The Safe

Use of
Patient
Restraints
Safe Use of Patient Restraint
Definitions
 Any method of physically restricting a person’s freedom
of movement, physical activity or normal access to his or
Restraint
Restraintis:
is: her body.
 Patient immobilization that is a normal component of
a procedure is not considered restraint.

 A manual method, physical or mechanical device,

Medical
Medical material, or equipment that immobilizes or reduces
(Non-behavioral)
(Non-behavioral) the ability of a patient to move his or her arms, legs,
Restraint:
Restraint: body or head freely to protect the patient.

 The restriction of patient movement in response to

Behavioral
BehavioralHealth
Health severely aggressive, destructive, violent or suicidal
Restraint:
Restraint: behaviors that place the patient or others in
imminent danger.

 Forensic restriction used by law enforcement for

Restraint
Restraintis
isnot:
not: security purposes.

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Safe Use of Patient Restraint
Side Rails – Restraint or Not?

Click the answer

The use of side rails may pose risk to patient’s safety. Clinical judgment
determines whether or not the use of side rails is considered restraints.

 Raising all four side rails to prevent the Not

Restraint
patient from exiting the bed Restraint

 Four or full side rails to prevent the

patient from rolling our of bed Not
 Patient actively seizing Restraint
Restraint
 Post-op patient recovering from
anesthesia
 Patient on a gurney
Not
 Raising fewer than four side rails (when Restraint
Restraint
bed has more than two)

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Safe Use of Patient Restraint
Alternatives to Restraints

Restraints must never be used as a

substitute for good nursing care or staff
convenience. Restrained patients
require MORE CARE and INCREASED
DOCUMENTATION.

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Safe Use of Patient Restraint
Patient Assessment
To Determine the NEED for RESTRAINT USE:
 Attempt Alternatives
 Use safe, effective and least restrictive method of restraint
 Clinical Justification based on observed patient actions or behaviors
 Interference with therapy or patient care
 Pulling tubes
 Picking at wounds
 Removing dressings
 Activity or thoughts with a reasonable probability of harm to self
 Wandering
 Unsteady gait (high risk for falls)
 Suicidal
 Activity or thoughts with a reasonable probability of harm to others
 Confused patient striking out at others
 Homicidal attempt or talks about killing/harming someone
 Violent patient in alcohol or drug withdrawal

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Safe Use of Patient Restraint
Restraint Orders
Restraints will be initiated or continued on the order of a
treating physician. The order must meet the following criteria:

 Reason for the restraint.

 Be time specific
 Include type of restraint.
 Reflect least restrictive manner.
 Be in accordance with safe and
appropriate restraining techniques.
 Be discontinued at the earliest point
in time.
 Never be written as a standing order or
PRN.

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Safe Use of Patient Restraint
Medical vs. Behavior Health Orders

Medical Behavioral Health

Time 24 hours 4 hours 18yrs or older
Limitations 2 hours 9-17yrs
1 hour 8yrs and under
RN Every 2 hours or sooner Continuously document every 15
Assessment mins

MD Every 24 hours prior to writing Every 8 hours 18yrs or older

Assessment new order Every 4 hours 17yrs and younger

Emergency Notify MD ASAP, within 1 hour Notify MD ASAP, within 1 hour MD

Application by MD must provide telephone or must assess patient and write order.
RN written order. MD must assess
patient ASAP, within 24 hours.
Restraint Requires new order, and MD assessment. -Even if original order has not
Reapplication exceeded its “time limit.” This does not include the temporary release that
occurs for patient assessment.

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Safe Use of Patient Restraint
Application of Restraint

 Must have quick-release application

 Use the correct size
 Note “front” and “back” of device
 Secure to bed springs or frame, not mattress or
bed rails
 Do not apply one-sided restraints
 Do not restrain feet while their hands are free
 Place call light and necessary items within
reach
 Do not position pregnant patients 20
weeks or greater on their back, nor should
chest or waist restraints be used

Restraints should be discontinued as soon as it

is no longer indicated by the patient’s actions.

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Safe Use of Patient Restraint
Documentation

Patient basic needs must be attended to,

including:
 Nutrition
 Hygiene
 Circulation
 Elimination
 Range of motion
 Hydration

Document the following in Patient’s record in KP

Health Connect:
 Physician’s order
 Initial assessment by the RN and 1 hour in-person evaluation by MD
 Patient’s actions or condition that indicated the initial and continued use of restraint
 Less restrictive alternatives considered
 Patient monitoring and response to interventions used
 Significant changes in the patient’s condition
 Reassessment/observations, discontinuation of restraints
 Education and information about restraints provided to the patient and family

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 Safe Use of Patient Restraint
Observation & Monitoring
Assessment will include:
 The patient’s physical and emotional well-being .
 Comfort and care needs, including hygiene, elimination, hydration, nutrition
 The appropriateness of restraint application, removal, and
reapplication
 Assessment of the need for continuing or discontinuing restraint

Patient death associated with

restraint use:
 RN will immediately notify Nurse
Manager or House Supervisor
 Complete a UOR (unusual occurrence
report)
 Hospitals AR&L Director or designee will
notify CMS

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 Safe Use of Patient Restraint

“HEY! I THINK HE JUST MOVED!

ADD ONE MORE!”
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 Safe Use of Patient Restraint

TYPES OF
RESTRAINTS

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 Safe Use of Patient Restraint
Physical restraints

Physical restraints limit

a client’s movement.

Eg: table fixed to a chair

or a bed rail that cannot
be opened by the client.

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 Safe Use of Patient Restraint
Environmental restraints

Environmental restraints
control a client’s
mobility.

