Physical restraints are highly regulated interventions in healthcare settings, used only as a last resort to protect a patient or others from immediate physical harm. A physical restraint is any manual method or mechanical device attached to the patient’s body that restricts their freedom of movement or normal access to their body. The use of these devices is governed by strict protocols, continuous assessment, and the overriding goal of patient safety and dignity.
Understanding the Use of Physical Restraints
Physical restraints are never used for staff convenience, punishment, or discipline. Their application is limited to situations involving severe self-destructive behavior or the interruption of life-saving medical treatment, such as preventing a patient from pulling out an endotracheal tube, central line, or urinary catheter. Before a restraint is applied, less restrictive alternatives must be attempted and documented, such as verbal de-escalation, moving the patient closer to the nursing station, or providing a sitter for continuous observation.
A physician’s order is necessary before applying a physical restraint, and this order cannot be a standing order or written “as needed” (PRN). If the situation is an emergency and presents an immediate threat, the restraint may be applied first, but a physician must be notified immediately to obtain a time-limited order. These orders are limited in duration, typically to four hours for adults for behavioral restraints, requiring frequent reassessment and renewal by a licensed independent practitioner.
The Critical Anchor Point: Securing to the Bed Frame
The most important rule for securing a physical restraint is to anchor it to a non-moving part of the bed, specifically the bed frame beneath the mattress. This fixed point ensures that the restraint’s tension and slack remain consistent, regardless of whether the head of the bed is raised or lowered. The bed frame provides a stable and secure anchor.
A common and dangerous mistake is securing the restraint to a side rail, headboard, or footboard. Tying to a movable part creates a high risk of serious injury, including nerve damage, strangulation, or positional asphyxiation. If a side rail is lowered while the restraint is secured to it, the patient’s limb could be pulled sharply or the restraint could tighten dangerously around the neck or torso.
When securing the restraint to the bed frame, ensure the patient has some limited range of motion to prevent injury, while still preventing access to tubes or lines. The restraint should be tied with enough slack to allow a small amount of movement, but not so much that the patient can become entangled or fall out of bed.
Safe Knot Technique and Quick Release
The knot used to secure the restraint must be a quick-release knot, such as a slip knot or a half-bow knot, which can be untied rapidly with a single pull. This technique is essential for situations requiring immediate release, such as cardiac arrest, fire, or the need for emergency access to the patient. A simple square knot or a tight knot that cannot be quickly undone is never acceptable, as it can delay life-saving interventions.
Before the knot is tied to the anchor point, the restraint itself must be properly applied to the patient’s limb, ensuring adequate padding is placed over bony prominences to prevent skin breakdown. The restraint should be secure enough to prevent the patient from escaping but loose enough to allow two fingers to be inserted comfortably between the restraint and the patient’s skin. This two-finger check confirms that circulation is not impaired at the site of application.
Immediately following the application, the nurse must check the neurovascular status of the restrained extremity. This involves assessing circulation, sensation, and movement (CSM) distal to the restraint location to ensure blood flow is not compromised. The quick-release end of the knot must be positioned so that the patient cannot reach it to untie the restraint, but it remains easily accessible to staff.
Mandatory Monitoring and Documentation
Continuous observation of the restrained patient is mandatory, especially for those in restraints for violent or self-destructive behavior, often requiring a staff member or sitter to be present. For behavioral restraints, a documented assessment is typically required every 15 minutes, focusing on the patient’s behavior, orientation, and physical status. For non-behavioral or medical restraints, the assessment schedule may be slightly less frequent, often every two hours.
The assessment must cover skin integrity, circulation, range of motion, and the patient’s psychological status to ensure humane care. The patient’s basic needs must be met, requiring the release of the restraint at regular intervals to provide hygiene, toileting, nutrition, hydration, and range-of-motion exercises. These releases and interventions must be meticulously documented to demonstrate appropriate care while restrained.
Comprehensive charting is a legal requirement, necessitating documentation of the reason for application, all alternatives attempted, the specific type of restraint, and the location of its application. The record must also include the time of application, the results of all neurovascular checks, and periodic reassessments of the patient’s need for the restraint. Staff must attempt to discontinue the restraint at the earliest possible time, and this ongoing effort to reduce the restriction must also be recorded.