Want to know more

PHYSICAL RESTRAINTS

The information in this "Want to know more" section is organized according to the following major components of the NURSING PROCESS:

 

Goal

Minimize use of physical restraint except in emergent and critical care situations.

 
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Background

Risk factors for physical restraint use:

  • Severe cognitive impairment and/or physical impairment
  • Presence of medical devices in cognitively impaired patients
  • Fall-injury risk
  • Diagnosis or presence of psychiatric disorder (e.g., alcohol withdrawal)

 

Morbidity and mortality risks associated with physical restraints

  • Increased agitation or confusion
  • New-onset pressure ulcers
  • Pneumonia
  • Nerve injury
  • Strangulation/asphyxiation

 

 
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Definitions

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. Medications such as sedatives and hypnotics may be considered chemical restraints (and are regulated in nursing homes).

 
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Assessment/Screening Tools

If restraints are under consideratioan, 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

 

Contact Further Assessment and search for Alternatives to:

  • Prevent Falls/Injury
  • Maintain Therapy
  • Manage Behaviors

 

 

Prevent Falls/Injury: Alternatives to Physical Restraints

Table 22.1 Evidence-Based Interventions to Reduce Fall Risk (Update 2008)
Patient-Centered Interventions Organizational Interventions Environmental Interventions
Supervised, progressive ambulation
 
 
PT/OT consultation: weakened or unsteady gait, trunk weakness, upper arm weakness
 
 
 
Provide physical aids, hearing, vision, walking
 
 
Modify clothing: skid-proof slippers, slipper-socks; robes no longer than ankle length
 
Bedside commode if impaired or weakened gait
 
Postural hypotension: behavioral recommendations such as ankle pumps, hand clenching, reviewing medications, elevating head of bed
Examine pattern of falls on unit (e.g., time of day, day of week)
 
Examine unit factors that can contribute to falls that can be ameliorated (e.g., report in back room versus walking rounds to improve surveillance)
 
Restructure staff routines to increase number of available staff throughout day
 
Set and maintain toilet schedules
 
 
 
Install electronic alarms for wanderers
 
 
Provide bed/chair alarms*
 
 
 
Moving patient closer to nurse station
 
Increased checks on high-risk patients
Keep bed in low, locked position
 
 
Safety features such as grab bars, call bells, and bed alarms are in good working order
 
 
 
Ensure that bedside tables and dressers are in easy reach
 
 
Clear pathways of hazards
 
 
 
Bolster cushions to assist with posture, maintain seat in chair
 
Adequate lighting, especially bathroom at night
 
 
Furniture to facilitate seating: reclining chairs†, extended arm rests, high back
Depression  
  • Lack of sadness
  • Somatic complaints, such as appetite changes, vague GI symptoms, constipation, and sleep disturbances
  • Hyper activity
  • Sadness misinterpreted by provider as normal consequence of aging
  • Medical problems that mask depression
Note that alarms do not necessarily prevent a patient from attempting to arise from bed or chair or leave a unit. They are primarily to be used to ensure more timely notification to staff that patients are attempting unsupervised transfers or ambulation. † For those with poor trunk balance and who slide out of chairs; in other instances, could be viewed as a restraint.
Although there is no strong evidence to support each of these interventions, they have been used in multicomponent interventions studies that have demonstrated reduced fall risk (Oliver et al., 2007 [Level I]).

Reprinted with permission from Springer Publishing Company. Mion, L.C., Halliday, B.L., & Sandhu, S.K. (2008). Physical restraints and side rails in acute and critical care settings: Legal, ethical, and practice issues.  In E. Capezuti, D. Zwicker, M. Mezey, & T. Fulmer (Eds.), Evidence-Based Geriatric Nursing Protocols for Best Practice. (3rd ed., pp. 353-367).  New York: Springer Publishing Company, Inc.


