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CONSIDER: PHYSICAL RESTRAINTS

DEFINITION

Physical Restraint: Any physical or mechanical device, material or equipment that the individual cannot remove easily and that restricts freedom of movement or access to one's body (HCFA, 1999). Examples include posey vests, wrist or leg restraints, hand mitts, chairs with tabletops, and full siderails.

ASSESSMENT/SCREENING/DIAGNOSIS

If restraints are under consideration, Screen, for need for further assessment:

Provide plan for Surveillance/Supervision that may include:

  • Room/position closer to staff
  • Periodic checks
  • Environment free of hazards such as poorly fitted mattresses and siderails

Conduct Further Assessment and search for Alternatives to:

  • Prevent Falls/Injury
  • Maintain Therapy
  • Manage Behaviors

Prevent Falls/Injury: Alternatives to Physical Restraints

Assess for: Alternative Approaches to Restraints:
History of Falls
  • Identify interventions successful at home or at transferring facility
Medical problems: e.g. fluid overload, dehydration, infection, drug toxicity, offending medications
  • Prompt treatment and ongoing evaluation
Disruption in normal routine, including meaningful activity, exercise and rest
Unmet care need
  • Attend to needs for toileting, food and fluids, sleep, comfort
  • Address sensory needs
Presence of pain (Remember restlessness can be a common sign of pain in cognitively challenged older adults)
  • Analgesics
  • Positioning and other non-pharmacologic interventions (such as massage
  • Ongoing pain assessment, including effect of analgesic, pain diary (See Topic: Pain)
Gait instability and weakness
  • Consult physical therapy, mobility- exercise, walking program
  • Protective devices: hip pads and/or helmet
  • Skid-proof slippers and non-skid strips near bed
  • Seating that promotes good body alignment and support; Avoid use of wheelchair for prolonged sitting





Elopement risk
Falls from bed
  • Grab, bars ½ or ¼-length siderails to promote bed mobility
  • Adjustable height bed (100 to 120% of lower leg length)
  • Eliminate full side-rails. Use very low bed (7-13 inches off the floor) and mats at bedside
  • Pressure-sensitive or motion sensors to alert staff
Orthostatic hypotension
  • Eliminate/reduce dose of medications affecting blood pressure
  • Identify BP parameters with medical provide
  • Monitor orthostatic blood pressure (See Topic: Falls & Medication)

Maintain Therapy: Alternatives to Physical Restraints Assess: Is treatment consistent with patient wishes/advance directives?

  • Elicit patient feelings
  • Care conference/Ethics consult as indicated

Assess: Are there alternatives for treatment

If not, Assess for: Alternative Approaches to Restraints:
Risk to maintaining lines safely and comfortably
  • Garden gloves with soft ball inside
  • Camouflage IV line with clothing, stockingette, kling dressing
  • Camouflage g-tube with abdominal binder
  • Replace large NG tubes with smaller one (advocate for g-tube when long-term use is anticipated)
  • Endotracheal tube holders and freedom splints for endotracheal tube
Fear and anxiety
  • Companionship and supervision
  • For oriented patient, guided exploration of the device
Unmet care needs
  • Attend to needs for toileting, food and fluids, sleep, comfort, pain relief
  • Address sensory needs
    		•
    Boredom and/or diminished attention span

    Manage Behaviors, including wandering: Alternatives to Physical Restraints For more on agitation - See the Dementia Topic

    Assess for: Alternative Approaches to Restraints:
    Undetected medical problems
    • Correct underlying problem such as dehydration and constipation
    Unmet physical needs
    • Attend to needs for toileting, food and fluids, sleep, comfort, pain relief
    • Address sensory needs
    "Agenda" behavior. Query family to determine meaning behind behavior, including past patterns
    • Caregiver consistency
    • Use calm, simple statements and physical cues as needed
    • Validate, don't correct
    • Plan consistent, supervised walking and exercise as tolerated
    • Consult with recreation specialist and/or OT for plan for structured activity
    • Enlist family support
    Environmental safety
    • Close supervision, especially in high-risk areas - ER and diagnostic areas
    • Avoid rooms near areas of high traffic or noise
    • Remove cues that promote "leaving," e.g., visual access to elevators, stairways, street clothes
    • Institute regular patient checks, especially at shift change
    • Use volunteers, paid "sitters," or specialized staffing as appropriate

    If restraints are used, you need:

    • An order from licensed medical provider
    • Plan for re-evaluation of continued need
    • Plan to prevent physical decline related to restraint use
    • Ongoing evaluation for alternative approaches to restraint use


    Last updated - February 2005