02.07 Restraints 101

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Overview

  1. Restraints
    1. When to use restraints
    2. Types of restraints
    3. Restraint spectrum
    4. Violent versus nonviolent
    5. Documentation

Nursing Points

General

  1. When to use restraints
    1. Lines, drains and airways
    2. Safety
    3. Combative patients
    4. Delirium
    5. Remove as soon as possible
  2. Types of restraints
    1. Posey
    2. Mitts
    3. Soft (wrist and 4 point)
    4. Enclosure bed
  3. Restraint spectrum
    1. Start with least aggressive
      1. Redirection
      2. Reorientation
    2. Sitter
    3. Physical restraints
    4. Chemical restraints
    5. Using both physical and chemical
  4. Violent versus nonviolent
    1. Doctor’s orders
    2. Frequency of checks
    3. Why violent versus nonviolent
  5. Documentation
    1. Reasons for restraints
    2. Start and stop times
    3. Plan of care
    4. Regulations (CMS/TJC)
    5. Unit and facility policy

Assessment

  1. Skin breakdown
    1. Check skin at restraint sites to prevent skin breakdown
    2. Utilize preventative measures for skin if necessary

Nursing Concepts

  1. Safety

Patient Education

  1. Educate patient and family on needs of restraints

Reference Links

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Video Transcript

In today’s lesson, we’re going to take a look at restraints and some basic principles behind using them.

When we talk about restraints, we need to recognize two things. Number 1, don’t take their use lightly. Only use them when you absolutely have to. And number 2, take them off as soon as possible. You are LITERALLY restraining a person. It’s not just keeping them from injuring themselves – you’re essentially keeping them from moving. So really think about this, especially from a humanist perspective.

But let’s look at why we use restraints. First, we use them from a safety standpoint. If you have a patient who has a really important line or tube, line a breathing tube, you want to make sure they won’t reach up and pull it out. They could really injury themselves. Those endotracheal tubes have big balloons in them and the last thing you need to do is ripping that thing out and damaging their airway.

The last thing you want to do is have to do an emergency intubation at bedside. If your patient keeps pulling at lines, then that’s another reason you’d want to use a restraint. And I’ve seen plenty of foley’s pulled out with the balloon fully inflated – so we do things sometimes to protect our patients even though they make not like it.

If your patient continually tries to get out of bed and they’re a huge fall risk, then using a variety of restraint methods might help to keep your patient safe.

Another reason you’d want to use restraints is if a patient is posing an immediate harm to themselves or others. If you have a patient who is threatening you, and you have every reason to believe it (like the one time I was threatened to be kicked in the head, and then was), then by all means, that’s a justifiable reason to restrain a patient.

But just because you justify your reason to use a restraint, doesn’t mean you can. You have to basically prove they need to be restrained, and for good reason. There are some hoops we have to jump through, which I’ll talk about later. But first, let’s look at at types of restraints.

We have two different types of restraints. We have physical restraints and then we have chemical restraints.

Physical restraints are things that physically keep your patient from moving around or pulling out lines. So mitts, posey or soft wrist restraints. Chemical restraints are things like drugs that sedate the patient.

A posey vest is a vest that keeps a patient lying down or sitting in their chair. It only covers their chest. Mitts are like big boxing gloves that you put on the patients hands to keep them from using their fingers. There’s an important note – find out what your unit policy is regarding mitts – some facilities say that they’re not a restraint, and some do, so find out from your unit.

The next, and most common type are wrist restraints. These wrap around the wrist and then tie to the bed frame to keep the patient’s arm from moving up and down. Sometimes, and I’ve had to do this occasionally with my combative and delirious patients, are using four point restraints. It’s far less common and requires more paperwork. But just know that it’s there. Another thing about wrist restraints – don’t tie them to the side rail, and make sure they have a quick release, like a knot or snap. If the restraint is tied to the bed rail, and it drops, you can REALLY hurt your patient. The other thing is that if you need to disconnect them in a hurry, then you need that quick release.

There’s another thing called an enclosure bed, which is really like a big playpen with a top. It keeps the patient from getting out of bed. I’ve never seen these in person, but I know some hospitals use them.

Just know that you’ve got your two types of restraints, physical and chemical.

So when do you use what? Let’s take a look.

When we look at restraints, we really need to focus on this thing called the restraint spectrum. You can move back and forth along it as you go along.

