Restraint devices, such as belts, vests, or limb holders, are tools used in a medical setting to limit a patient’s movement for safety. They are never intended for convenience or punishment. Restraints are a serious intervention considered a last resort, implemented only after less restrictive alternatives have failed to manage a patient’s behavior or medical need. Because restraints carry inherent physical and psychological risks, strict protocols governing their application and ongoing management are mandatory.
Establishing Necessity and Justification
The decision to apply physical restraints is governed by strict legal and ethical mandates, emphasizing that this action is a therapeutic intervention. Restraints are justified only when a patient poses an imminent danger to themselves or others, such as attempting to remove life-sustaining medical equipment or exhibiting violent behavior. Before application, all less-restrictive interventions, including verbal de-escalation, reorientation, and environmental modification, must be attempted and documented as unsuccessful.
A physician’s order is required to initiate the use of restraints, though a trained nurse may apply them in an emergency before obtaining the order. For violent or self-destructive behavior, a practitioner must complete a face-to-face assessment within one hour of initiation. These orders are time-limited, typically expiring within a few hours, and require a reassessment and new order for continuation, preventing routine or indefinite use.
Step-by-Step Procedure for Safe Application
Preparation for restraint application begins with gathering the appropriate equipment, which must be correctly sized, and ensuring adequate staff are present to perform the application safely and efficiently. If the patient is calm enough, staff should briefly explain the purpose of the restraint to the patient and, if applicable, their family, emphasizing that it is for safety. This explanation can help reduce the patient’s distress and minimize resistance during the process.
The patient’s position is a paramount safety concern during application, and they should be placed in a safe position, preferably supine (lying on their back). Prone positioning, or lying on the stomach, must be avoided entirely because it significantly increases the risk of positional asphyxia, a potentially fatal complication where the patient’s ability to breathe is restricted. Once the patient is positioned, the restraints themselves must be secured to prevent circulation impairment or skin injury.
When securing the device to the patient’s limb, two fingers should fit easily beneath the restraint to ensure adequate circulation to the extremity. Padding should be placed beneath the restraint, particularly over any bony prominences, to protect the skin from friction and pressure that could cause tissue breakdown. The straps of the restraint must be secured to the bed frame, specifically to a part of the frame that moves up and down with the bed, and never to the side rails.
Attaching the restraints to the side rails is dangerous because lowering the rail can cause injury or death by hyperextension or entanglement. The straps must be secured using a quick-release knot. This knot allows staff to immediately free the patient in an emergency, such as cardiac arrest or fire, by releasing instantly with a single pull.
The number of points restrained is determined by the patient’s behavior, with a four-point restraint (securing all four limbs) being more restrictive than a two-point restraint. Regardless of the type, restraints should never be secured around a patient’s neck or chest, as this directly interferes with breathing and increases the risk of strangulation. The restraints should be positioned to allow for a small amount of movement, preventing absolute immobility and minimizing the risk of joint stiffness or muscle strain.
Essential Monitoring and Documentation
The application of a restraint device requires a continuous and highly structured safety protocol that demands frequent patient monitoring. For patients restrained due to violent or self-destructive behavior, continuous, face-to-face observation is often required, with an assessment documented every 15 minutes. This frequent monitoring is necessary to immediately detect signs of distress or physical harm.
For all restrained patients, staff must regularly check the circulation, sensation, and movement (CSM) of the restrained extremities, typically every 15 minutes for behavioral restraints. Skin integrity checks are also mandatory to look for redness, blistering, or pressure injuries, especially under the device and over bony areas. These checks ensure the restraint is not too tight and is not causing neurological or vascular compromise.
Beyond physical checks, staff must attend to the patient’s basic needs, including offering opportunities for hydration, nutrition, and elimination, and providing range-of-motion exercises to the restrained limbs. This ongoing care demonstrates respect for the patient’s dignity and helps prevent complications associated with immobility. The patient’s mental status, level of agitation, and response to the intervention must also be continuously assessed and documented.
Documentation is a legally mandated aspect of the restraint process and must be meticulously detailed. The record must start with a clear description of the patient behavior that necessitated the restraint, specify the type of restraint used, the exact time of application, and the results of all circulation and skin checks. Crucially, documentation must include ongoing reassessment to determine if the restraint can be safely discontinued, as the intervention must be ended at the earliest possible time.