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PHYSICAL RESTRAINTS

The information in this "Want to know more" section is organized according to the following major components of the NURSING PROCESS:

• Goal
• Background
• Definitions
• Assessment/Screening Tools
• Nursing Care Strategies/Treatment/Management

Goal

Minimize use of physical restraint except in emergent and critical care situations.

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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

• Increased agitation or confusion
• New-onset pressure ulcers
• Pneumonia
• Nerve injury
• Strangulation/asphyxiation

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Definitions

Physical Restraint: any physical or mechanical device, material or equipment that the individual cannot remove easily and that restricts freedom of movement or access to one's body (HCFA, 1999). Examples include posey vests, wrist or leg restraints, hand mitts, chairs with tabletops, and full siderails. Medications such as sedatives and hypnotics may be considered chemical restraints (and are regulated in nursing homes).

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Assessment/Screening Tools

If restraints are under consideratioan, Screen, for need for further assessment:

• Cognitive Function: Try This: Mini Mental Status Exam -MMSE
• Delirium: Try This: Confusion Assessment Method -CAM
• Fall Risk Assessment: Try This: Fall Risk Assessment

Provide plan for surveillance/supervision that may include:

• Room/position closer to staff
• Periodic checks
• Environment free of hazards such as poorly fitted mattresses and siderails

Contact Further Assessment and search for Alternatives to:

• Prevent Falls/Injury
• Maintain Therapy
• Manage Behaviors

Prevent Falls/Injury: Alternatives to Physical Restraints

Assess for:	Alternative Approaches to Restraints:
History of Falls	Identify interventions successful at home or at transferring facility
Medical problems: e.g. fluid overload, dehydration, infection, drug toxicity, offending medications	Prompt treatment and ongoing evaluation
Disruption in normal routine, including meaningful activity, exercise and rest	Scheduled walking/exercise, diversion, including Therapeutic Activity Kit*
Unmet care need	Attend to needs for toileting, food and fluids, sleep, comfort Address sensory needs
Presence of pain (Remember restlessness can be a common sign of pain in cognitively challanged older adults)	Analgesics Positioning and other non-pharmacologic interventions (such as massage) Ongoing pain assessment, including effect of analgesic, pain diary Try This: Falls Risk Assessment
Orthostatic hypotension	Eliminate/reduce dose of medications affecting blood pressure Identify BP parameters with medical provider Monitor orthostatic BP (See Topics: Falls & Medication)
Elopement risk Falls from bed If patient is cognitively challenged, and unable to walk without assistance	Grab bars, ½ or ¼-length siderails to promote bed mobility Adjustable height bed (100 to 120% of lower leg length) Eliminate full side-rails. Use very low bed (7-13 inches off the floor) and mats at bedside Pressure-sensitive or motion sensors to alert staff
Gait instability and weakness	Consult physical therapy, mobility- exercise, walking program Protective devices: hip pads and/or helmet Skid-proof slippers and non-skid strips near bed Seating that promotes good body alignment and support; Avoid use of wheelchair for prolonged sitting
Orthostatic hypotension	Eliminate/reduce dose of medications affecting blood pressure Identify BP parameters with medical provider Monitor orthostatic BP

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 alternatives for treatment?

If not: Assess for:	Alternative Approaches to Restraints:
Risk to maintaining lines safely and comfortably	Garden gloves with soft ball inside Camouflage IV line with clothing, stockingette, kling dressing Camouflage g-tube with abdominal binder Replace large NG tube with smaller one (advocate for g-tube when long-term use is anticipated) Endotracheal tube holders and freedom splints for endotracheal tube
Fear and anxiety	Companionship and supervision For oriented patient, guided exploration of the device
Unmet care needs	Attend to needs for toileting, food and fluids, sleep, comfort, pain relief Address sensory needs
Boredom and/or diminished attention span	Diversion, provide something to hold, music. Enlist input of family. Use Therapeutic Activity Kit*

Manage Behaviors, including wandering: Alternatives to Physical Restraints

If not: Assess for:	Alternative Approaches to Restraints:
Undetected medical problem	Correct underlying problem such as dehydration and constipation
Unmet physical needs	Attend to needs for toileting, food and fluids, sleep, comfort, pain relief Address sensory needs (See Topic: Sensory)
"Agenda" behavior. Query family to determine meaning behind behavior, including past patterns.	Caregiver consistency Use calm, simple statements and physical cues as needed Validate, don't correct Plan consistent, supervised walking and exercise as tolerated Consult with recreation specialist and /or OT for plan for structured activity Enlist family support
Environmental safety	Close supervision, especially in high-risk areas - ER and diagnostic areas Avoid rooms near areas of high traffic or noise Remove cues that promote "leaving," e.g., visual access to elevators, stairways, street clothes Institute regular patient checks, especially at shift change Use voluteers, paid "sitters", or specialized staffing as appropriate

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

Parameters of Assessment

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

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Nursing Care Strategies/Treatment/Management

Prevention

• Develop a nursing plan tailored to the patient's presenting problem(s) and risk factors
• Consider alternative interventions
• 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
• Reassess the patient's response every hour
• Remove the restraint every two hours
• Renew orders every 24 hours 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 caregivers 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.

Reprinted with Permission from Springer Publishing Company. McConnell, A., & Mion. L. (2003). Use of Physical Restraints in the Acute Care Setting In Mezey, M. D., Fulmer, T., & Abraham, I. (Eds.) Zwicker, D. (Managing Ed.) Geriatric Nursing Protocols for Best Practice. (2nd ed.). New York: Springer Publishing Company.

Last updated - February 2005

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