Use of Physical Restraints with Elderly Patients

Rosanne M. Radziewicz, RN PMHCNS-BC, Shelly Amato, MSN RN CRRN, Cheryl Bradas, BSN RN, Lorraine C. Mion, PhD, RN, FAAN

Goal:

Minimize use of physical restraint in acute care settings

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:

• New onset or increased agitation or confusion
• Delirium
• New onset pressure ulcers
• New onset urinary incontinence
• Constipation, fecal impaction
• Bruising, skin tears, or changes in skin integrity
• Pneumonia
• Nerve injury
• Musculoskeletal injury: strains, fractures, contractures, decreased range of motion
• Physical deconditioning and functional decline
• Strangulation/asphyxiation resulting in encephalopathy or death

Definitions:

Physical Restraint: any manual method, physical or mechanical device, or equipment that immobilizes or reduces the ability of the person to move his or her arms, legs, body or head freely (Centers for Medicare and Medicaid, Effective 1-1-08, §482.13(e). Examples from the Interpretive Guidelines (§482.13(e)(1)(i)(A-C) include waist, vest, wrist or leg restraints, hand mitts, chairs with tabletops, full siderails, 'net beds' or 'enclosed beds', 'freedom' elbow splints, or tucking a patient's sheets so tightly that the patient cannot move.

Assessment/ Screening Tools (see PDF files on right side of page)

If restraints are under consideration, screen cognitive and physical status for conditions commonly associated with restraints:

• Delirium: Confusion Assessment Method (CAM)
• Assessing and managing delirium superimposed on dementia
• Cognitive function: Mental Status Assessment of Older Adults: The Mini Cog
• Fall risk assessment

Provide plan for surveillance/supervision that may include:

• Room/position closer to staff
• Periodic checks (e.g., every 15 minutes)

Assess environment:

• Free of hazards such as poorly fitted mattresses and siderails
• Cluttered pathways
• Adequate lighting

Conduct Further Assessment and search for Alternatives to:

• Prevent Falls/Injury
• Maintain Therapy
• Manage Behaviors

Prevent Falls/Injury: Alternatives to Physical Restraints

* - Activity Kit from the just released Try This: Therapeutic Activity Kit (see PDF file on right of this page):

An activity kit that is a carefully selected collection of tactile, auditory, and visual items will provide solace, an opportunity for emotional expression, and relief from loneliness and boredom. Added benefits include enhanced cognitive integration, perceptual processing, and neuromuscular strength. The activity kit includes a wide range of items that are commonly used to provide diversion, such as games, audiotapes, and nontoxic art supplies. In addition, items such as pieces of textured fabric, cloth to fold, tools, and key and lock boards, are included for the person with more advanced dementia.

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 alternative routes for treatment?

• E.g., replace peripheral intravenous line with heplock

Manage Behaviors, including wandering: Alternatives to Physical Restraints
See dementia stat for agitation.

Assess : Typical baseline (pre-admission) behavior

• Obtain baseline behavior from primary caregiver
• Obtain common techniques used by primary caregiver and incorporate as part of plan of care

If new, escalating or different behavior from baseline:

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
• Educate patient/family on need for restraint use and plan of care

Parameters of Assessment

• Baseline and current cognitive state, determine if new onset delirium
• Physical function: ability to transfer and walk. See Function topic.
• 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 Falls Topic.

Nursing Care Strategies

Prevention

• Develop a nursing plan tailored to the patient's presenting problem(s) and risk factors
• Consider alternative interventions
• After consultation with physician, 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 (e.g., hand mitts rather than wrist restraints)
  • Ensure proper sizing and fit of restraint
  • Reassess the patient's response at least every 2 hours
  • Release the restraint at a minimum every two hours
  • Renew orders every calendar day 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 staff 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.

Last updated - February 2009