What are the different types of patient restraints?

According to the American Medical Association, patients should never be restrained punitively or for the convenience of staff. Understanding what are the different types of patient restraints is critical for ensuring they are used ethically and only as a last resort for patient safety in senior care.

Quick Summary

The main categories of patient restraints are physical, which limit movement with devices like soft wrist ties or bed rails; chemical, involving medication to manage behavior; and environmental, which control a patient's mobility through their surroundings. Restraints are legally and ethically restricted for use only when necessary to protect a patient or others from imminent harm.

Key Points

• Three Main Types: Patient restraints are categorized into physical (devices), chemical (medication), and environmental (restricting space).

• Use Only as a Last Resort: All restraints should be used only after less restrictive interventions have failed and must be medically necessary, not for convenience.

• Physical Restraints Vary: Physical restraints can range from soft hand mitts to more restrictive wrist/ankle ties and pose inherent risks like injury and skin breakdown.

• Chemical Restraint Misuse: Inappropriate use of psychoactive drugs for sedation is a serious ethical issue and is illegal in many contexts, especially for the elderly.

• Regulations and Ethics are Strict: Federal and state laws strictly govern the use of restraints, mandating consent, ongoing assessment, and documentation of alternatives.

• Prioritize Restraint Alternatives: Effective care focuses on de-escalation techniques and environmental modifications to prevent the need for restraints altogether.

Understanding the Three Main Categories of Restraints

Patient restraints are used to ensure the safety of the patient, staff, and other individuals when a person's behavior poses a significant risk. The decision to use a restraint is serious and should be made only after all other less restrictive interventions have failed. Understanding the different categories is the first step toward ethical and informed care, especially within the context of healthy aging and senior care, where unique challenges often arise.

Physical Restraints

Physical, or mechanical, restraints involve the use of a device to restrict a patient's movement. These are the most commonly understood type of restraint and vary significantly in how restrictive they are. Proper application and regular assessment are paramount to prevent injury, discomfort, and psychological distress.

Common Types of Physical Restraints

• Soft Wrist and Ankle Restraints: These are the most common form of limb restraints, typically made of soft fabric to prevent a patient from pulling at medical tubes (e.g., IV lines, catheters) or attempting to get out of bed unsafely. They are secured with a quick-release tie to a stationary part of the bed frame, not the bed rails.
• Hand Mitts (Mittens): A less restrictive option than wrist ties, these thumbless gloves prevent the patient from grasping objects or pulling at lines, while still allowing for some arm and hand movement. They are often used for confused or elderly patients.
• Posey Restraints and Belts: These devices, including belts or vests, are used to secure a patient to a chair or bed to prevent them from falling or wandering. Due to the risk of asphyxiation, vest restraints have been largely discontinued by many healthcare organizations.
• Bed Rails: While seemingly innocuous, bed rails are considered a physical restraint if they prevent a resident from leaving the bed voluntarily. For many patients, they can assist with mobility, but for others, particularly those with dementia or agitation, they can become a trap and cause injury.

Chemical Restraints

Chemical restraints involve the use of psychoactive medications to control a patient's behavior or movement. This is only considered a restraint if the drug or dosage is not part of the standard treatment plan for the patient's condition and is used solely for behavioral control. The misuse of chemical restraints, particularly in nursing homes, is a serious concern, with some studies highlighting their inappropriate use for convenience rather than medical necessity.

Common Medications Used as Chemical Restraints

• Antipsychotics: Drugs like Risperdal and Haldol, which are meant to treat psychosis, are sometimes used inappropriately to sedate patients with dementia.
• Benzodiazepines: These medications, including Ativan and Valium, are typically for anxiety or insomnia but can be misused to sedate agitated patients.
• Sedative Antidepressants: Certain antidepressants, such as Trazodone, which have sedative effects, can also be used as chemical restraints.

Environmental Restraints

Environmental restraints control a patient's mobility within their surroundings. This category focuses on restricting access to certain areas rather than directly restraining the person's body. These are often used in facilities with patients who are at risk of wandering or causing harm to themselves or others.

Examples of Environmental Restraints

• Seclusion: Placing a patient involuntarily in a room they cannot leave is a form of environmental restraint. This is a severe measure and should be used only in emergency situations under strict protocols.
• Locked Units: In senior care or memory care facilities, locked wards or units are a form of environmental restraint used to prevent residents with dementia from wandering off the premises.
• Lap Trays and Wheelchair Tables: When a patient cannot remove a lap tray from their wheelchair, it can become a form of physical restraint, restricting their ability to stand.

