for the purpose, type, location, and time or duration of the restraint. Determine whether a signed consent document for restraint use is needed.
- Review the manufacturer’s instructions for restraint application, and determine the most appropriate size restraint.
- Inspect the area where the restraint is to be placed. Note if there is any nearby tubing or devices. Assess the condition of the patient’s skin, sensation, adequacy of circulation, and range of joint motion.
Follow-up
- After applying a restraint, evaluate the patient’s condition for signs of injury every 15 minutes.
- Remove the restraints at least every 2 hours, and assess the placement of the restraint, patient's circulation, skin condition, position and provide range of motion exercise, toileting and skin care.
- Evaluate the patient for any complications of immobility.
- Routinely observe the patient’s IV catheters, indwelling urinary catheters, and drainage tubes.
- Continually evaluate the patient’s need for restraints according to agency policy.
- When a restraint is used for a patient with violent or self-destructive behavior, a licensed health care provider must evaluate the patient in person within 1 hour of initiating the restraint.
Documentation
- Record the patient’s behavior before and after the restraints were applied, the patient’s level of orientation, and the patient’s or family member’s statement of understanding the purpose of the restraint and his or her consent, if consent is required.
- Record any alternatives to restraints that were attempted and the patient’s response to them.
- Record the reason for the restraint, the type and location, the time at which the restraints were applied, the time at which the restraints ended, and the routine observations made every 15 minutes (or per agency policy), including skin color, pulse, sensation, vital signs, and behavior.
Review Questions
1. To which patient might the nurse apply a physical restraint?
An 83-year-old patient with dementia and a history of wandering whose fall risk assessment indicates a high risk of falling
A 42-year-old critical care patient with a traumatic brain injury who has repeatedly tried to pull out her shunt- A 74-year-old patient confined to bed that is at risk of pressure ulcers
- A 60-year-old patient with dementia who seemed increasingly confused shortly after having had restraints applied for 1 hour that morning
INCORRECT. There is no evidence that the use of restraints prevents falls or reduces wandering. Research has shown that patients suffer fewer injuries if left unrestrained.
CORRECT. The critical care nurse might apply a physical restraint to keep this patient from injuring herself by dislodging her shunt. Disruption of therapy causes patient injury, pain, or discomfort and increases the risk of infection.
INCORRECT. Use of physical restraints does not prevent pressure ulcers; to the contrary, pressure ulcer formation is a possible complication associated with the use of physical restraints. Any patient with a physical restraint must be monitored frequently for skin integrity, pulse, temperature, and color, as well as sensation and range of motion of the restrained body part.
INCORRECT. The nurse would not apply a physical restraint to a patient who had exhibited increased confusion, disorientation, or agitation during the previous application of a restraint. Instead, the nurse would evaluate the cause of the behavior and try to eliminate it, provide appropriate sensory stimulation, reorient the patient, use restraint alternatives, and enlist the family's support if possible.
2. Why does the nurse instruct nursing assistive personnel (NAP) to remove the wrist restraint of a confused patient every 2 hours?
- To try a less restrictive type of restraint if a more confining restraint has proved effective
- To double-check the size by inserting two fingers between the wrist and the restraint
- To check the skin integrity and range of motion of the wrist
- To comply with Joint Commission standards
INCORRECT. In acute care settings, the health care provider must order the least restrictive type of restraint first, not after a more confining restraint has proved effective.
INCORRECT. The nurse would select the appropriate size restraint for the patient, according to the manufacturer's instructions, when the restraint is initially applied, and he or she would double-check the fit when the restraint is applied, not 2 hours later. The fit need not be checked at 2-hour intervals thereafter.
CORRECT. The nurse instructs the NAP to remove the wrist restraint of a confused patient every 2 hours to ensure that the wrist is checked for skin integrity, pulse, temperature, color, sensation, and range of motion.
INCORRECT. The Joint Commission policy states that, in most circumstances, a physical restraint may be maintained up to 4 hours in an adult.
3. What would the nurse instruct nursing assistive personnel (NAP) to report when caring for a patient in a wrist restraint?
- “Tell me if the patient’s pulse changes.”
- “Tell me if the skin under the restraint becomes abraded or raw.”
- “Let me know if you think she’s ready for them to come off.”
- “Let me know if the patient needs anything for pain.”
INCORRECT. When caring for a patient in a wrist restraint, the nurse would assess the patient for pulse changes in the extremity to which the restraint has been applied. This skill would not be delegated to NAP.
CORRECT. When caring for a patient in a wrist restraint, the nurse would instruct NAP to report the condition of the skin beneath the restraint.
INCORRECT. Patient assessment is a nursing responsibility, and the nurse would make the determination of when a patient’s restraints can be removed, in accordance with agency policy and all applicable laws and regulations.
INCORRECT. Assessment of pain is a nursing responsibility and cannot be delegated to NAP.
4. The nurse is discussing the risk of falling with the wife of a patient with cognitive impairment. What is the nurse’s best response when the patient's wife says, “I don’t like him being tied down in the bed?”
- "I’m sure you don’t want him to fall again."
- "Can you suggest an alternative?"
- "What did you do to prevent him from falling when he was at home?"
- "We will try all other alternatives before using physical restraints."
INCORRECT. This is not the correct answer because it appears to use guilt to secure family consent.
INCORRECT. This is not the correct answer because it indicates impatience with the family’s concerns and places an inappropriate responsibility on the patient's wife.
INCORRECT. This is not the correct option, because it appears to place responsibility for the patient’s safety on the family. In addition, the patient's condition and circumstances are different in the facility than they were at home, so using the same fall-prevention strategies is likely to be ineffective.
CORRECT. This is the correct answer because the response attempts to reassure the family that restraints will be used only as a last resort.
5. When a nursing assistive personnel (NAP) enters the room of a patient in a belt restraint, he finds the patient’s gown bunched around the patient’s chest and the patient asking for help. What would the NAP do?
- Check the patient’s blood pressure and pulse before smoothing the gown
- Untie the restraint and smooth the patient’s gown
- Put on the call light for help
- Ask the patient what specific help she would like
INCORRECT. Checking the patient’s blood pressure and pulse is not appropriate at this time.
CORRECT. The NAP would untie the restraint, smooth the patient’s gown, and replace the restraint.
INCORRECT. Putting on the call light is not appropriate, since the call light is intended to summon the NAP.
INCORRECT. Asking the patient what help is needed is not appropriate. The difficulty is obvious, and the patient may have a cognitive impairment that makes clear expression of his or her needs impossible.
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