The use of patient restraints refers to mechanical or physical devices that limit a person’s movement for their own protection or the safety of others. While the goal is always a restraint-free environment, these devices function as a last resort safety measure when necessary. Restraints are never intended as a form of discipline or staff convenience. Their application and management are highly regulated processes focused solely on protecting the patient or those around them from immediate harm.
When Restraints Are Medically Necessary
Restraints are justified only when all other less restrictive interventions have failed to ensure patient safety. They are primarily used in two categories: preventing the interruption of life-sustaining treatment and managing severe agitation or violence. Medical restraints are applied when a patient’s altered mental status (e.g., delirium or confusion) causes them to attempt to remove necessary medical devices. This includes pulling out IV lines, feeding tubes, catheters, or endotracheal tubes, which pose an immediate threat to health.
Behavioral restraints are used in emergency situations when a patient exhibits violent, aggressive, or self-destructive behavior. This is necessary when the patient poses an immediate physical danger to themselves, staff, or other patients. Before application, the healthcare team must attempt and document less restrictive measures, such as redirection, frequent observation, de-escalation techniques, or medication review. The decision to use a restraint must be based on a current and thorough medical and psychosocial assessment, ensuring the intervention is clinically appropriate.
Principles of Safe Securement and Anchor Points
The primary safety principle when applying a restraint is ensuring the patient cannot suffer injury from the device or the structure it is attached to. Restraint ties must be secured to a stationary part of the bed structure that does not move when the bed position is changed.
Restraints must be secured to the bed frame itself and never to the side rails. Tying to a side rail creates a high risk of serious injury, including asphyxiation, if the rail is accidentally lowered or if the patient becomes entangled. The bed frame provides a fixed, stable anchor point that prevents the restraint from tightening or shifting dangerously regardless of the bed’s height or position.
The knot used to secure the restraint to the bed frame must be a quick-release knot, often resembling a slip knot or a half-bow. This specific knot allows the nurse to release the restraint instantly with a single pull in an emergency, such as if the patient’s circulation is compromised or if cardiopulmonary resuscitation (CPR) is required. The restraint itself must be padded at the point of contact on the patient’s limb to prevent skin breakdown, friction injuries, or nerve damage. A fundamental safety check involves ensuring the restraint is snug enough to restrict movement but loose enough to allow at least two fingers to be inserted between the restraint and the patient’s skin. This measure is designed to prevent any impairment of circulation or nerve function.
Essential Patient Monitoring Requirements
Once a restraint has been applied, continuous monitoring is required to prevent complications and ensure the patient’s well-being. Monitoring is an active physical assessment of the patient’s condition and the restraint’s effectiveness. For patients in physical restraints, the nurse must assess the circulatory status, skin integrity, and comfort of the restrained limb at least every 15 minutes.
This frequent assessment includes checking for a pulse distal to the restraint, evaluating capillary refill time, and observing the skin for changes in color, temperature, or swelling. Beyond physical safety, nurses must also assess the patient’s mental status, behavior, and the continuing justification for the restraint. Regularly scheduled release periods are mandated to address basic human needs and prevent the complications of immobility.
These release periods generally occur at least every two hours. During this time, the restraint is temporarily removed to allow for range of motion exercises, skin care, toileting, and offering hydration and nutrition. This scheduled care helps prevent serious complications such as pressure ulcers, deconditioning, and contractures that can result from prolonged immobility. The ongoing monitoring and care provision must be meticulously documented, reflecting the nurse’s commitment to preserving the patient’s dignity and seeking the earliest opportunity for safe restraint discontinuation.
Legal and Ethical Frameworks for Restraint Use
The application of a physical restraint is governed by strict legal and ethical frameworks designed to protect the patient’s rights and autonomy. Restraints should only be used with a physician’s or licensed independent practitioner’s order. This order is not a standing order and must be renewed frequently. For non-violent, medical restraints, a new order is often required every 24 hours, but this can vary based on institutional policy and patient age.
The underlying ethical principle is the use of the “least restrictive measure” necessary to achieve patient safety. This means selecting the restraint type that limits movement only as much as is needed and using it for the shortest duration possible. Documentation is a significant legal requirement, necessitating a record of the patient’s behavior, the alternative measures attempted, and the justification for continued use.
Informed consent from the patient or their legal representative is required, explaining the reason, the type, and the expected duration, except in emergency situations where immediate danger is present. The ultimate goal is the prompt discontinuation of the restraint, requiring continuous reassessment to determine if the patient’s condition has improved enough for safe removal. Using any restraint for convenience, punishment, or as a substitute for adequate staffing is a violation of federal regulations and ethical care standards.