1. Self- Learn Packet Revised November 2002
Restraints
Updated 01/07
All Staff
Self- Learn Packet
Revised November 2002

2. OBJECTIVES
At the conclusion of the self-learning packet, the learner will be able to:
1. Define the difference between Behavioral Restraints and Medical/Surgical Restraints.
2. State three benefits of limiting restraint use.
3. List at least four myths concerning the use of restraints.
4. Identify factors which increase the use of restraints.
5. State two situations in which restraints might be useful in patient care.
List three complications of restraint use.
7. Assess a patient for the least restrictive form of restraint.
8. Identify six alternatives to restraint use.
9. State the age-related differences in evaluation and renewal of restraints.
10. State GBMC’s philosophy for the use of restraints.
11. State GBMC’s policies for restraints use.

3. WHAT ARE RESTRAINTS? Definitions
Restraints are any method, physical or mechanical device, materials or equipment attached or adjacent to the patient’s body that her or she cannot easily remove which restricts a person’s movement, physical activity, or normal access to his or her body.

4. Name Change “Medical/Surgical” Non-Behavioral has been changed to
This follows what JCAHO uses in their standards

5. PURPOSE FOR RESTRAINTS
Two types of restraints defined by JCAHO are based on the purpose for the restraints
Behavioral Restraint (Almost exclusively in ER)
Used for the control of aggressive/violent behavior or behavior that is dangerous to self or others.
Medical/Surgical Restraint (Most common on units)
Used for care management for a patient who is exhibiting behavior that is interfering with treatment (e.g. pulling on IV, Foley, or dressings).

6. When Physical Restraints are NOT Considered to be Restraint Devices
When used for the purposes of security, detention or public safety on patients under forensic custody (under police guard).
When used as a voluntary mechanical support to achieve proper body position, balance, or alignment.
When used as a positioning or securing device to maintain position, limit mobility or temporarily immobilize a patient during medical, diagnostic, or surgical procedures (less than 30 minutes in children).

7. Types of Physical Restraints
Restraints may be made of soft or harder material
Neoprene (for Behavioral Restraints only)
Soft Foam Wrist or ankle straps
Roll Belts
All 4 side rails up on a bed
Mitts (secured or unsecured to bed frame)
All 4 bed rails up
Mitts
Roll Belt
Wrist/Ankle
“Neoprene”

8. WHY LIMIT THE USE OF RESTRAINTS?
Because doing so:
Benefits the patient
Being able to move about freely is important for the patient’s health and a sense of dignity.
Helps the Hospital
It allows the hospital to comply with laws and meet accepted care standards.
Standards and Laws limit the use of restraints
1. JCAHO
2. Federal Omnibus Budget Reconciliation Act
(OBRA) of 1987 (long-term care facilities)
3. CMS (formerly HCFA) Standards (Medicare/Medicaid)
4. State Law

9. MYTHS ABOUT RESTRAINTS
Decreases risk of falls
Increases sense of security
Decreases lawsuits
Lowers staff costs
Improves quality of life
No other alternative

10. SOMETIMES RESTRAINTS CAN BE USEFUL
Allow Needed Treatment (Medical/Surgical)
A combative or confused patient may have to be restrained
so staff can:
Perform an exam
Treat a wound
Administer an IV
Give other needed medical treatment
Keep the Patient and Others Safe (Behavioral)
A violent patient may need to be restrained temporarily if no other calming efforts work.

11. RESTRAINTS CAN ALSO CAUSE SERIOUS HARM
Injuries from improperly positioned restraints
Patients get tangled in straps and choke
Patients struggle to get free and end up broken bones, cuts, concussions, or other injuries as a result
Medical complications from keeping the body and limbs in the same position for long periods can cause:
Poor circulation
Incontinence
Constipation
Weak muscles and bones
Pressure Sores
Mental and Emotional Problems
Restrained patients often feel humiliated or imprisoned and become
Depressed
Agitated
Uninterested in eating, sleeping, and socializing

12. ASSESSING THE PATIENT IS THE FIRST STEP
The health team’s goal in restraint use is to find the safest, least
restrictive way to care for the patient.
Discover the Cause of the Problem
If the patient wanders, try to figure out what he or she is seeking.
If the patient is unsteady, look for underlying problems, such as poor shoes, side effects of medications, or bad eyesight.
Learn About the Patient’s Interests
A confused or agitated patient may be happier if allowed to follow familiar routines.
Give the Patient a Say
Discuss problems openly with the patient..
If possible, ask the patient how he/she would solve the problem.
Involve Family Members
They can provide information about the patient’s habits.
They can take part in his or her daily activities.
Document a Care Plan

13. Alternative Interventions
Alternative means of meeting the patients needs should be attempted first.
Move patient closer to nurses station
Keep patient door open
Bed in low position
Call bell within reach
Reorient patient to environment
Conceal IV site & tubing with Stretch Netting
Decrease noise/minimize stimulation
Bed/Exit alarms with sensor pads (Posey Sitter II)
Encourage family involvement

14. More Alternative Interventions
Wrap Around Belt may be applied as long as it is documented patient can “demonstrate” self release with Velcro.
Exit Alarms with sensor pads for beds or chairs
Bed Alarms if available on beds.

