What is a safe technique when applying physical restraints?

According to the Centers for Medicare & Medicaid Services, the use of physical restraints must be a last resort and based on a physician's order, never for convenience or discipline. So, what is a safe technique when applying physical restraints to ensure the dignity and well-being of the individual?

Quick Summary

The safest technique involves a multi-step, person-centered approach, prioritizing de-escalation and alternatives first. If absolutely necessary, use the least restrictive device, ensure proper sizing, use quick-release knots tied to a non-movable bed part, and perform continuous monitoring.

Key Points

• Last Resort Only: Physical restraints should be used exclusively as a last resort, after all less-restrictive alternatives have been exhausted, and never for convenience or discipline.

• Least Restrictive Method: Always select the least restrictive restraint that effectively addresses the safety risk, such as soft mitts over full limb restraints if appropriate.

• Proper Application: Ensure restraints are correctly sized, padded, and tied to a non-movable part of the bed frame using a quick-release knot, allowing two-finger slack for circulation.

• Continuous Monitoring: A restrained patient requires frequent, close observation to check for signs of compromised circulation, skin breakdown, and emotional distress.

• Thorough Documentation: Document all aspects of the restraint process, including the reason for use, alternatives attempted, application, monitoring, and removal.

When Are Physical Restraints a Last Resort?

In the context of senior care, physical restraints are not tools of convenience but a critical intervention reserved for specific, medically necessary situations. The guiding principle is to protect the patient from causing immediate, serious harm to themselves or others when all less restrictive alternatives have failed. It is imperative to have a physician's order detailing the type of restraint, the specific behavior necessitating it, and the duration of its use. Any use for discipline, convenience, or staff shortage is a violation of patient rights and is considered abuse. Proper training is non-negotiable for all staff involved in their application and monitoring.

The Importance of a Patient-Centered Approach

Before even considering a physical restraint, a thorough assessment of the patient's underlying needs is essential. Agitation or confusion might stem from an easily treatable cause, such as pain, an infection, or even simple boredom. Interventions should focus on addressing these root causes first. Validating the individual's feelings and concerns can often de-escalate a situation more effectively than any physical measure. Ultimately, maintaining the patient's dignity and autonomy is paramount.

Safe Application Techniques: A Step-by-Step Guide

When the decision to apply a physical restraint is made, following a precise, standardized procedure is crucial to prevent injury and ensure safety.

1. Assess and Prepare: Before approaching, ensure you have the correct, appropriately-sized restraint device and a clear understanding of the physician's order. Gather any necessary assistance and communicate the plan clearly to all team members.
2. Position the Patient: The patient should be in proper body alignment to prevent nerve and neurovascular damage. Position the bed or chair at a safe, low height with the wheels locked. Avoid the prone position, as it is extremely dangerous and can lead to asphyxiation.
3. Protect Bony Prominences: Use padding to protect bony areas like wrists or ankles from pressure and skin breakdown. The restraint itself should be applied over clothing to avoid friction burns.
4. Apply the Restraint: Secure the restraint firmly but not too tightly. A crucial check is ensuring you can comfortably slide two fingers between the restraint and the patient's skin. This prevents impaired circulation, swelling, and nerve damage. Mitt restraints can prevent grabbing but still allow some arm movement.
5. Use Quick-Release Knots: Fasten the straps with a half-bow or slipknot. This type of knot can be undone quickly in an emergency, unlike a standard square knot that may become impossibly tight under tension. The knot must be easily accessible to staff but out of the patient's reach.
6. Secure to a Non-Moving Part: Always tie the restraint to the patient's bed frame—never to the side rail. This prevents injury if the side rail is lowered or if the bed position is adjusted. Ensure enough slack is given to prevent restriction of movement when the head of the bed is raised.

Continuous Monitoring and Assessment

Proper application is only half the battle. Continuous, vigilant monitoring is essential to ensure the patient's safety and comfort. Neglect while a patient is restrained can have severe, life-threatening consequences.

