Restraints and Restraint Use

OBJECTIVES:

At the end of this class, you will be able to:

  1. Define what a physical restraint is.
  2. Details ways that that you can help with the goal of a restraint free hospital or nursing home.
  3. List some of the most common reasons that restraints are used.
  4. Detail things that you can do to prevent the use of restraints.
  5. Observe, monitor and care for restrained patients and residents.
  6. Report things that make a person at risk for harm to self and others.
  7. Describe why restraints must be placed on a person in the correct and safe manner.

INTRODUCTION


Doctors and some nurses have to make a very difficult decision to restrain a person. We do not want to use restraints, but sometimes it is necessary. We do not use a lot of restraints because restraints prevent a person from being able to move freely. They may also stop a person from being able to take care of themself. For example, if a person is restrained in bed with a vest they are not able to get out of bed and go to the bathroom whenever they want to. They will have to depend on the nursing assistant and others for this need and other basic needs. If a person has a restraint on their arm they may not be able to brush their teeth or even comb their own hair. Again, this kind of care has to be given by the nursing assistant or other members of the healthcare team.

All restraints have to be very necessary before they are used. Before they are used many other things have to be tried to keep the person safe. These things are called preventive or alternative measures. These measures prevent the use of restraints for many patients and residents. These measures are an alternative to restraints. Preventive and alternative measures that you can use are described below in this class.

When these preventive things do not work and the person is still in danger of hurting themselves or other people, a restraint is sometimes used. They are NEVER used to make our job easier. They are NOT for staff convenience. They are also NEVER used to punish a person. They are only used to protect a person from harm.



When restraints are used, nursing assistants and other members of the team must continue to maintain the person’s right to dignity and give the person the best possible care. It is also very important to make sure that the person is safe and not in danger of getting hurt while they have a restraint on.

A doctor’s order is necessary before a restraint is used. Some nurses can also order them. A nursing assistant can NEVER apply a restraint unless they are told to do so by the nurse.



Nursing assistants, and others, who put on restraints that are ordered by a doctor must be taught about the correct and safe way to put them on and take them off. If you have not been shown how to put a specific restraint on or take it off, do not do it. Ask the nurse to teach you. When the nurse tells you that you are competent to put on and take off a restraint, you can then do it without the nurse in the room with you.


If you forget how to do it after you are taught, tell the nurse so that you can be shown how to do it again. NEVER put a restraint on unless you are sure that you are doing it in the correct way. You can cause the person serious harm and even death if you do not do it in the correct way.

WHAT IS A RESTRAINT?

A restraint is anything that prevents a person from complete freedom to move about. Restraints can be physical and chemical. A chemical restraint is a medicine, or drug, that makes the person very sleepy and not able to move about with freedom.

A physical restraint is any device that is placed on or near a person that stops them from moving about freely.

Some examples of physical restraints are:

  • a vest,
  • soft padded wrist restraints,
  • side rails that are used to stop a person from getting out of bed,
  • a sheet tied around a person to keep them from falling out of a chair
  • tight sheets to prevent a person from getting up out of their bed and
  • a mitten to stop a person from pulling on their urinary catheter.



Special procedures, including observation of the person, must be done when a person is restrained except for certain situations when a device is NOT considered a restraint. The following are NOT considered a restraint needing special monitoring and care when the device is:

  • a usual part of care. For example, when an IV board is used to keep an IV line open for fluids we do not have to follow special restraint procedures;
  • used to give the patient or resident postural support or to help the person to maintain normal body alignment. For example, a splint or brace does not require special restraint procedures even though it limits the person’s movement and freedom;
  • used to keep the person free of injury as a result of a physical problem. Some examples include the use of the top side rails to help a weak person to turn from side to side when they are in bed and padded side rails for a person that may get injured from a seizure;


  • put on by the police. For example, special restraint procedures are not needed when hand cuffs are used by the police on criminals that are in the hospital or nursing home.

A RESTRAINT FREE ENVIRONMENT

The safety of our patients and residents is VERY important. We must make sure that all of our patients and residents are safe and free of harm. When a person is in danger of getting hurt or hurting others, we try to do special preventive things, other than using restraints right away, in order to keep them safe. We have a goal to keep people safe without restraints, but this is not always possible when the only way to keep a person safe is to use a restraint.



Yes, we try to have a restraint free hospital or nursing home but this is not always possible. We must balance the need for safety with the need of the person to be free and without a restraint whenever we can, however.

THE MOST COMMON REASONS FOR RESTRAINTS

Restraints are most often used in hospitals and nursing homes to:

  • prevent patients and residents from falling;
  • stop a person from pulling out a necessary tube, line or catheter such as an IV line and a urinary drainage catheter;
  • protect patients, residents, family members, staff and visitors from the violent actions of a patient or resident. For example, a patient that is punching other patients or staff may have to be restrained unless other measures can stop this dangerous behavior;
  • help a confused or disoriented person to get medical help when they are not cooperating. For example, a person that comes to the emergency with a drug overdose may be out of control and in need of restraint so that they can get medical help.


