2. DefinitionDefinition
Any action or deed that is used for theAny action or deed that is used for the
purpose or intent of restricting the freepurpose or intent of restricting the free
movement or decision making abilities ofmovement or decision making abilities of
another person; as such it may constituteanother person; as such it may constitute
an imposition on a person’s rights andan imposition on a person’s rights and
dignity.dignity.
3. CONTCONT
• Restraint consist of any physical orRestraint consist of any physical or
chemical restraint used on a patient to keepchemical restraint used on a patient to keep
him from causing harm to self or to others.him from causing harm to self or to others.
• Is used only as an emergency therapeuticIs used only as an emergency therapeutic
measure and only where no other option ismeasure and only where no other option is
available.available.
5. Arguments for the use of RestraintArguments for the use of Restraint
11..EthicalEthical
22..BeneficenceBeneficence
33..ProfessionalProfessional
6. Statement ofStatement of
AccountabilityAccountability
• Physician- responsible for writingPhysician- responsible for writing
and reviewing the restraint order.and reviewing the restraint order.
• Responsible nurse- responsible forResponsible nurse- responsible for
assessment and documentationassessment and documentation
• Head nurse- responsible forHead nurse- responsible for
monitoring the policy fullymonitoring the policy fully
implemented.implemented.
7. Order for RestraintOrder for Restraint
• Use only after written order by theUse only after written order by the
physician, unless emergencyphysician, unless emergency
situation occurs.situation occurs.
• Patient is reassessed every 24 hoursPatient is reassessed every 24 hours
for continued need for restraint.for continued need for restraint.
• New order is required after 24New order is required after 24
hours.hours.
8. CONTCONT……
• No standing order allowedNo standing order allowed
• Physician and nurse must documentPhysician and nurse must document
in their notes the indication forin their notes the indication for
restraint.restraint.
• Type of restraint to be usedType of restraint to be used
• The projected time restraint is to beThe projected time restraint is to be
employedemployed..
9. Alternative for RestraintAlternative for Restraint
• Provide for companionship and supervisionProvide for companionship and supervision
• Modify the environmentModify the environment
• Provide readily orientation andProvide readily orientation and
psychosocial interventions.psychosocial interventions.
• Offer diversionary and physical activitiesOffer diversionary and physical activities
• Design creative alternativesDesign creative alternatives
10. Restraint TypeRestraint Type
• Soft wrist restraintSoft wrist restraint
• Soft ankle restraintSoft ankle restraint
• Velcro wrist restraintVelcro wrist restraint
• Velcro ankle restraintVelcro ankle restraint
• Posey vestPosey vest
• Geri- chair that restrict the patient fromGeri- chair that restrict the patient from
leaving the chairleaving the chair
11. AssessmentAssessment
• Check for circulation, condition of limbsCheck for circulation, condition of limbs
• Attention should be given to patient’s needsAttention should be given to patient’s needs
including hydration, elimination andincluding hydration, elimination and
nutritionnutrition
• Vital signsVital signs
12. Behavior Required for ReleaseBehavior Required for Release
• Follows instructions, directionsFollows instructions, directions
• Calm, in controlCalm, in control
• Verbal contactVerbal contact
• Asks for assistanceAsks for assistance
13. How to Apply RestraintHow to Apply Restraint
• Apply restraint according to theApply restraint according to the
manufacturer’s directionsmanufacturer’s directions
• It should be easy to remove in the event ofIt should be easy to remove in the event of
fire and emergenciesfire and emergencies
• Extremity restraints must be attached toExtremity restraints must be attached to
the frame of bed and not to the side rails.the frame of bed and not to the side rails.
Allow length of strap for acceptableAllow length of strap for acceptable
movementsmovements
14. CONTCONT……
• Extremity restraints must be assessed andExtremity restraints must be assessed and
one extremity must be released every 2one extremity must be released every 2
hours.hours.
• A vest restraint must be applied with atA vest restraint must be applied with at
least two fingers space between body andleast two fingers space between body and
vest.vest.
• Apply restraint in such a manner that doesApply restraint in such a manner that does
not restrict circulation.not restrict circulation.
16. Education of FamilyEducation of Family
• Teach/ explain the reason for the restraint, theTeach/ explain the reason for the restraint, the
care that will be provided while restrained and thecare that will be provided while restrained and the
criteria for the removal of the restraint.criteria for the removal of the restraint.
• Restraint may be removed based on the nurse’sRestraint may be removed based on the nurse’s
assessment of risk when the family is present atassessment of risk when the family is present at
the bedside.the bedside.
• Document patient/ family education onDocument patient/ family education on
appropriate forms.appropriate forms.
17. Staff EducationStaff Education
• On- going restraint education andOn- going restraint education and
training will be provided both astraining will be provided both as
part of the initial orientation of allpart of the initial orientation of all
staff who have direct patient carestaff who have direct patient care
responsibilities.responsibilities.
18. DocumentationsDocumentations
• Fill Restraint Form.Fill Restraint Form.
• Date and time restraint is initiatedDate and time restraint is initiated
• Date of assessmentDate of assessment
• Reason for restraintReason for restraint
• Alternative methods attempted prior to restraintAlternative methods attempted prior to restraint
• Attempts to discontinue restraintAttempts to discontinue restraint
• Date and time restraint is discontinuedDate and time restraint is discontinued
19. Document Release of a PatientDocument Release of a Patient
from Restraintfrom Restraint
• Restraint should be frequently evaluated andRestraint should be frequently evaluated and
ended at the earliest possible time based on theended at the earliest possible time based on the
assessment and re-evaluation of the patient’sassessment and re-evaluation of the patient’s
condition.condition.
• Rationale for removing the patient from restraintRationale for removing the patient from restraint
will be documented on the patient’s medicalwill be documented on the patient’s medical
record.record.
• The physician or RN may terminate the restraintThe physician or RN may terminate the restraint
when in their clinical judgment.when in their clinical judgment.
20. CONTCONT……
• Reusable restraint cuffs and straps are to beReusable restraint cuffs and straps are to be
sprayed with disinfectant and wiped after use andsprayed with disinfectant and wiped after use and
before storage in the linen room.before storage in the linen room.
• Cloth restraint devices will be placed in soiledCloth restraint devices will be placed in soiled
linen hampers after use.linen hampers after use.
• Disposable restraint will be discarded.Disposable restraint will be discarded.
• Restraint devices should not be sent home withRestraint devices should not be sent home with
patient or family.patient or family.
