Evidence-Based Content - Updated July 2012
A. The use of physical restraints or side rails for the involuntary immobilization of the patient may not only be an infringement of the patient’s rights, but can also result in patient harm, including soft tissue injury, fractures, delirium, and even death (Ref 1; 2; 3).
B. The primary ethical dilemma resulting from physical restraint is the clinician’s value or emphasis of beneficence versus the patient’s autonomy.
C. Use of physical restraint should be used as a last resort; only used when less restrictive mechanisms have been determined to be ineffective; the use of restraint must be in accordance with a written modification to the patient’s plan of care; used in accordance with the order of a physician or licensed independent practitioner (LIP); must never be written as a PRN order; each order must be renewed every 4 hours, for adults up to 24 hours at which time a reevaluation by a LIP is required for reasons of violent or self-destructive behavior; each order of restraint use for nonviolent reasons must be renewed according to hospital policy; and restraint must be discontinued at the earliest possible time (Ref 4).
A. Definition: The Centers for Medicare and Medicaid Services (CMS) defines physical restraint as “any manual method, physical or mechanical device, material, or equipment that immobilizes or reduces the ability of the patient to move his or her arms, legs, body or head freely” (Ref 4). Examples include wrist or leg restraints, hand mitts, Geri-chairs, and, in certain situations, full side rails and reclining chairs.
B. Etiology: Hospital nurses’ reasons for use of physical restraint are prevention of patient disruption of medical devices and therapy (75%), confusion (25%), and fall prevention (18%). (Ref 5)
1. Prevalence of physical restraint use on individual non-ICU rates range from 0 to 123 restraint days/1,000 patient days, with overall rates ranging among types of units from 3.6 (pediatric units) to 49.2 (neuroscience units). (Ref 5)
2. Individual ICU rates range from 0 to 267.9 restraint days/1,000 patient days with overall rates ranging by types from 50.6 (pediatric ICUs) to 267 (neurology and neurosurgery ICUs). (Ref 5)
A. Assess for underlying cause(s) of agitation and cognitive impairment leading to patient-initiated device removal (refer to Chapter 8, Assessing Cognitive Function; Chapter 9, Depression in Older Adults; Chapter 10, Dementia; and Chapter 11, Delirium).1. If abrupt change in perception, attention, or level of consciousness:a. Assess for life-threatening physiologic impairments2. Differential assessment (interdisciplinary)
b. Respiratory, neurologic, fever and sepsis, hypoglycemia and hyperglycemia, alcohol or substance withdrawal, and fluid and electrolyte imbalance
c. Notify physician of change in mental status and compromised physiologic statusB. Assess fall risk: intrinsic, extrinsic, and situational factors (refer to Chapter 15, Fall Prevention: Assessment, Diagnoses, and Intervention Strategies)a. Obtain baseline or premorbid cognitive function from family and caregivers
b. Establish whether the patient has history of dementia or depression
c. Review medications to identify drug–drug interactions, adverse effects
d. Review current laboratory values
C. Assess for medications that may cause drug–drug interactions and adverse drug effects (refer to Chapter 17, Reducing Adverse Drug Events).
A. Interventions to Minimize or Reduce Patient-Initiated Device Removal
1. Disruption of any device
a. Reassess daily to determine whether it is medically possible to discontinue device; try alternative mode of therapy (Ref 6; 7; 8).2. Attempted or actual disruption: ventilator
b. For mild-to-moderate cognitive impairment, explain device and allow patient to feel under nurse’s guidance.
a. Determine underlying cause of behavior for appropriate medical and/or pharmacologic approach3. Attempted or actual disruption: nasogastric tube
b. More secure anchoring
c. Appropriate sedation and analgesia protocol
d. Start with less restrictive means: mitts, elbow extenders
a. If for feeding purposes, consult with nutritionist and speech or occupational therapist for swallow evaluation.4. Attempted or actual disruption: intravenous (IV) lines
b. Consider gastrostomy tube for feeding as appropriate if other measures are ineffective.