Eg:a secure unit or

garden, seclusion

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 Safe Use of Patient Restraint
Chemical Restrain

Chemical restraints are any form of

psychoactive medication used not to treat
illness, but to intentionally inhibit a
particular behaviour or movement.

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 Safe Use of Patient Restraint
TYPES OF PHYSICAL RESTRAINTS

1. Mummy restraint

2. Elbow restraint

3. Extremity restraint

4. Abdominal restraint

5. Jacket restraint

6. Mitten or finger restraint

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 Safe Use of Patient Restraint

Mummy restraint
It is a short-term type of restraint used on infants
and small children during examinations and
treatment of head and neck. It is used to
immobilize the arms and legs of the child for a brief
period of time.

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 Safe Use of Patient Restraint

Elbow restraint
This restraint is used to prevent flexion of the elbow
and to hold the elbow in an extended position so
that the infant cannot reach the face.
plastic elbow restraint ,elbow cuff and well padded
wooden splint can also be used

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 Safe Use of Patient Restraint
Extremity restraint
It is used to immobilize one or more extremities. One type of
extremity restraint is clove-hitch restraint which is done
with gauze bandage strip (2 inches wide) making figure-of-
eight.
The end of the gauze to be tied to the frame of the crib/bed.
This restraint should be used with padding of wrist or ankle.
Precautions to be taken to prevent tightening of the bandage

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 Safe Use of Patient Restraint
Abdominal restraint
This restraint helps to hold the infant in a supine position
on the bed

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 Safe Use of Patient Restraint
Mitten or finger restraint
Mitts are used for infants to prevent self-injury by
hands in case of burns, facial injury or
operations, eczema of the face or body.
Mitten can be made wrapping the child's hands in
gauze or with a little bag putting over the baby's
hand and tie it on at the wrist.

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 Safe Use of Patient Restraint

POTENTIAL RISKS AND SIDE EFFECTS OF

RESTRAINT USE:
1. Psychological/Emotional:
 Increased agitation &hostility
 Feelings of humiliation, loss of dignity
 Increased confusion
 Fear

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 Safe Use of Patient Restraint

2. Physical:
 Pressure ulcers, skin
trauma
 Decreased muscle mass,
tone, strength, endurance
 contractures, loss of
balance, increased risk of falls
 Reduced heart and lung
capacity

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 Safe Use of Patient Restraint

2. Physical:
 Physical discomfort,
increased pain
 Increased constipation,
increased risk of fecal
impaction
 Increased incontinence
and urinary stasis
 Obstructed and
restricted circulation
 Reduced appetite,
Dehydration
 Death
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 Safe Use of Patient Restraint
Restraint guidelines:

Doctors order
Informed consent
Follow proper technique
Least restrictive
Pad boney prominence
Maintain Good body alignment

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 Safe Use of Patient Restraint Restraint Orders
Situational Medical Behavioral
-Obtain written or verbal -May apply in emergency,
* Initiation of but get doctor order with in
order within 12 hours of
1 hour. Dr must do face-to-
initiation, physician exam face assessment within 1
Restraints within 24 hours. hour of restraint initiation.
(ALWAYS
after - In accordance with
following limits up to a total
alternatives - Every 24 hours of 24 hours:
tried)
- 4 hrs for adults 18 and up.

* Renewing -2 hrs for children

9-17 yrs of age.
Order
-1 hr for children
nine and under.

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 Safe Use of Patient Restraint

Roles of Health
Care Professional

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 Safe Use of Patient Restraint

Monitor a patient in restraint every 15 minutes

for:

• Signs of injury
• Circulation and
range of motion
• Comfort
• Readiness for
discontinuation of
restraint

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 Safe Use of Patient Restraint

DOCUMENTATION IN EVERY 2 HOURS FOR:

1. Release the patient, turn
and position
2. Institute a trial of restraint
release
3. Hydration and nutrition
needs
4. Elimination needs
5. Comfort and repositioning
needs

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 Safe Use of Patient Restraint

RESPONSIBILITIES..

 Assess the client’s behaviour and the need

for restraint & applies as a last resort.
 Get written order and obtain consent as per
hospital policy
 Must communicates with the client and family
members
 Complies with institutional policies and
guidelines for restraint
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 Safe Use of Patient Restraint

RESPONSIBILITIES ….

 Explain the client the reason for the restraint

and cooperation
 Arrange adequate assistance from
competent staff before carrying out the
restraint procedure
 Apply the least restrictive, reasonable and
appropriate devices to restrain the client.
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 Safe Use of Patient Restraint

Arrange the client under restraint in a place for

easy, close and regular observation
particular attention to his/her safety, comfort,
dignity, privacy and physical and mental
conditions.
attend the client’s biological and psychosocial
needs during restraint at regular intervals.
 reviews the restraint regularly, or according to
institutional policies.
consider the earliest possible discontinuation of
restraint.
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 Safe Use of Patient Restraint

document the use of restraint for record

and inspection purposes.
Explore interventions, practices and
alternatives to minimize the use of restraint.
Nurse must maintain his/her competence
in the appropriate and effective use of
restraint through continuous education.

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 Safe Use of Patient Restraint

FACTS

“ Restraints may be used to protect a

patient from a greater risk of harm,
although evidence is lacking to
support the effectiveness of using
physical restraints to prevent
treatment interference.”

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 Safe Use of Patient Restraint

FACTS

Studies have repeatedly demonstrated that there

is no increase in serious injuries when physical
restraints are replaced with other less restrictive
safety measures based on the individual’s
specific needs.
Studies have also demonstrated a dramatic
decrease in behavior problems when restraints
are removed.
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 Safe Use of Patient Restraint

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