  • or uncooperative patient or resident to be adequately assessed while under the influence of drugs or alcohol; and
  • prevent a person from leaving the hospital or nursing home when they may kill or seriously hurt others or themselves. For example, a person at risk for suicide may need a restraint to prevent self harm and even death.


THE ROLE OF NURSES AND NURSING ASSISTANTS

The registered nurse (RN):

  • assesses the patient or resident and their current condition,
  • plans for and provides preventive actions that can keep the person safe without the use of restraints,
  • begins restraints without a doctor’s order in emergency situations, and
  • assigns the care of patients and residents who have and do not have a restraint.

Nursing assistants:

  • provide care to patients and residents with restraints,
  • put on and take off restraints, as assigned,
  • observe and report the patient’s and resident’s condition and their responses to restraints.

THINGS THAT MAY PREVENT THE USE OF RESTRAINTS

We must all work together in order to prevent the use of restraints, unless they are absolutely necessary. Preventive actions can include such things as when the doctor changes an order and a person can now get oral feedings rather than a tube feeding when they are pulling on their feeding tube and able to eat by mouth.

Other things that we can do to keep the person safe without restraints include:

Closer Monitoring of the Patient or Resident

  • Special sitters and family members can sometimes help.
  • Observe patients and residents at risk for harm more often. Increase the frequency of your rounds. See them every 15 minutes instead of every hour.
  • Suggest that the person be moved to a room or bed that is more visible to the staff.

Making the Area Safer for the Patient or Resident

  • A dim night-light in a patient’s room may help to safely walk to the bathroom without falling.

  • Putting a bedside commode close to the bed may prevent falls for some patients and residents.
  • Keeping a patient’s or resident’s urinal in close reach may prevent falls for some patients.
  • Having the call light close to the person or pinned to their gown will allow the person to call for help when they need it.
  • Teach the patient or resident how to use the call bell.
  • Remind the person to call for help when they need it.
  • Answer call lights right away. Do NOT delay.
  • Remind the patient or resident at risk for falls to use the grab rails in the hallways and bathrooms.


  • Always keep the bed in the lowest position possible. If a person falls from their bed in the low position they will not have as great an injury as they would with the bed in the high position.
  • Keep all bed gatches under the bed so that they will not cause a person to trip over them.
  • Keep the area safe and without any hazards.

Other things that you may use to prevent falls and wandering are a bed and/or chair alarm. You may also care for a person that has a low bed and/or a gym mat in place. Low beds and mats next to the bed will lower the amount of injury when a person falls out of their bed.

Changing the Way We Give Care to the Patient or Resident

  • Know your patient or resident and their usual routines. Know what they prefer. Giving care that meets the person’s needs, desires and routines can help to prevent confusion, agitation, and fighting care or treatment. Knowing your patients and residents can prevent the need for restraints for disturbed and violent behavior.


  • Try to give care to the same patients or residents every day whenever this is possible. These patients or residents will get to know you and you will get to know them and their needs much better. Many patients and residents react with disturbed behavior when they do not know the nursing assistant that is giving them care.
  • Use toileting routines, such as bowel and bladder retraining and cues to prevent falls among those who are incontinent of urine and/or feces and among those who are at risk for falls while trying to get to the bathroom without help.
  • If your patient or resident needs eyeglasses, hearing aids, canes, walkers and other things to make up for a physical problem, encourage them to use it. Falls can be prevented with canes, walkers and eyeglasses. Confusion and disturbed behavior may be prevented when a person can see and hear you and what is going on around them.
  • Try to redirect the patient or resident if they are trying to pull on or pull out a catheter, tube or line. A long sleeve gown or robe over an IV line may prevent a person from pulling it out.

Reality Orientation and Other Interventions

Some of the things that you can do to prevent a person from the risk of violent injury to self and/or others without using a restraint include:

  • Distracting and re-directing the patient or resident away from things that trigger, or cause, problem behavior(s). For example, if the patient has hit another patient several times, keep these two patients in different areas. If a person becomes hostile and upset when they sit in a certain area in the patient dining room, let them choose another place to sit for meals.



  • Involving the patient or resident in care. Explain all care to the person in a way that they can understand. This can lower a person’s fears and anxiety.
  • Listen to the patient’s or resident’s feelings, concerns and fears
  • Verbally redirect the patient or resident when they are doing things that are unsafe. Give them constant reminders. Reward them with praise when they change their behavior.
  • Decrease confusion by giving the person links to reality. Watching television, listening to a radio, and having a calendar and clock often help to decrease confusion.


