A. Introduction

Welcome to this lesson on patient restraint application and management. This lesson covers the safe and effective use of restraints, including patient assessment, appropriate restraint selection, correct application, and patient monitoring.

B. Understanding Patient Restraints

It’s essential to understand what patient restraints are and the principles guiding their use.

• Physical restraints are any manual method, physical or mechanical device, material, or equipment that immobilizes or reduces a patient’s ability to move their arms, legs, body, or head freely.
• Chemical restraints are medications used to control a patient’s behavior or restrict their freedom of movement that are not standard treatment for the patient’s medical or psychiatric condition.

Restraints may be indicated to prevent patient self-injury, to prevent patient injury to others, or to prevent disruption of essential medical treatment.

The principles of restraint use are:

• Restraints should be used only when less restrictive alternatives have been exhausted.
• Restraints must be ordered by a licensed healthcare provider.
• The type of restraint must be appropriate to the patient’s needs.
• Restraints must be applied safely and correctly.
• Patients in restraints must be monitored closely.
• Restraints should be discontinued as soon as possible.

Ethical considerations include:

• Autonomy: Respecting the patient’s right to make decisions, which restraints can limit.
• Beneficence: The obligation to do good, as restraints may prevent harm.
• Non-maleficence: The obligation to do no harm, requiring careful consideration of restraint use.
• Justice: Fairness in resource and treatment distribution, ensuring restraints are used equitably.

C. Legal and Regulatory Considerations

Restraint use is governed by strict legal and regulatory guidelines, including:

• The Joint Commission standards
• Centers for Medicare & Medicaid Services (CMS) regulations
• State-specific regulations
• Hospital policies and procedures

A restraint order must include the patient’s name, date and time, type of restraint, reason, duration, and physician signature. Informed consent should be obtained whenever possible, and patients have the right to be free from unnecessary restraint. Improper restraint use can lead to legal issues like false imprisonment.

D. Patient Assessment

Thorough patient assessment is required before, during, and after restraint application.

Pre-restraint assessment includes:

• Identifying behaviors necessitating restraint use
• Assessing physical and mental status
• Reviewing medical history and medications
• Evaluating skin integrity and circulation
• Determining understanding and communication abilities
• Assessing for contraindications to specific restraints

Ongoing assessment of a patient in restraints includes:

• Vital signs
• Level of consciousness and mental status
• Circulation, sensation, and movement (CSM)
• Skin integrity
• Comfort level and pain
• Hydration and nutritional status
• Elimination needs
• Psychological status and emotional needs
• Continued need for restraints

Using a standardized assessment tool ensures consistency, improves communication, and provides a clear record.

E. Types of Restraints

Several types of restraints are available, each with specific uses.

• Physical restraints include limb restraints (wrist, ankle), soft restraints, belt restraints, vest restraints, and mitten restraints.
• Chemical restraints are medications like sedatives, antipsychotics, and anxiolytics used to manage behavior.

The least restrictive restraint should be selected, allowing the greatest possible freedom while ensuring safety.

F. Application of Restraints

Correct application is crucial for patient safety and comfort.

General principles include:

• Obtain a physician’s order (except in emergencies to prevent immediate harm).
• Gather the correct type and size of restraints.
• Explain the procedure to the patient and/or family.
• Ensure proper body alignment and positioning.
• Pad bony prominences.
• Apply restraints snugly but not too tightly (check for two-finger fit).
• Secure restraints to a non-movable part of the bed frame with quick-release knots.
• Leave enough slack for some movement.
• Check restraints frequently for tightness, circulation, and skin integrity.

Quick-release knots are essential for rapid removal in emergencies.

G. Monitoring Patients in Restraints

Patients in restraints require frequent and thorough monitoring, including:

• Every 15 minutes for the first hour
• Every 2 hours thereafter, or more frequently as needed

Parameters to monitor include vital signs, level of consciousness, CSM, skin integrity, comfort, hydration, elimination needs, psychological status, and the continued need for restraints. Assess circulation, sensation, and movement. Provide ongoing reorientation and reassurance.

H. Release of Restraints

Restraints should be released as soon as the patient no longer meets the criteria for their use.

The process involves:

• Obtaining a physician’s order for discontinuation.
• Removing one restraint at a time, if appropriate.
• Assessing the patient’s condition and behavior after each restraint removal.
• Continued close monitoring after all restraints are removed.
• Providing ongoing support and reassurance.

Criteria for discontinuation include the patient no longer exhibiting the behaviors that necessitated restraints, less restrictive alternatives are effective, the patient can understand and follow directions, or the patient’s condition has improved.

I. Complications

Complications can occur, including:

• Skin breakdown and pressure ulcers
• Circulatory impairment
• Nerve damage
• Muscle weakness and atrophy
• Contractures
• Agitation and increased anxiety
• Humiliation and loss of dignity
• Aspiration
• Strangulation (from improperly applied restraints)
• Death (rare, but possible)

Early recognition, prompt management, and prevention are essential. Frequent monitoring and assessment are crucial.

J. Alternatives to Restraints

Alternatives to physical restraints should be used whenever possible. These include:

• Frequent observation and redirection
• De-escalation techniques
• Family involvement
• Environmental modifications
• Diversional activities
• Medication review and adjustment
• Use of sitters or bed alarms
• Addressing underlying medical conditions
• Providing comfort measures

Individualized care planning is essential, addressing the underlying causes of behavior and selecting the most appropriate interventions.

K. Documentation

Accurate and complete documentation is essential, including:

• Patient identification
• Date and time of application
• Type of restraint
• Reason for use
• Physician’s order
• Pre-restraint assessment
• Patient’s behavior necessitating restraints
• Alternatives attempted
• Explanation to patient/family
• Patient’s response
• Ongoing assessment findings
• Complications and management
• Time of release
• Post-restraint assessment

Clear and concise documentation provides an accurate record, facilitates communication, supports quality improvement, and reduces legal risks. Medicolegal considerations include adherence to regulations, proper assessment and documentation, informed consent, least restrictive restraint use, and complication prevention and management.

L. Hands-on Skills Practice

You will now practice the application and management of patient restraints in small groups, including:

• Performing a pre-restraint assessment
• Selecting the appropriate type of restraint
• Applying restraints safely and correctly on a simulated patient
• Assessing a simulated patient in restraints
• Releasing restraints
• Documenting the procedure

Your instructor will provide feedback and use a checklist to assess your performance.

M. Question and Answer Session

This is your opportunity to ask questions for clarification and to address any concerns related to patient restraint application and management. We will also summarize the key learning points.

N. Assessment and Evaluation

We will assess your understanding and skills through:

• Skills Checklist
• Direct Observation
• Verbal Questioning
• Written Post-Test (Optional)
• Participant Feedback