Your least aggressive types of restraint measures are going to be things like reorienting your patient, or having family at bedside. You can also redirect your patient. You can hide your lines if you need to. If that doesn’t work, then you can move up to have a sitter at the bedside to help reorient your patient.

That’s when we move into the physical restraints. So, if your patient is still trying to pull at lines, you can try mitts. If they get out of those, then you can try wrist restraints. The goal here though is to use the least restrictive means necessary.

Also, it’s not a one size fits all. Some patients do ok with one or a combination of restraints. Sometimes your patient will only need a posey, sometimes a posey and mitts. But use your judgment.

The other thing to remember here is that you can go back down the spectrum. Loosen restraints before you just take them off. If you take a restraint off and discontinue it, and all of a sudden your patient starts pulling at their lines again, you’re in trouble. Little steps when removing restraints, and watch your patients.

I just want to touch on this really quickly, but I think it’s an important concept for you to know.

There’s an idea of violent versus nonviolent restraints. The biggest difference is that you need to know if your patient is an immediate danger to themselves or others, like if they threaten suicide or to hurt, maim or kill you. If they are, then you’ll need violent restraints most likely. The big thing to know here is that the requirements for violent restraints are more strict. Your order is usually shorter, you have to assess your patient far more quickly, and your provider has to see them within a given time frame, which is usually an hour.

Just make sure you check your facility policy for what the biggest difference is, and how you need to handle them.

The other thing we need to discuss when we talk about restraints is documentation. You’ll need to be especially meticulous about your documentation. Make sure your start and stop times on your orders are perfect, make sure your plan of care is updated (i.e. patient won’t have skin breakdown due to restraints). Also make sure that your documentation adheres to any Joint Commission or CMS regulations, and that you’re following unit and facility policy. The last thing you’ll need is some problem with a patient in restraints. Also make sure that you document that you checked the restraints for skin breakdown, allowed them to go to the bathroom and that they’re getting some form of nutrition and hydration – you need to show that you’re still assisting them with their ADLs.

Restraints really are about safety – so I really want you guys to focus on that as a nursing concept. Safety for both the nurse and the patient.
So let’s recap.

Know the difference between the different types of restraints available and also know when you should use them.

Because restraints can actually make agitation worse, take them off as soon as possible.

Restraints aren’t the same way for every patient. Use your judgment to determine the least restrictive way to restrain a patient.

Remember violent restraints are way more involved. More frequent checking, and your orders don’t last as long. Make sure you have the right order.

Finally, CYA. Make sure your restraint documentation is on point.

That’s our lesson on restraint basics. Make sure you check out all the resources attached to this lesson. Now, go out and be your best selves today. And, as always, happy nursing!!

Read more

  • Question 1 of 8

A nurse is caring for a client who has dementia as a result of Alzheimer’s disease. The provider writes an order for bilateral wrist bands for restraints prn. Which action of the nurse is most appropriate regarding this order?

  • Question 2 of 8

A client is continuing to attempt to get out of bed after being informed to stay in bed while recovering from surgery. Which situation best describes the concept of least restrictive device use regarding restraints?

  • Question 3 of 8

A client is becoming violent toward the staff. The nurse decides to enforce behavioral health restraints and seclusion to protect the client and staff. Which principles must the nurse consider before implementing this type of restraint? Select all that apply.

  • Question 4 of 8

A client with schizophrenia has become very angry and is throwing items at the nursing staff. The nurses have tried other forms of calming the client, but nothing has worked. Which of the following accurately describes the staff’s ability to use restraints in this situation?

  • Question 5 of 8

Despite trying multiple interventions to manage a client’s behavior, the nurse has decided to use restraints through an order from the provider. In which situation would the client most likely need mitt restraints?

  • Question 6 of 8

A nurse is caring for an 86-year-old client receiving enteral nutrition through an NG tube. The client continues to pull at the tube in an attempt to take it out. The client has had wrist restraints on and off for the past two days while in the hospital and the nurse is considering what options could be implemented instead. Which of the following should the nurse consider for alternatives to using wrist restraints?

  • Question 7 of 8

A 10-month-old child is recovering from a cleft lip repair, and the provider has determined the child would benefit from restraints post-operatively. Which kind of restraints would the nurse most likely apply to this child?

  • Question 8 of 8

A client who is cognitively impaired has become agitated and upset with the nursing staff. The nurse does not want to use restraints with the client but is struggling to keep her calm. Which is an example of an appropriate intervention that would be an alternative to using restraints?

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