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 challanged older adults)
  • Analgesics
  • Positioning and other non-pharmacologic interventions (such as massage)
  • Ongoing pain assessment, including effect of analgesic, pain diary Try This: Falls Risk Assessment
Orthostatic hypotension
  • Eliminate/reduce dose of medications affecting blood pressure
  • Identify BP parameters with medical provider
  • Monitor orthostatic BP
    (See Topics: Falls & Medication)
Elopement risk
Falls from bed



If patient is cognitively challenged, and unable to walk without assistance
  • 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
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
Orthostatic hypotension
  • Eliminate/reduce dose of medications affecting blood pressure
  • Identify BP parameters with medical provider
  • Monitor orthostatic BP

 

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 tube 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

 

If not: Assess for: Alternative Approaches to Restraints:
Undetected medical problem
  • 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 (See Topic: Sensory)
"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 voluteers, 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 injury, including a plan for supervision
  • Plan to prevent physical decline related to restraint use
  • Ongoing evaluation for alternative approaches to restraint use

 

 

Parameters of Assessment

  • Baseline and current cognitive state, determine if new onset delirium
  • Physical function: ability to transfer and walk (See Topic - Function)
  • Therapeutic devices: alternative modes of therapy
  • Identify risk factors for falls and disruption of therapy(e.g., for fall risk, assess memory, balance, orthostatic blood pressure, vision and hearing, use of sedative hypnotic drugs or narcotic agents). (See Topic: Falls)

 

 
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Nursing Care Strategies/Treatment/Management

Prevention

  • Develop a nursing plan tailored to the patient's presenting problem(s) and risk factors
  • Consider alternative interventions
  • Refer to occupational and physical therapy for self-care deficits or mobility impairment; use adaptive equipment as appropriate
  • Document use and effect of alternatives to restraints

 

 

Treatment

  • Use restraints only after exhausting all reasonable alternatives
  • When using restraints:
    • Choose the least restrictive device
    • Reassess the patient's response every hour
    • Remove the restraint every two hours
    • Renew orders every 24 hours after evaluation by licensed independent practitioner

 

 

  • Modify the care plan to compensate for restrictions imposed by physical restraint use:
    • Change position frequently and provide skin care
    • Provide adequate range of motion
    • Assist with ADL, such as eating and use of toilet

 

 

  • Continue to address underlying condition(s) that prompted restraint use (e.g., delirium).
  • Refer to geriatric nurse specialist, occupational therapist etc, as appropriate.

 

Expected Outcomes
Patient

  • Physical restraints will be used only under well-documented exceptional circumstances, after all reasonable alternatives have been tried.

 

 

Healthcare Provider

  • Providers will use a range of interventions other than restraints in the care of patients.

 

 

Institution

  • Incidence and/or prevalence of restraint use will decrease.
  • Use of chemical restraints will not increase.
  • The number of serious injuries related to falls, agitated behavior, and premature disruption of medical devices will not increase.
  • Referrals to occupational therapists, physical therapists, psychiatric-liaison services, etc. will increase, as will availability of adaptive equipment.
  • Staff will receive ongoing education on the prevention of restraints.

 

 

Follow-up Monitoring

  • Document incidence and or prevalence of physical restraint, both house-wide and unit-specific, on an on-going basis.
  • Educate caregivers to continue assessment and prevention.
  • Identify patient characteristics and care problems that continue to be refractory and involve consultants (e.g., geriatric specialists, psychiatric liaison specialists) in devising an expanded range of alternative approaches.

 

Reprinted with Permission from Springer Publishing Company. McConnell, A., & Mion. L. (2003). Use of Physical Restraints in the Acute Care Setting In Mezey, M. D., Fulmer, T., & Abraham, I. (Eds.) Zwicker, D. (Managing Ed.) Geriatric Nursing Protocols for Best Practice. (2nd ed.). New York: Springer Publishing Company.

 

Last updated - February 2005

Confusion Assessment Method (CAM).pdf Falls Risk Assessment.pdf Theraputic Activity Kits.pdf
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