• Circulation Checks: Assess the color, temperature, sensation, and pulse of the restrained extremities at least every 15-30 minutes, or as per facility policy. Report any signs of compromised circulation immediately.
• Skin and Joint Integrity: Check for any signs of skin irritation, redness, or breakdown. Reposition the patient frequently (e.g., every 2 hours) and provide range-of-motion exercises to prevent stiffness and pressure ulcers.
• Vital Signs and Comfort: Monitor the patient's vital signs and check their level of agitation and comfort. Offer hydration, toileting, and nutrition at regular intervals.
• Mental and Emotional Status: Observe the patient's psychological state. Being restrained can be a traumatic experience, leading to fear, anxiety, or increased agitation. Offer reassurance and reorientation frequently.

Understanding Different Restraint Types

Different situations may call for different types of restraints. The principle of using the least restrictive method still applies.

Restraint Type	Appropriate Use	Potential Risks
Soft Mitts	Preventing dislodging of IVs, tubes, or dressings.	Patient may still be able to pull on lines; potential for increased agitation.
Wrist/Ankle Ties	Limiting limb movement for safety during procedures or severe agitation.	Risk of impaired circulation, nerve damage, skin breakdown, and psychological distress.
Vest/Jacket	Securing a patient in a bed or chair to prevent falls.	High risk of suffocation via strangulation if not properly fitted and monitored.
Enclosure Bed	Preventing a patient who is impulsive from climbing out of bed and falling.	May increase agitation or fear; requires regular monitoring for safety.

Alternatives to Restraints

For the vast majority of situations, alternatives to physical restraints are a safer, more humane option. The focus should always be on proactive, preventative care. Examples include bed and chair alarms, frequent staff rounding, providing a calm environment, engaging distractions like music or simple tasks, and involving family for comfort.

Conclusion: Promoting Patient Dignity

In summary, knowing what is a safe technique when applying physical restraints is a critical, high-stakes skill for senior care providers. However, the ultimate goal is to minimize their use and prioritize a person-centered approach that honors the individual's dignity. When restraints are unavoidable, they must be applied correctly, monitored diligently, and documented thoroughly. The least restrictive option for the shortest time possible, coupled with continuous assessment and compassionate care, remains the highest standard of practice. For further guidance on the ethical and procedural standards for restraint use in healthcare, consult authoritative sources like the Code of Medical Ethics of the American Medical Association.

Thorough Documentation Is Key

Every step of the restraint process must be meticulously documented. This includes the reason for restraint, the alternatives attempted, the type and time of application, all monitoring assessments, and the patient's response. This documentation serves as a legal record and is a vital tool for ensuring accountability and improving future care plans. It should also include a plan for gradual de-escalation and eventual removal of the restraints as soon as the patient's condition allows.

Frequently Asked Questions

What is the very first step before applying any physical restraint?

The first step is a comprehensive assessment to identify and address the underlying cause of the patient's behavior, such as pain, infection, or anxiety. Use verbal de-escalation and other alternatives before considering restraints.

How do you tie a physical restraint safely?

A physical restraint must be tied with a quick-release knot, such as a half-bow or slipknot. This ensures it can be removed rapidly in an emergency. It should never be a standard square knot.

Where should a physical restraint be secured?

Restraints must be secured to a non-movable part of the bed frame, not the side rails. This prevents injury to the patient if the side rail is accidentally lowered or the bed position is adjusted.

How often should you monitor a patient in physical restraints?

Monitoring frequency can vary by facility policy, but circulation checks, skin integrity assessments, and checks on comfort should occur at least every 15-30 minutes. The patient must also be repositioned regularly, typically every two hours.

What are some alternatives to using physical restraints for confused seniors?

Alternatives include bed and chair alarms, providing a calm and distraction-free environment, engaging the patient in meaningful activities, and frequent staff rounding to check on needs like toileting or hunger.

What should you never do when applying a physical restraint?

Never tie restraints to a movable object like a side rail, use a standard knot, or apply them in a way that restricts a patient's breathing. Restraints must never be used for convenience, punishment, or due to staffing shortages.

How does proper physical restraint technique relate to patient dignity?

A proper technique respects patient dignity by using the least restrictive method for the shortest time, ensuring patient comfort, and prioritizing alternatives. It emphasizes that restraints are a last resort for safety, not a tool for control.