Skill 64

Restraint Application

A physical restraint is any manual method, physical or mechanical device, material, or equipment that immobilizes or reduces the ability of a patient to move his or her extremities, body, or head freely (CMS, 2008). Physical or chemical restraints should be the last resort and used only when reasonable alternatives fail. The use of physical restraints is no longer a safe strategy, yet many nurses still believe that restraints are needed to control behavioral symptoms and prevent falls in older adults with dementia (Evans and Cotter, 2008).

The CMS (2008) requires that a restraint be used only under the following circumstances: (1) to ensure the immediate physical safety of the patient, a staff member, or others; (2) when less restrictive interventions have been ineffective; (3) in accordance with a written modification to the patient’s plan of care; (4) when it is the least restrictive intervention that will be effective to protect the patient, staff member, or others from harm; (5) in accordance with safe and appropriate restraint techniques as determined by hospital policies; and (6) restraint use should be discontinued at the earliest possible time.

The use of restraints is associated with serious complications, including pressure ulcers, hypostatic pneumonia, constipation, incontinence, and death. Most patient deaths in the past have resulted from strangulation from a vest or jacket restraint. Numerous agencies no longer use vest restraints. For these reasons this text does not describe their use.

Delegation Considerations

The skills of assessing a patient’s behavior and level of orientation, the need for restraints, the appropriate restraint type, and the ongoing assessments required while a restraint is in place cannot be delegated to nursing assistive personnel (NAP). Applying and routinely checking a restraint can be delegated to NAP. The Joint Commission (2009) requires first aid training for anyone who monitors patients in restraints. The nurse directs the NAP by:

▪ Reviewing correct placement of the restraint and how to routinely check the patient’s circulation, skin condition, and breathing.

▪ Reviewing when and how to change a patient’s position and provide range-of-motion (ROM) exercises, toileting, and skin care.

▪ Instructing NAP to notify the nurse immediately if there is a change in level of patient agitation, skin integrity, circulation of extremities, or patient’s breathing.

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