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When and How to Use Restraints R T S E Learn About Possible Indications for Restraint, Types of Restraints, R F and How to Monitor Patients in Restraint

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When and How to Use Restraints R T S E Learn About Possible Indications for Restraint, Types of Restraints, R F and How to Monitor Patients in Restraint s t n i a When and how to use restraints r t s e Learn about possible indications for restraint, types of restraints, R f and how to monitor patients in restraint. o e s By Gale Springer, RN, MSN, PMHCNS-BC U e f ew things cause as much angst who are violent or aggressive, a for a nurse as placing a patient threatening to hit or striking staff, or S . Fin a restraint, who may feel his banging their head on the wall, who . n or her personal freedom is being need to be stopped from causing o taken away. But in certain situa - further injury to themselves or oth - s tions, restraining a patient is the on - ers. The goal of using such restraints u ly option that ensures the safety of is to keep the patient and staff safe c o the patient and others. in an emergency situation. For ex - F As nurses, we’re ethically obli - ample, a patient responding to hal - gated to ensure the patient’s basic lucinations that commands him or right not to be subjected to inap - her to hurt staff and lunge aggres - propriate restraint use. Restraints sively may need a physical restraint must not be used for coercion, to protect everyone involved. punishment, discipline, or staff con - venience. Improper restraint use Chemical restraint can lead to serious sanctions by the Chemical restraint involves use of state health department, The Joint a drug to restrict a patient’s move - Commission (TJC), or both. Use re - ment or behavior, where the drug straints only to help keep the pa - or dosage used isn’t an approved tient, staff, other patients, and visi - movement (such as when giving an standard of treatment for the pa - tors safe—and only as a last resort. intramuscular injection against the tient’s condition. For example, a patient’s will) is considered a physi - provider may order haloperidol in Categories of restraints cal restraint. A physical restraint a high dosage for a postsurgical pa - Three general categories of re - may be used for either nonviolent, tient who won’t go to sleep. (If the straints exist—physical restraint, nonself-destructive behavior or vio - drug is a standard treatment for the chemical restraint, and seclusion. lent, self-destructive behavior. (See patient’s condition, such as an an - What isn’t a restraint? ) tipsychotic for a patient with psy - Physical restraint Restraints for nonviolent, non - chosis or a ben zodiazepine for a Physical restraint, the most fre - self-destructive behavior . Typically, patient with alco hol-withdrawal quently used type, is a specific these types of physical restraints delirium, and the ordered dosage is intervention or device that prevents are nursing interventions to keep appropriate, it’s not considered a the patient from moving freely or the patient from pulling at tubes, chemical restraint.) Many healthcare restricts normal access to the pa - drains, and lines or to prevent the facilities prohibit use of medications tient’s own body. Physical restraint patient from ambulating when it’s for chemical restraint. may involve: unsafe to do so—in other words, to • applying a wrist, ankle, or waist enhance patient care. For example, Seclusion restraint a restraint used for nonviolent be - With seclusion, a patient is held in a • tucking in a sheet very tightly so havior may be appropriate for a room involuntarily and prevented the patient can’t move patient with an unsteady gait, in - from leaving. Many emergency de - • keeping all side rails up to pre - creasing confusion, agitation, rest - partments and psychiatric units have vent the patient from getting out lessness, and a known history of a seclusion room. Typically, med - of bed dementia, who now has a urinary ical-surgical units don’t have such a • using an enclosure bed. tract infection and keeps pulling room, so this restraint option isn’t Typically, if the patient can easily out his I.V. line. available. Seclusion is used only for remove the device, it doesn’t qualify Restraints for violent, self-destruc - patients who are behaving violently. as a physical restraint. Also, holding tive behavior . These restraints are Use of a physical restraint together a patient in a manner that restricts devices or interventions for patients with seclusion for a patient who’s American Nurse Today Volume 10, Number 1 www.AmericanNurseToday.com 26 F o c What isn’t a restraint? u s The following items aren’t consid - behaving in a violent or self-de - ered restraints: straint. Facility leaders should focus o structive manner requires continu - on reducing restraint use by sup - n • devices used to immobilize a pa - . ous nursing monitoring. tient temporarily during a diag - porting ongoing monitoring and . nostic procedure quality-improvement projects. S a Determining when to use a • orthopedic supportive