Muscular – Physical and/or Chemical RestraintsSECTION: 6.09

Strength of Evidence Level: 1__RN__LPN/LVN__HHA

PURPOSE:

To ensure patient safety by using restraints appropriately.

CONSIDERATIONS:

  1. Patients have a right to be free from mental and physical abuse and from physical and chemical restraints.
  2. Use of physical or chemical restraints requires a physician’s written order.
  3. The only exception to a physician’s written order is an emergency situation in which the nurse determines that the use of a physical restraint is necessary to protect the patient from injury to self or others. If such an emergency situation occurs, the nurse will promptly notify the physician of the event.
  4. Before a patient with an order is restrained, other measures of patient safety will be attempted (i.e., medication, increasing time with a caregiver).

EQUIPMENT:

Restraints as selected

Medications as selected

PROCEDURE:

  1. Carefully assess need for physical or chemical restraint. This assessment includes:
  2. Meaning behind patient’s behavior.
  3. Imbalance in blood chemistry.
  4. Sensitivity to drugs.
  5. Confusion/delirium related to infection, increased temperature.
  6. Input from other visiting staff (HHA, therapy, nurses).
  7. Explore alternatives to use of restraint. These may include:
  8. Providing supervision/companionship.
  9. Reality orientation.
  10. Relaxation techniques (massage, music, etc.).
  11. Active listening.
  12. Changing or eliminating treatments that irritate the patient.
  13. Diversionary activity.
  14. Obtaining a physician order for psychiatric nurse consultation, medical social worker or physical therapy services, if applicable.
  15. If alternatives to the use of restraints, such as sedation, are inappropriate or have been unsuccessful, obtain written consent of the patient or legal guardian, if possible. If not possible, document in the patient’s record.
  16. Contact the physician to report circumstances necessitating a physical restraint and obtain a verbal/written order for restraint. The order must specify:
  17. Type of restraint.
  18. Reason for restraint.
  19. Time and duration of use of restraint.
  20. Initiate soft physical restraint per physician order.
  21. In an emergency, physical restraint may be initiated prior to obtaining a verbal/written order, to protect the patient from injury to self and others.
  22. The nurse must document the circumstances requiring the use of restraints and promptly report (within 24 hours) any such action to the physician.
  23. Chemical restraints cannot exceed current medical orders.
  24. Instruct patient/family/caregivers regarding side effects and safety concerns about the restraint in use. Teach, demonstrate and supervise application of any device or adjustment in medication dose.
  25. The restraint must be soft and applied in such a way as to not cause abrasion or restrict blood circulation.
  26. A person in physical restraints must be observed by the caregiver at least every 30 minutes for the following:

(1)Restraint in the proper position.

(2)Any restriction in circulation.

(3)Any skin abrasion/irritation.

(4)Any change in patient condition.

(5)Any evidence of pain or discomfort.

(6)Evidence of coping/need for reassurance.

  1. A person undergoing chemical restraint must be observed for the following:

(1)Untoward side effects of the drug(s).

(2)Adequate hydration.

(3)Ongoing need for restraint.

(4)Evidence of coping/need for reassurance.

  1. Written instructions should be left in the home.
  1. Continually reevaluate the need for restraints. Reinforce the temporary nature of the situation and discontinue the restraints per medical order, as soon as no longer needed.
  2. Restraints are to be applied in such a way that they may be removed quickly in case of an emergency.
  3. When a caregiver initiates the restraints, the nurse:

a.Assesses need for restraint.

b.Assesses safety of restraint being used.

c.Instructs patient/family/caregivers regarding alternatives.

d.Instructs patient/family/caregivers regarding appropriate restraint.

e.Counsels patient/family/caregiver regarding liabilities and safety concerns related to inappropriate restraint.

(1)Notify physician immediately if the patient is endangered.

f.Informs patient/family/caregiver of their responsibility to notify the patient’s physician if restraint is initiated.

g.Document the situation, which may include Steps 9a-9f.

AFTER CARE:

1.Document in patient record:

a.Assessment findings.

b.Instructions regarding alternatives to restraintimplementation and response.

c.Description of implementation of physician order for temporary restraint.

d.Consent was obtained from patient or legal guardian.

e.Patient response to restraint during course of restraint.

f.Instructions given to patient/caregiver.

g.Communication with physician.

REFERENCES:

Strumpf, N. E., Robinson, J. P., Wagner, J. S. (1998). Restraint-Free Care: Individualized Approaches for Frail Elders. New York, NY:Springer Publishing Company, Inc.