15. USE RESTRAINTS AS A LAST RESORT
Use Restraints only when:
You have exhausted all alternative interventions
Vital treatments depend on their use
There is a clear and present danger
IF RESTRAINTS MUST BE USED
Protect the patient’s rights and dignity
Choose the least restrictive method
Document each occurrence of restraint use
Only properly trained and authorized staff may apply and remove restraints
Choose the correct restraint size - if too small, restraints may cause increased agitation and if too large, the patient can slide down in the restraint which could lead to asphyxiation.

16. GBMC RESTRAINT POLICIES
The following policies apply to the use of
restraints:
Physician orders cannot be written as “standing” or “prn”.
Restraints will not be used for the convenience of the staff.
The use of restraints will only be used to prevent the patient from harming themselves or others or when the patient is interfering with treatment.

17. PHYSICIAN’S ORDER CRITERIA FOR BEHAVIORAL RESTRAINTS
1. Physician must be informed and a face-to-face assessment with counter signed orders within ONE hour.
2. Order must include:
Start and stop time
Date
Reason for restraint
Type of restraint used
Signature of Physician
Maximum duration 4 hours ages adults 18 and older
2 hours ages 9-17 years old
1 hour 0-8 year old
4. The physician must make a face to face re-evaluation and
orders renewed every hours for Adults and older
every hours for Children 17 and younger

18. PHYSICIAN’S ORDER CRITERIA FOR MEDICAL/SURGICAL RESTRAINTS
1. Order must be obtained within 12 hours of initiation by the register nurse.
2. Physician must make face-to-face evaluation within 24 hours of initiation of restraints and sign order.
3. Order must include:
Start and stop time
Date
Reason for restraint
Type of restraint used
Signature of Physician
Maximum duration of order is 24 hours

19. Least to most restrictive
4 Side Rails up
Roll Belt
Mittens
1 or 2 point soft restraint
4 point soft restraint

20. APPLYING RESTRAINTS Mittens Roll Belt Limb Restraint
Place hands in each mitt and secure strap ABOVE wrist bone.
Roll Belt
Position patient in the middle of the mattress. Use quick release straps to secure to bed frame.
Limb Restraint
Using a padded limb restraint, wrap the limb with the restraint and secure the plastic clip.
Tighten the restraint so that the patient is unable to pass his/her wrist through the restraint, being careful not to restrict blood flow to the extremity.

21. Initiation of Restraints
Only a RN may initiate the first time application of restraints.
A NST or LPN may remove and reapply restraints as needed for safety and hygiene.

22. Documentation
RN or Unit Secretary MUST use Order Entry in Meditech and select type of restraint ordered: Med/Surg or Behavioral.
This will generate the proper flowsheet in PCS
Med/Surg Restraint Assessment Flowsheet
Behavioral Restraint Assessment Flowsheet

23. Documentation Behavioral Restraints Med/Surg Restraints
Q1h Assessment by RN/LPN in Meditech
Q15 mins.Observation by RN/LPN or NST on paper bedside flowsheet
Med/Surg Restraints
Q8h Assessment by RN/LPN in Meditech
Q2h Observation by RN/LPN or NST in Meditech

24. RESTRAINTS MONITORING
BEHAVIORAL
MEDICAL/SURGICAL
Use Prevention Management of Aggressive Behavior (PMAB) interventions for escalating behaviors in all clinical settings.
Observe every 15 minutes for behaviors and physical conditions and document on BehavioralRestraint/Seclusion Flowsheet
Offer liquid, nutrition, comfort, and bathroom every 2 hours
Remove restraints every 2 hour for no less than 5 minutes for range of motion and skin care.
Observe every 2 hours for behaviors and physical conditions and document in Meditech
Offer liquid, nutrition, comfort, and bathroom every 2 hours
Remove restraints every 2 hours for no less than 10 minutes for range of motion and skin care.

25. Congratulations!
You have completed the Restraints self-learning packet.
Complete the post test.