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AP P L YIN G RES TRAIN TS

RESTRAINTS
RESTRAINTS • The Centers for Medicare & Medicaid Services (CMS) states “all
Restraint is the restriction of an individual’s patients have the right to be free from physical or mental abuse,
freedom of movement. and corporal punishment. All patients have the right to be free from
• PURPOSES restraint or seclusion, of any form, imposed as a means of coercion,

APPLYING • To promote safety and prevent injury

• To allow a medical or surgical treatment to
proceed without client interference (e.g., to
discipline, convenience, or retaliation by staff. Restraint or seclusion
may only be imposed to ensure the immediate physical safety of the
patient, a staff member, or others and must be discontinued at the

REST RAINT S earliest possible time”.

prevent movements that would disrupt therapy
to a limb connected to tubes or appliance)

MICHAEL RABANAL GOZE, RN, MSN

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RESTRAINTS
CHEMICAL/PHARMACEUTICAL
RESTRAINTS
AP P L Y IN G RES TRAIN TS

M EC H AN I CAL RESTRAINTS

Applying restraints
Restraints should not be R E S T R AI N T P H Y SI CA L R E S T R A I NT CHEMICAL RESTRAINT
considered a part of routine • the application of
• are any form of
Chemical or pharmaceutical
• is the application by psychoactive
client care and should not be devices (including
included in a fall prevention belts, harnesses,
members of
healthcare workforce
the medication used not
to treat illness, but to
restraints, called ‘‘rapid
program. manacles, sheets and of hands-on intentionally inhibit a tranquilization’’ in older
particular behaviour or
A request from a family straps) to a person’s
body to restrict their
immobilization or the
movement. literature, should also be
member to apply a restraint is physical restriction of a
movement. person. considered in conjunction
not sufficient cause to apply a
restraint. with or in place of physical
Restraints are frequently used restraints.
for older adults with
dementia who are confused
and may pose a threat to
themselves.

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APPLYING RESTRAINTS

AP P L YIN G RES TRAIN TS

AP P L Y IN G RES TRAIN TS
Extrapyramidal syndrome (EPS) is a
ANTIPSYCHOTICS/NEUROLEPTICS potential side effect of haloperidol
Antipsychotics have a high therapeutic index and a
lack of addictive potential. This class of medication and, in rare cases, has been reported SECLUSION
has a high affinity for the dopamine-2 receptor. to occur days after administration,
Contraindications to these medications include an
even after only one dose. Signs of the involuntary confinement of
allergy to the class, Parkinson disease, and
anticholinergic drug intoxication. Relative EPS include akathisia and acute a client alone in a room or
contraindications include pregnancy, lactation, and area from which the client is
hypovolemia. dystonia (torticollis, opisthotonos, or
Haloperidol (Haldol), a butyrophenone physically prevented from
antipsychotic, is easily given intramuscularly (IM) at oculogyric crisis). Occurrence of EPS leaving.
doses of 2.5 to 10 mg. Repeat doses can be given at is easily treated with
30- to 60-minute intervals, but the desired effect is
usually obtained within three doses. The half-life of diphenhydramine (Benadryl) or
haloperidol is 10 to 19 hours.
benztropine (Cogentin).

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Applying restraints
AP P L Y IN G RES TRAIN TS

RESTRAINTS
Although restraints are used with the
THE STANDARDS ADDRESS TWO TYPES OF BEHAVIORS IN
WHICH RESTRAINTS MIGHT BE NECESSARY:
LEGAL IMPLICATION OF RRSTRAINTS

intention to keep a patient safe, they

impact a patient’s psychological safety and
dignity and can cause additional safety nonviolent, non–self-destructive behavior
There must be a face-to-face evaluation of the client within 1 hour by the
issues and death. physician or LIP, or an RN or physician assistant (PA) who has been trained
restraints may be necessary to directly support
medical healing
according to the new requirements.
A restrained person has a natural
tendency to struggle and try to remove
the restraint and can fall or become fatally A written restraint order for an adult with violent or self-destructive behavior,
entangled in the restraint. following evaluation, is valid for only 4 hours for up to a total of 24 hours.
Furthermore, immobility that results from
the use of restraints can cause pressure
injuries, contractures, and muscle loss.
violent or self-destructive behavior
All orders must be renewed daily.
Restraints take a large emotional toll on restraint or seclusion may be used to protect the client
the patient’s self-esteem and may cause from injury to self or others
humiliation, fear, and anger.
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• The type or technique of restraint or seclusion

