Patient Restraints

Ministry Door County Medical Center

1. Door County Memorial Hospital
Restraints & Safety
Staff Education

2. Purpose: The purpose of this presentation is to provide nursing
staff with information on how to care for patients in need of
restraints
•Goal: The goal of this self-directed presentation
is to educate staff to use restraints as a last
resort and, when used, to provide a safe
environment for the patient in restraints.
•Objectives: After completing this presentation,
the participant will be able to:
–Explain what measures to try before putting a patient
in restraints.
–Describe the type of order that must be written for
restraints.
–Describe methods to safely care for a patient in
restraints.

3. Restraint Safety Information
•A physical restraint is any manual method, physical or
mechanical device, material, or equipment that immobilizes or
reduces the ability of a patient to move his or her arms, legs,
body, or head freely.
•A chemical restraint is a drug or medication that is used as a
restriction to manage the patient’s behavior or restrict the
patient’s freedom of movement and is not a standard treatment
or dosage for the patient’s condition.
•Seclusion is the involuntary confinement of a patient alone in a
room or area from which the patient is physically prevented
from leaving.
•The use of seclusion or medication as a
restrictive intervention, restraint and/or
chemical restraint is not employed at
DCMH .

4. There are many potential risks
and side effects of restraint use:
•Psychological/Emotional:
• Increased agitation, hostility, aggression and combativeness
• Feelings of humiliation, loss of dignity
• Increased confusion
• Fear
•Physical:
• Pressure ulcers, skin trauma (tears, cuts, bruises)
• Bone loss (demineralization) from decreased weight bearing activity
• Decreased muscle mass, tone, strength, endurance
• Deconditioning leads to stiffness, contractures, loss of balance, increased risk of
falls
• Reduced heart and lung capacity, increased risk of orthostatic hypotension and
respiratory infection
• Physical discomfort, increased pain
• Increased constipation, increased risk of fecal impaction
• Increased incontinence and risk of urinary tract infection due to urinary stasis
• Obstructed and restricted circulation
• Reduced appetite
• Dehydration
• Death

5. All alternatives must be tried before
restraints are to be used. This includes:
•Offer bedpan or bathroom every 2 hours
•Offer fluids and nourishment frequently, keep water within
reach
•Provide diversional activity
•Decrease stimuli and noise
•Provide change of position, up to chair, ambulation
•Have patient wear glasses and/or hearing aides
•Activate bed alarm
•Increase observation
–Ask family to sit with patient
–Alert other staff to be observant
–Move patient to a room near the nurse’s station
•If the patient is interfering with his medical equipment
–Educate frequently not to touch the treatment device
–Place the device out of site if possible
–Cover the device (i.e. wrap I.V. site with Coban or Kerlex)

6. Important Reminders
•Document all alternatives that were tried
before restraint use. The decision to use
restraints must include the full awareness of
the patient’s rights, dignity, modesty and well
being. Patients and families must be
provided with information on restraints to
allow for an informed decision. This should
include providing them with “Information
Sheet: Using Restraints Safely.”

7. Patient and Family Education:
•Discuss with patient and family
safety concerns, i.e. risks of pulling
out IV.
•Explain the behavior that initiated
restrain use
•Explain the alternatives tried
•Assure that safety/comfort will be
met

8. Restraint Orders
Situational Medical Behavioral
* Initiation of
Restraints
(ALWAYS after
alternatives
tried)
* Renewing
Order
-Obtain written or
verbal order within
12 hours of initiation,
physician exam
within 24 hours.
- Every 24 hours
-May apply in
emergency, but get
doctor order with in 1
hour. Dr must do face-
to-face assessment
within 1 hour of
restraint initiation.
- In accordance with
following limits up to a
total of 24 hours:
- 4 hrs for adults 18 and
up.
- 2 hrs for children
9-17 yrs of age.
-1 hr for children
nine and under.

9. Safe application of wrist/ankle
restraints:
•Always use quick release knots
•DON’T tie to side rails or cross behind patient
•Keep side rails up at all times
•Have call light in reach
•Keep sharp objects away from patient
•Never use a draw sheet tied around the patient’s
waist as a restraint
•Use only hospital approved soft restraints on wrists
and ankles
•If leather restraints are required: keep padding under
leather, keep key behind headboard or taped to the
wall above headboard at all times

10. Monitor a patient in restraint every
15 minutes for:
•Signs of injury
•Circulation and range of motion
•Comfort
•Readiness for discontinuation of
restraint

11. Documentation (on the restraint
management flow sheet) every 2 hours for:
•Release the patient, turn and position
•Institute a trial of restraint release
•Hydration and nutrition needs
•Elimination needs
•Comfort and repositioning needs

12. Correct way to tie a
quick –release knot.
To make a quick-release knot, make a regular over
hand knot, but slip a loop (instead of the end of the
strap) through the first loop.

13. Reminder- on restraints
•Remember not to tie to side rails or
cross behind the patient.

14. Additional Information
•For additional information on restraints
refer to:
- Restraints policy, found on the J
drive in the Administrative Policies
under Patients Rights &
Organizational Ethics.
- MedFilms, Educational Video:
“Patient Restraints and Seclusion”
located in Nursing Education Office.

15. References:
•Door County Memorial Hospital. (2008,
July). Policy and Procedures:
Administrative Policies, Patient Rights
& Organizational Ethics. Restraints.
Sturgeon Bay, WI
•Carter, Pamela J., (2007) Lippincott's
Essentials for Nursing Assistants: A
Humanistic Approach to Caregiving
(pp 279-286). Lippincott Williams &
Wilkins.