A physical restraint is a device, material, or equipment that limits a patient’s ability to move their arms, legs, or head freely, such as belts, mitts, or raised bed rails. These are distinct from chemical restraints, which involve psychoactive medication. Healthcare providers use physical restraints as a temporary measure to protect the patient from self-harm, like pulling out tubes, or to ensure the safety of staff when a patient is physically aggressive. Restraints are implemented only as a last resort when less restrictive alternatives have failed. Once applied, continuous monitoring and protocols for release must be followed to prevent harm and ensure the restraint is discontinued as soon as safely possible.
The Necessity of Periodic Release
Restraints must be removed on a regular schedule to counteract the serious physiological harm that prolonged immobilization can inflict. A primary concern is preventing pressure injuries, which develop when sustained pressure limits blood flow to the skin and underlying tissue. The constant friction and pressure from the restraint, particularly over bony prominences like the wrists or ankles, can rapidly lead to skin breakdown and open wounds.
Maintaining adequate circulation is another major reason for routine release. Restraints can compress blood vessels, restricting blood flow to the extremities distal to the device. This circulatory impairment can cause tissue damage, nerve damage, or the formation of blood clots, such as deep vein thrombosis. Regular removal allows staff to directly assess the skin color, temperature, and capillary refill time of the restrained limbs.
Physical restraints prevent the natural movements that maintain muscle tone and joint flexibility. Periodic release is necessary to perform gentle range of motion exercises for the restrained limbs. This active or passive movement helps prevent joint stiffness and muscle contractures, which can quickly lead to permanent loss of mobility, especially in older adults.
Finally, periodic release addresses the patient’s fundamental needs for hygiene, hydration, and elimination. Patients in restraints often cannot independently reach a call light, access water, or use a toilet. Releasing the restraint allows the care team to offer fluids, reposition the patient for comfort, provide necessary hygiene, and assess the need for toileting. These actions are essential for dignity and preventing complications like dehydration or incontinence.
Standard Protocol for Release and Reassessment
The frequency of restraint removal is governed by strict clinical and regulatory standards based on the patient’s condition and the reason for the restraint. For patients restrained for non-violent, non-self-destructive behavior—such as preventing the removal of a feeding tube—the standard protocol requires release at least every two hours. This two-hour interval is a minimum requirement to mitigate the risks of pressure, circulatory compromise, and joint immobility.
During this mandated release period, the patient receives comprehensive reassessment and care. The care team must temporarily remove the restraint from one extremity at a time to examine the skin integrity directly underneath the device for signs of friction, redness, or blistering. They also check the pulse and capillary refill in the limb to ensure blood flow has not been compromised.
The release time is used to perform a specific set of therapeutic actions. These actions include:
- Repositioning the patient to relieve pressure points.
- Performing active or passive range of motion exercises on the restrained limbs to maintain function.
- Offering opportunities for toileting, hydration, and nutrition.
- Addressing any other comfort measures the patient may require.
The final step in the standard protocol is the reassessment of the ongoing need for the restraint. The care team must document whether the original behavior or medical symptom requiring the restraint is still present. If the patient has calmed or the immediate risk has passed, the restraint must be discontinued. This continuous evaluation prevents the restraint from becoming a routine part of care rather than an emergency intervention.
Immediate Complications Requiring Urgent Removal
Certain acute patient changes demand the immediate removal of a physical restraint, regardless of the two-hour standard release schedule. These changes are warning signs of severe injury and require rapid intervention to prevent permanent harm. The most serious complication to watch for is impaired circulation to the restrained extremity.
Signs of a circulatory crisis include the limb distal to the restraint becoming cold, pale, or cyanotic, which signals a lack of oxygenated blood flow. A diminished or absent pulse in the extremity, or a capillary refill time longer than two or three seconds, are urgent indicators of vascular compromise. In these cases, the restraint must be removed instantly and medical staff notified to prevent irreversible tissue death.
Another emergent complication involves signs of nerve damage, which can manifest as numbness, tingling, or a loss of movement in the restrained limb. Severe pain, burning, or an acute increase in swelling at the restraint site also indicates an immediate problem, possibly from nerve compression or a worsening pressure injury. Direct friction burns or deep lacerations from the restraint material must also be treated as an immediate complication requiring removal and medical attention.
Finally, any sign that the restraint is interfering with the patient’s respiratory function requires immediate removal. This risk is highest with vest or chest restraints, where a shift in position can cause the device to compress the chest or neck, leading to difficulty breathing, gasping, or choking. If the restraint is causing acute distress or a direct threat to the patient’s airway, the device must be immediately removed to prioritize safety.