  • Help the person to relax. Try warm baths, warm drinks, such as tea or warm milk, and a back massage.
  • Give the person a chance to rest and a time for social and physical activity. Exercise groups, ambulation with assistance, when needed, group activities to socialize and talk with others, music, games, arts and crafts often help to prevent acting out behavior.


  • Allowing as much independence in the activities of daily living (ADL), as possible

WHAT YOU MUST DO WHEN RESTRAINTS ARE USED

There are a large number of restraints that can be used. When restraints are needed, the LEAST restrictive of all must be used. The one that keeps the person safe and takes away the LEAST amount of freedom is the restraint that should be used and ordered by the doctor. A restraint that takes away more freedom of movement than needed to protect the person from harm should NEVER BE USED.



Restraints are started on a patient with an order from a doctor and also, in some very severe emergencies for a short time, by a nurse without the order from a doctor. For example, if a patient begins to hit and punch staff and other patients and nothing can stop it, a registered nurse can restrain the violent patient so that they do not bring serious injury to other people.

THE SAFE APPLICATION OF RESTRAINTS

You must follow your hospital or nursing home procedure on how to apply a restraint exactly! Do NOT do it in any other manner. You must follow the procedure without any changes.

Restraints should never be put on:

  • an arm with an arterial line,
  • skin that is burned, sore or injured in any way,
  • a broken arm or leg.


Restraints should never be tied to a part of a bed or chair that is moveable. For example, a vest restraint should NEVER be tied to a side rail or the bottom of the bed that moves when the head of the bed is moved up.

All nursing assistants, patient care technicians and other healthcare workers that put on a restraint and care for the patient in restraints must have education about the correct way to put a restraint on and the things that must be done for the patient or resident once they are restrained. If you have not been given this education or you are unsure of the way to put a restraint and care for the patient or resident, ask the charge nurse to teach you. Do NOT put a restraint on a patient or resident if you are unsure of the correct procedure. Do NOT care for a person with a restraint if you are unsure of the correct procedure.



When you put a restraint on a patient or resident:

  • Tell the patient or resident and the family member what you will be doing and why you are doing it. For example, you can say, “Mr. Brown, I am going to put this padded, soft restraint on your left wrist because you are trying to pull out your IV on your right arm and this IV is needed so that you can get your medicines.”
  • Tell the patient or resident and the family member what you, and other people, such as the nurse, will do to make sure that the person stays safe and cared for.

Immediately report to the nurse if the patient, resident or family member says that they do not want a restraint to be used. If the person cannot be left alone without the restraint, put the nurse call light on so someone can get the nurse or stay with the person until you have had a chance to talk to the nurse about whether or not the restraint must still be used when a patient, resident or family member tells you that they do not want the restraint. Tell the person that you will be speaking to the nurse if they say that they do not want the restraint to be used. For example, you should say, “Mrs. Brown, let me speak to the nurse about this restraint.”


OBSERVING THE PATIENT OR RESIDENT THAT IS RESTRAINED

All patients or residents that are restrained must be observed very often. At times you may have to stay in the room with the patient or resident. Other times, you may be asked to look at the patient every 5, 10 or 15 minutes depending on the patient or resident and their condition. If the person is stable and safe you may be asked by the nurse to observe the person every hour or so.

When you monitor the patient or resident that is restrained, you must look at the person and observe their:

  • Physical State. Is the person safe and not in danger of harm from the restraint? Is the person breathing? What is the person’s skin color? Pink? Blue? Gray? Is the blood circulation good? Is the restraint too tight? Is the person in pain? Is the person comfortable? Does the person have to go to the bathroom? Is the person hungry? Is the patient or resident clean and dry?
  • Mental State. Is the person confused? Is the patient or resident angry, upset or agitated? Is the person afraid or fearful?
  • Response to the Restraint. Is the patient or resident still in danger of harm with the restraint on? Has the person gotten better and perhaps no longer in need of the restraint? Does it seem that the person is no longer confused and, therefore, not in need of a restraint to stop the patient or resident from pulling their IV out, for example?

All monitoring of a person with a restraint must be documented. Some hospitals and nursing homes use a restraint flow sheet. Others may want you to write a note in the progress notes. Check your hospital or nursing home procedures for documentation during restraint or ask the nurse where this special monitoring is documented if you are not sure.

You must immediately report to the nurse if you have noticed that something is not normal or correct while you are monitoring the person in restraints. If the person is in danger, fix the problem if you can. If you cannot fix the problem, call for help. Do NOT leave the person that is in danger alone. Stay with the person and call for help.

