This document discusses techniques for dealing with aggression and violence, including breakaway techniques, restraint, and seclusion. It defines breakaway techniques as physical skills to safely break away from an aggressor. Restraint is defined as intentionally restricting a person's movement and can be environmental, physical, or chemical. Seclusion involves isolating a person in a locked room. The document provides guidance on monitoring patients in restraint, including checking them every 15 minutes for safety. It emphasizes using the least restrictive techniques and following policy guidelines when employing restraint or seclusion.

1. Ms. Mary Sebastian
Professor, Vice-Principal
KIMS Nursing College
BREAK-AWAY AND RESTRAINING
TECHNIQUES

2. Breakaway techniques are a set
of physical skills which are
intended to help someone ‘break
away’ from an aggressor in a
safe manner.
In a way, it is very similar to self defense.

3. AIM
To deal with threatening situations by teaching the
delegate in care environment the correct procedures for
protecting themselves and those around them in
circumstances of aggression and physical assault.
IMPORTANCE
1. Teaches you to protect yourself and others from
physical attacks. Other people who could be in danger
are patients, members of staff, visitors etc.,
2. Teaches key points in law, in particular, health and
safety legislation.

4. IS BREAKAWAY TRAINING
FOR ME?
Confrontation in the workplace is inevitable. Having it
as a skill is vital should a situation ever occur. As a
care giver, it is your responsibility to look after those
who are vulnerable and less able than yourself and
breakaway training facilitates this to some extent.
Physical attacks can occur in a variety of situations
such as whilst standing, sitting behind a desk, walking
etc. The point is that by learning how to deal with
attacks in different situations you can effectively
resolve the issue.

5. WARNING SIGNS AND
DANGER SIGNS
With breakaway training, it’s important to be aware
of warning signs and danger signs, so let’s take a
look at the difference between the two. When
warning signs manifest it might be possible to
intervene and attempt to resolve the situation.
However, with danger signs, it is recommended that
you leave and pursue help from security staff .

6. WARNING SIGNS:
• Direct, prolonged eye contact
• Standing tall
• Exaggerated movements
• Breathing rate increases
• Quick movements
• Shifting weight from one foot to the
other

7. DANGER SIGNS:
• Fist clenching
• Lips tighten over teeth
• Hands rise above the waist
• Shoulders tense
• Stance moves from square to sideways
• Facial colour may pale

8. A – Attire
A – Alarm
B – Bouncer
S – Space
S – Safe Presence

9. PUNCH

10. KICK

11. CHOKING

12. WRIST
GRAB

13. CLOTHES
GRAB

14. GRAB FROM
FRONT &
BEHIND

15. HAIRPULL

16. BITING

17. RESTRAINTS
Agitation and violent behavior are frequently seen in acute care
settings, such as emergency departments and inpatient
psychiatric facilities.
[5, 6, 7] Approximately 10% of psychiatric patients in the
emergency department will have violent behavior and possibly
require some form of restraint
Restraint is defined as ‘the intentional restriction of a person’s voluntary movement
or behavior. (Counsel And Care UK, 2002)
Restraint refers to “Any manual method or physical or mechanical device, material
or equipment that immobilizes or reduces the ability of a person to move his or her
arms, legs, body or head freely. (ANA)

18. INDICATION
• Is no longer exerting
control over his/her own
behaviour.
• To prevent harm to self and
others.
• To prevent serious
disruption of treatment
environment.
• For safety of patient and
others
• To reduce stimulation
METHODS
• Verbalise the
methods
(De-escalation)
• Medicate client as
necessary
• Seclusion
• Restrain

19. TYPES OF RESTRAINTS
• Environmental
• Physical/Mechanical
• Chemical

20. ENVIRONMENTAL RESTRAINTS
It can include modification of an individual’s surroundings
to restrict or control movement e.g., seclusion rooms,
locked doors.
ACUTE PSYCHIATRIC WARD (LOCKED UNIT) SETTING:
• Provide 24 hours care
• Admitted for voluntary or in voluntary basis
• Severity of illness
• Availability of team members
• Limiting access beyond the unit (locked unit)
• Limiting access beyond the patient’s room (locked room
• Placement of the patient in a separate room that is locked (Seclusion)

21. MECHANICAL RESTRAINT:
Partially impairs the free movement of a limb or totally unable to freely walk or
stand as a result of the application of the restraint.
PHYSICAL RESTRAINT may involve:
• Applying a wrist, ankle, or waist restraint
• Tucking in a sheet very tightly, so the patient can’t move
• Keeping all side-rails up to prevent the patient from getting out of bed.
PHYSICAL / MECHANICAL RESTRAINT
Physical restraint, the most frequently used type, is a specific intervention
or device that prevents the patient from moving freely or restricts normal
access to the patient’s own body

22. POINTS TO REMEMBER
• Secure the limb holder cuff tightly enough to prevent the patient from
pulling the limb out of the cuff.
• Loose enough to allow adequate circulation.
• Allow a one-finger space between the cuff and the patient’s limb.
• Tie the straps to a movable part of the bed frame, out of the patient’s
reach.
• Do not tie it to a side rail or cross behind the patient.
• 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.
• Ensure that the bow/knot used can be released with a single pull on the
tail of the straps.
• Maintain proper alignment of body and limbs,

23. SECLUSION
It means the isolation of a user or a space,
where his or her freedom of movement is
constricted or restricted.
Seclusion is the involuntary confining of a
person alone in a room from which the person
is physically prevented from leaving (Brown,
2000).

