Restraints

Define Restraints

Devices used to limit physical activity of a client or part of body

Define Least Restrictive Restraints

the restraint that permits the most freedom of movement to meet the needs of the client.

Recall facts about a restraint

-NOT apart of routine care.

-Should NOT be used for fall prevention programs.

-ONLY used if there is a threat to physical safety to themselves, staff, others.

-Least restrictive restrains should be used.

-Discontinue ASAP

When should the decision to use a restraint be made?

The decision to use a restraint must be based on a comprehensive, individualized patient assessment. (A family’s request alone doesn’t justify a restraint, but it should prompt a nurse to assess the client and situation.)

What are the two types of behaviors that may require restraints?

• Nonviolent, non–self-destructive behavior

  Restraints would support medical healing.

• Violent or self-destructive behavior

  Restraints would protect client from injury to self or others.

How can restraints support medical healing?

By preventing a client from interfering with treatment or devices (e.g., IV line, respirator, or dressing).

Physical restraints

Any manual method or device that limits a patient's ability to move their arms, legs, body, or head freely.

Chemical restraint

A medication used to control behavior or restrict movement by reducing consciousness or motor function. **Last resort

Environmental Restraints

Involuntary confinement of a client alone in a room or area from which the client is physically prevented from leaving.

When is an environmental restraint used?

Only for violent or self-destructive behavior that poses an immediate threat to the client’s safety or others.

Who approves the use of restraints, and who applies them?

The use of restraints must be approved by a Licensed Independent Practitioner (LIP). Nurses are responsible for applying the restraint after receiving this approval.

What must happen within 1 hour of applying a restraint?

A physician or LIP must perform a face-to-face evaluation of the patient within 1 hour of the restraint being applied.

What are the steps for properly applying restraints?

1. Ensure restraints can be quickly released in case of an emergency.

2. Tie the restraints with a knot that won’t tighten when pulled.

3. Pad bony prominences to prevent skin abrasion.

4. Apply restraints in a way that allows the client to move as freely as possible while maintaining safety.

How long are restraint orders for violent or self-destructive behavior valid?

Restraint orders for violent or self-destructive behavior are valid for 4 hours at a time, up to a total of 24 hours in a 24-hour period.

How often do non-violent restraint orders need to be renewed?

Non-violent restraint orders must be renewed according to hospital policy.

What monitoring is required for restrained and secluded patients?

Continuous visual and audio monitoring is required for restrained and secluded patients.

What are the risks and potential consequences of restraint use on individuals?

Physical risks: Muscle atrophy, bone loss, contractures, pressure ulcers, constipation, decreased appetite.
Psychological effects: Boredom, loneliness, depression, loss of dignity.
Serious outcomes: Death due to strangulation, suffocation, broken necks, burns, pneumonia, and sepsis.
Care neglect: Improper care related to hygiene, skin assessments, hydration, nutritional needs, elimination, pain assessment, and monitoring.

What should be assessed when restraints are applied to a limb?

Assess circulation and sensation.
Remove restraints for skin integrity, ROM, & skin care assessments.

What is the nurse’s role in assessing and using restraints or seclusion?

Nurses assess the need for restraint or seclusion, select the appropriate type based on the client’s condition & behavior, & regularly reassess to ensure safety and that the client’s needs are met.

What is the least restrictive restraint based on the reason it is needed?

The least restrictive restraint should be chosen based on the reason for its use (e.g., falls might warrant a lower level of restraint like bed alarms, dislodging tubes may require more protective restraints).

What are the indications for different types of restraints?

• Physical restraints: To prevent injury or disruption (e.g., preventing falls or self-harm).

• Chemical restraints: To control severe agitation or aggression.

• Environmental restraints: To limit a patient’s movement when other interventions are ineffective.