TAKING CARE OF THE PATIENT OR RESIDENT THAT IS RESTRAINED

Patients and residents that have a restraint must be given the best care possible. They also need to be cared for more often than patients and residents without restraints. Care is given at LEAST every 2 hours and more often when the person needs it.



Some of the care that you will give to the person in restraints includes:

  • Perform range of motion to the restrained body parts unless the person is sleeping
  • Turn and positioning the person if they are not able to turn and position themself
  • Provide skin care as needed.
  • Clean, bathe and dry the patient or resident if they are wet or soiled.
  • Take care of the person’s toileting, fluid and nutrition needs.
  • Make sure that the person is comfortable and not in distress.
  • Insure the person’s dignity and freedom from pain and anxiety.
  • Give the person as much independence as possible.


MAINTAINING DIGNITY

When a patient or resident is restrained, nursing assistants and all other healthcare workers must:

  • Give the person respect during all care and communication.
  • Keep the patient or resident and their room safe and clean.
  • Give the person privacy.
  • Keep the person comfortable.
  • Let the patient or resident participate in care as much as possible.
  • Tell the patient or resident and family members that care and monitoring will be done often.
  • Tell the patient or resident and/or family members that the restraint is being used to keep the person safe NOT for punishment or staff convenience


WHAT TO DO WHEN RESTRAINTS ARE STOPPED

Restraints are stopped when the doctor’s order expires and whenever the patient behavior gets better to the point that the restraint is no longer needed. Restraints to prevent a person from pulling out their medical tube, line, catheter or other treatment are stopped when the tube, line or catheter is taken out. A person that is no longer violent is not in need of a restraint. This restraint would then be stopped by the doctor or the nurse in charge.

At times you may be asked by the nurse to continue observing the patient or resident very closely even after the restraints have been stopped. This is sometimes done for a period of time just to make sure that the person stays safe and free from harm after the restraints are taken off.

SOME PROBLEMS THAT CAN OCCUR AS A RESULT OF RESTRAINTS



Restraints can cause problems, especially when:

  • they are NOT put on in the right way,
  • when the patient or resident is NOT observed properly and
  • when the person is NOT given the proper care.

Some of the problems that can happen with restraints are:

  • Bruises,
  • Abrasions,
  • Skin tears,
  • Choking,
  • Strangulation,
  • Death, and
  • Mental distress.

Nursing assistants and other healthcare providers, such a patient care technicians, rehabilitation aides, and restorative care aides, can prevent these problems by doing the following, as assigned by the charge nurse:

  • Providing care,
  • Monitoring and observing the patient or resident,
  • Reporting any problems to the nurse IMMEDIATELY, and
  • Putting on the restraint(s) in the correct manner.

GETTING TRAINING AND EDUCATION ABOUT RESTRAINTS AND RESTRAINT USE


Your hospital or nursing home has given you education and training about restraints and restraint use when you began to work there. Your hospital or nursing home must also make sure that you get more education every once in a while to make sure that you still remember about how to put a restraint on and how to follow the procedures about restraints and restraint use. Some of the things that you will learn include the proper and safe way to apply restraints, patient monitoring, the patient care that must be given during restraint episodes, patient rights and patient dignity.

PERFORMANCE MEASUREMENT

The use of restraints has both benefits and risks. Your hospital or nursing home collects data to make sure that restraints are used only when necessary and to make sure that they are used correctly when they are needed. The goal of this performance improvement activity is to find out how well your hospital or nursing home has been able to improve the quality of life and care for our patients and residents while insuring their safety and freedom from injury while under our care.




Performance measurement data is looked at for all restraint episodes. This data includes:

  • the patient or resident name
  • the patient or resident age,
  • the patient’s or resident’s diagnosis
  • the specific patient or resident behavior that made the restraint necessary
  • the nurse’s name that started the use of the restraint in an emergency or by using a protocol for restraint use (Many hospitals and nursing homes have protocols to prevent falls, disturbed behavior and the taking out of tubes, lines and catheters.
  • the name of the doctor or nurse practitioner that wrote the restraint order

SUMMARY

All hospitals and nursing homes try to stay restraint free, however, this is not always possible. There are times that restraints are needed to keep the patient or resident safe and free from harm.

Nursing assistants must know how to put a restraint on safely, and how to monitor and care for the person that is restrained.

REFERENCES

Berman, Audrey, Shirlee Snyder, Barbara Kozier and Glenora Erb. (2010). Kozier & Erb's Fundamentals of Nursing: Concepts, Process, and Practice. 8th Edition. Pearson Prentice Hall.

Nettina, Sandra M. (2009). The Lippincott Manual of Nursing Practice. 7th Ed. Lippincott, Williams and Wilkins.

Wold, Gloria Hoffmann. (2008). Basic Geriatric Nursing. Elsevier Mosby.



Copyright 2010 Alene Burke
 



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