devices To help ensure a restraint is ap - f • helmets or age-appropriate pro - plied safely, nurses should receive e restraint The patient’s current behavior de - tective equipment, such as hands-on training on safe, appropri - U strollers and cribs. s termines if and when a restraint is ate application of each type of re - e needed. A history of violence or a straint before they’re required to Keeping all side rails up on a bed o previous fall alone isn’t enough to for seizure precautions and placing apply it. Such training also should f support using a restraint. The deci - the patient on a narrow stretcher are occur during orientation and should R sion must be based on a current considered safety interventions, not be reinforced periodically. e s thorough medical and psychosocial restraints. The goal is to use the least re - t r nursing assessment. Sometimes, ad - strictive type of restraint possible, a i dressing the issue that’s underlying and only as a last resort when the n t a patient’s disruptive behavior may the following risks: risk of injury to the patient or oth - s eliminate the need for a restraint. • Placing a restrained patient in a ers is unacceptably high. Consider Also, caregivers must weigh the supine position could increase using restraint only after unsuccess - risks of using a restraint, which aspiration risk. ful use of alternatives, and only as could cause physical or psychologi - • Placing a restrained patient in a long as the unsafe situation occurs. cal trauma, against the risk of not prone position could increase Remember—restraint use is an ex - using it, which could potentially re - suffocation risk. ceptional event and shouldn’t be a sult in the patient harming him- or • Using an above-the-neck vest part of a routine protocol. • herself or others. Input from the that’s not secured properly may entire care team can help the increase strangulation risk if the Selected references provider decide whether to use a patient slips through the side American Psychiatric Nurses Association. restraint. rails. APNA Position Statement on the Use of Seclusion and Restraint. Original 2000; re - • A restraint may cause further vised 2007; revised 2014. www.apna.org/i4a/ Alternatives to restraints psychological trauma or resurfac - pages/index.cfm?pageid=3728. Accessed Use restraints only as a last resort, ing of traumatic memories. November 4, 2014. after attempting or exploring alter - To help reduce these risks, make American Psychiatric Nurses Association. natives. Alternatives include having sure a physical restraint is applied Seclusion & Restraint Standards of Practice. staff or a family member sit with safely and appropriately. With all May 2000; Revised May 2007; revised April the patient, using distraction or de- types of restraints, monitor and as - 2014. www.apna.org/i4a/pages/index.cfm? pageid=3730. Accessed November 4, 2014. escalation strategies, offering reassur - sess the patient frequently. To re - ance, using bed or chair alarms, and lieve the patient’s fear of the re - Federal Register. Part II; Department of Health and Human Services, Centers for administering certain medications. straint, provide gentle reassurance, Medicare & Medicaid Services; Medicare and If appropriate alternatives have support, and frequent contact. Mon - Medicaid Programs. 42 CFR Part 482; Medi - been attempted or considered but itor vital signs (pulse, respiration, care and Medicaid Programs; Hospital Condi - have proven insufficient or ineffec - blood pressure, and oxygen satura - tions of Participation: Patients’ Rights; Final tive or are deemed potentially un - tion) to help determine how the Rule. December 8, 2006. www.cms.gov/ Regulations-and-Guidance/Legislation/ successful, restraint may be appro - patient is responding to the re - CFCsAndCoPs/downloads/finalpatientrights priate. A provider order must be straint. rule.pdf. Accessed November 26, 2014. obtained for patient restraint. Be Joint Commission, The. Hospital Accredita - sure to update and revise the care Changing the culture tion Standards. Provision of Care, Treatment plan for a restrained patient to help The American Psychiatric Nurses and Services. Standards PC.03.05.01 through find ways to reduce the restraint Association’s position statement on PC.03.05.19. 2010. period and prevent further restraint the use of restraint suggests a unit’s Joint Commission, The. Sentinel Event Alert. episodes. philosophy on restraint use can in - Issue 8, November 18, 1998. Preventing Re - fluence how many patients are straint Deaths. www.jointcommission.org/ assets/1/18/SEA_8.pdf. Accessed November Reducing restraint risks placed in restraints. Interacting with 4, 2014. Restraints can cause injury and patients in a positive, calm, respect - even death. In 1998, TJC issued a ful, and collaborative manner and Gale Springer is a mental health clinical nurse sentinel event alert on preventing intervening early when conflict aris - specialist at the Providence Regional Medical in restraint deaths, which identified es can diminish the need for re - Everett, Washington.
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