c. Anchoring of tube, either by taping techniques or commercial tube holder
d. If restraints are needed, start with least restrictive: mitts, elbow extenders
a. Commercial tube holder for anchoring5. Treatment (Interdisciplinary)
b. Long-sleeved robes, commercial sleeves for arms
c. Consider Hep-Lock and cover with gauze
d. Taping, securement of IV line under gown, sleeves
e. Keep IV bag out of visual field
f. Consider alternative therapy: oral fluids, drugs
a. Treat underlying disorder(s)6. Attempted or actual disruption: bladder catheter
b. Judicious, low dose use of medication if warranted for agitation
c. Communication techniques: low voice, simple commands, reorientation
d. Frequent reassurance and orientation
e. Surveillance and observation: Determine whether family member(s) willing to stay with patient; move patient closer to nurses’ station; perform safety checks more frequently; redeploy staff to provide one-on-one observation if other measure is ineffective
a. Consider intermittent catheterization if appropriate
b. Proper securement, anchoring to leg. Commercial tube holders available
B. Interventions to Reduce Fall Risk
1. Patient-centered interventionsC. Review medications using Beers Criteria for potentially inappropriate medications
a. Supervised, progressive ambulation even in ICUs (Ref 9; 10)2. Organizational interventions (Ref 7)
b. Physical therapist/occupational therapist (PT/OT) consultation: weakened or unsteady gait, trunk weakness, upper arm weakness
c. Provide physical aids in hearing, vision, walking
d. Modify clothing: skidproof slippers, slipper socks, robes no longer than ankle length
e. Bedside commode if impaired or weakened gait
f. Postural hypotension: behavioral recommendations such as ankle pumps, hand clenching, reviewing medications, elevating head of bed
a. Examine pattern of falls on unit (e.g., time of day, day of week)3. Environmental interventions (Ref 11; 12)
b. Examine unit factors that can contribute to falls that can be ameliorated (e.g., report in back room versus walking rounds to improve surveillance)
c. Restructure staff routines to increase number of available staff through- out the day
d. Set and maintain toilet schedules
e. Install electronic alarms for wanderers
f. Consider bed and chair alarms (note: no to little evidence on effectiveness)
g. Moving patient closer to nurse station
h. Increased checks on high-risk patients
a. Keep bed in low, locked position
b. Safety features, such as grab bars, call bells, bed alarms, are in good working order
c. Ensure bedside tables and dressers are in easy reach
d. Clear pathways of hazards
c. Bolster cushions to assist with posture, maintain seat in chair
d. Adequate lighting, especially bathroom at night
e. Furniture to facilitate seating: reclining chairs (note: may be considered restraint in some instances), extended arm rests, high back
1. Patient will remain free of restraintsB. Nursing Staff
2. Physical restraints will be used only as a last resort
1. Will be able to accurately assess patients who are at risk for use of physical restraintC. Organization
2. Will only use physical restraints when less restrictive mechanisms have been determined to be ineffective
3. Will have an increased use of nonrestraint, safety alternatives
1. Will have a decrease in incidence and/or prevalence of restraints
2. Will not have an increase of falls, agitated behavior, and patient-initiated removal of medical devices
A. Monitor restraint incidence comparing benchmark rates over time by unit
B. Document prevalence rate of restraint use on an ongoing basis
C. Focus education on assessment and prevention of delirium and falls
D. Consult with interdisciplinary members to identify additional safety alternatives
A. American Nurses Association. (2001). Position statement: Reduction of patient
restraint and seclusion in health care settings. Retrieved from NursingWorld
B. Maccioli, G. A., Dorman, T., Brown, B. R., Mazuski, J. E., McLean, B. A.,
Rosenbaum, S. H., . . . Society of Critical Care Medicine. (2003). Clini-
cal practice guidelines for the maintenance of patient physical safety in the
intensive care unit: Use of restraining therapies—American College of Criti-
cal Care Medicine Task Force 2001–2002. Critical Care Medicine, 31(11),
From Evidence-Based Geriatric Nursing Protocols for Best Practice, 4th Edition. © Springer Publishing Company, LLC.
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3. Miles, S.H. (1993). Restraints and sudden death. Journal of the American Geriatrics Society, 41(9), 1013. Evidence Level V.
4. HHS, 2007
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Last updated - July 2012