LEGAL IMPLICATIONS OF RESTRAINTS
• Restraint may be used to ensure the
STANDARD used must be the least restrictive intervention

STANDARDS client’s immediate physical safety, even if the that will be effective to protect the client, a staff

S FOR USE
client is not violent or self-destructive. member, or others from harm. Restraint or seclusion must be discontinued at the earliest possible time .

FOR USE OF
OF
• Seclusion may only be used for the • The use of restraint or seclusion must be
implemented in accordance with safe and “As-needed” (prn) orders for restraints are prohibited.
RESTRAINTS management of violent or self-destructive
appropriate restraint and seclusion techniques
RESTRAINT
behavior that is an immediate threat to the
client’s physical safety. per hospital policy. Restraints should be used only after every other possible means of
AND ensuring safety have been unsuccessful and documented.
• Restraint or seclusion may only be used S AND • Restraint or seclusion must be discontinued at

SECLUSION when less restrictive interventions have been the earliest possible time. Nurses must document that the need for the restraint was made clear
determined to be ineffective to protect the
client, a staff member, or others from harm. SECLUSION both to the client and to support people such as family members.

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ALTERNATIVES TO RESTRAINTS ALTERNATIVES TO RESTRAINTS

Prepare clients before a move to limit relocation shock
and resultant confusion.
Replace full-length side rails with half- or three-quarter-length rails to prevent confused clients from
Ask family members or Reduce stimulation (e.g., • Stay with a client using a bedside commode or climbing over rails or falling from the end of the bed.
Assess for pain and treat
ALTERNATIVES
significant others to stay noise, lights); play bathroom if the client is confused or sedated or has a gait
appropriately. disturbance or a high-risk score for falling. • Use rocking chairs to help confused clients expend some of their energy so that they will be less
with the client. soothing music. inclined to wander.
TO • Provide frequent toileting, if needed; provide a bedside
commode. • Wedge pillows or pads against the sides of wheelchairs to keep clients safely positioned.

Assign nurses in pairs to RESTRAINTS • Monitor all the client’s medications and, if possible,
act as “buddies” so that Place unstable clients in attempt to lower or eliminate dosages of sedatives or
• Place a removable lap tray on a wheelchair to provide support and help keep the client in place.
one nurse can observe an area that is constantly psychotropics.
the client when the or closely supervised.
• To quiet agitated clients, try a warm beverage, soft lights, a back rub, or a walk.
other leaves the unit.
• Position beds at their lowest level to facilitate getting in
and out of bed.
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SELECTING A RESTRAINT
jacket or vest restraints
Use “environmental restraints,” such as pieces of furniture or large plants
as barriers, to keep clients from wandering beyond appropriate areas. It is safe for the
It does not interfere
It restricts the client’s particular client.
ALTERNATIVES
with the client’s
Place a picture or other personal item on the door to clients’ rooms to
help them identify their room.
movement as little as
possible.
Choose a restraint
with which the client
treatment or health
problem.
TYPES OF belt restraints
TO cannot self-inflict injury.
RESTRAINT
Try to determine the causes of the client’s sundowner syndrome
(nocturnal wandering and disorientation as darkness falls, associated with

RESTRAINTS
dementia). Possible causes include poor hearing, poor eyesight, or pain.
mitt or hand restraints
Allow restless clients to walk after determining the safety of the
environment.
It is readily changeable.
It is as discreet as S
possible.
Establish ongoing assessment to monitor changes in physical and
cognitive functional abilities and risk factors. limb restraints
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Applying restraints Applying restraints Applying restraints

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Applying restraints Applying restraints

APPLYING AN
EXTREMITY
RESTRAINT

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MICHAEL R. GOZE, MSN

9/6/2022