24. DEGREE OF SECLUSION
• Closed or unlocked door
• Placing a patient in a locked room with
a mattress but no linens
• Limited opportunity for communication.

25. PRINCIPLES OF SECLUSION
• Containment – Restricted to a place where
they are safe.
• Isolation - the need for patients to distance
themselves from relationships
• Seclusion- provides a decrease in sensory
input to external stimulation.

26. INFRASTRUCTURE OF SECLUSION
• The seclusion room must be located near the nurses’ station for ease of
observation.
• Adequate temperature control to prevent hypo- or hyperthermia
and promote comfort should be provided.
• The ceiling must be beyond the reach of the mental health care user.
• Windows must pose no safety or security risk.
• Unbreakable safety glass.
• Contraindications
• Seclusion and restraint should not be used
• Patient is suicidal or actively self-harming.
• For children up to 12 years
• As punishment or a threat
• For the convenience of personnel
• Management strategy to compensate for a shortage of staff
• Where there are clinical or medical conditions requiring.

27. COLOUR CODES
•Code Violet
•Code Blue
•Code Pink
•Code Red
•Code White

28. CODE WHITE
The term is used to alert staff when a violent or
potentially violent patient who is
unmanageable by any other means presents a
danger to self or others.
Team uses evidence-based therapeutic
methods to help the patients calm down.

29. WHEN TO CALL A CODE WHITE
• Verbally or physically threatening towards
themselves, staff, patients, or visitors
• Damaging the property
• Not responding to verbal de-escalation
techniques
• Require restraint (chemical and/or physical)
and is anticipated to be resistive to the
restraining procedure
• Urgent assistance is required

30. ROLES AND RESPONSIBILITIES
• Proceed to the designated location.
• Always have an eye on the violent
patient direct visitors and patients away
from the immediate danger area.
• Assist the team in verbal or physical
interventions

31. TEAM MEMBERS
• Nurse assigned to the patient
• Nurse manager/delegate of area
• First clinician on scene
• Any clinician or therapist working with
patient
• Any clinician or therapist from
patient’s unit

32. POST-INCIDENT REVIEW
• They should address what happened
during the incident
• Patient demographics
• Description of the incident
• Precipitating factors
• Behaviours witnessed
• Type of intervention
• Medication administration
• Debriefing session
• Information given to relatives.

33. R ESTR A IN T OR D ER S
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’s order within 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 9 and under.

34. MONITOR
• Breathing
• Behaviour
• Skin colour
• Care for the patient’s head
and airway
• Ensure no pressure is
applied to the neck, thorax,
abdomen and pelvic area

35. RESTRAINT GUIDELINES
• Doctor’s order
• Informed consent
• Follow proper technique
• Least restrictive
• Maintain good body
alignment

36. RISKS WITH RESTRAINTS
• Falls
• Strangulation
• Loss of muscle tone
• Pressure sores
• Decreased mobility
• Agitation
• Reduced bone mass
• Stiffness, frustration, loss of dignity,
incontinence and constipation

37. ROLE OF A NURSE
• Assess the client’s behavior and the need for restraint.
• Get written order and obtain consent.
• Communicate with the client and family members.
• Comply with institutional policies and rules.
• Explain the client the reason for the restraint and
cooperation.
• Arrange adequate assistance from competent staff.
• Apply the least restrictive, reasonable and appropriate
devices.
• Apply restraints with care that not to injure a patient.
• Each staff member should be assigned responsibility.
• Observe the patient every 15 min.
• All the needs of the patient must be met.
• Patient should be gradually decreased from seclusion or
restraint.

38. DOCUMENTATION
MONITOR A PATIENT IN RESTRAINT EVERY
15 MINUTES FOR:
• Signs of injury
• Blood circulation and range of motion.
• Readiness for discontinuation of restraint.
• Hydration and nutritional needs, elimination
needs, comfort and repositioning needs.

39. RESTRAINT CARE
Patient Name:
Age/Sex
I.P.No.
Ordered by (Dr.)
Date:
Explained to the patient/relative the need for restraints
Restrained in the right position
Head is raised on a pillow
Peripheral Pulse
Injuries
Vitals
Nutritional Needs(sips of water, juices etc)
Elimination Needs(urinal/diaper/mackintosh/
condom catheter)
RESTRAINT CHECKLIST – TIME
Restrained AM/PM
Unrestrained AM/PM
Restrained AM/PM
Unrestrained AM/PM
Restrained AM/PM
Unrestrained AM/PM
When patient is under control remove one restraint at a time at 5-min interval, until only
two restraints are on.
Remove all restraints when patient is completely sedated