Comparison of Patient Restraint Types

Feature	Physical Restraints	Chemical Restraints	Environmental Restraints
Method	Devices attached to the body or surroundings.	Psychoactive medications.	Altering the physical environment.
Action	Limits physical movement.	Modifies behavior by affecting the central nervous system.	Restricts mobility and access to certain areas.
Primary Use	Prevents interference with medical treatment or risk of falling.	Manages severe agitation or aggressive behavior.	Prevents wandering, elopement, or access to dangerous areas.
Risks	Skin breakdown, circulation issues, aspiration, injury, psychological trauma.	Increased risk of falls, confusion, side effects, potential for abuse.	Feelings of isolation, loss of dignity, potential for trauma.
Ethical Considerations	Requires regular assessment, least restrictive option, quick release mechanism.	Requires a physician's order, informed consent, and is not for convenience.	Needs to be part of a structured care plan and not used punitively.

Ethical and Legal Considerations

The use of restraints is a serious matter governed by federal and state laws. Regulations like the Nursing Home Reform Act mandate that residents have the right to be free from restraints imposed for convenience or discipline. Any use must be medically necessary, temporary, and involve the least restrictive method possible. Healthcare professionals must exhaust all other alternatives before resorting to restraints.

The Importance of Alternatives

Before applying any form of restraint, alternatives should be attempted and documented. These alternatives, especially important in senior care, can include:

• Frequent and intentional rounding by staff.
• Alarms on beds and chairs to signal movement.
• Optimizing the environment with adequate lighting and removing hazards.
• Providing a calming atmosphere with soothing music.
• Engaging patients with personalized activities and distractions.
• Involving family and friends to provide company.
• Providing regular toileting, hydration, and nutrition to prevent agitation caused by unmet needs.

Best Practices for Application and Monitoring

When a restraint is deemed necessary, strict protocols must be followed to ensure patient safety:

1. Obtain a Physician's Order: A physician must order the restraint, specifying the type, duration, and reason.
2. Use Least Restrictive Option: The mildest form of restraint that is effective for the situation should be chosen.
3. Ensure Proper Fit: Restraints must be applied correctly, with enough slack to allow for two fingers to fit underneath, and secured with a quick-release mechanism.
4. Monitor Regularly: The patient's circulation, skin integrity, and sensation must be checked frequently, often every two hours or more often as per policy.
5. Reassess Continuously: The need for the restraint should be continuously re-evaluated, and it should be removed as soon as the patient is no longer at risk.

For more detailed guidance on ethical practices, consult resources like the American Medical Association's Code of Medical Ethics.

Conclusion

Navigating what are the different types of patient restraints requires a deep understanding of the distinctions between physical, chemical, and environmental methods. In the context of senior and elder care, the ethical mandate is to use restraints only as a last resort, prioritizing patient dignity and safety above all else. By understanding the types, recognizing the risks, and exhausting all possible alternatives, caregivers can ensure the highest standard of patient-centered care is maintained.

Frequently Asked Questions

What is the primary purpose of using patient restraints?

The primary purpose is to ensure the safety of the patient, other patients, and staff. This may be necessary to prevent a patient from harming themselves, such as pulling out a necessary medical tube, or to prevent a fall.

Are bed rails considered a type of restraint?

Yes, bed rails are considered a physical restraint if they are used to prevent a resident from leaving the bed voluntarily. However, they may not be a restraint if used to assist a mobile patient with moving around in bed.

How do chemical restraints differ from regular medication?

A medication becomes a chemical restraint when it is used to intentionally restrict a patient's movement or behavior, and the drug or dosage is not a standard, medically approved treatment for the patient's condition. The intent and context of the medication's use are key factors.

What are some alternatives to using patient restraints?

Alternatives include frequent staff observation, bed or chair alarms, adjusting the patient's environment (e.g., lighting, noise), engaging the patient in activities, addressing underlying physical needs (hunger, thirst, toileting), and utilizing trained de-escalation techniques.

Can restraints be used for staff convenience?

No, it is illegal and unethical to use restraints for staff convenience or as a form of punishment. Restraints must be medically justified, and all other options must be exhausted first.

What risks are associated with using restraints on elderly patients?

Elderly patients are at a higher risk for serious complications from restraints, including skin breakdown, aspiration, nerve damage, circulation issues, increased agitation, and psychological trauma.

How often should a patient in a physical restraint be monitored?

A patient in a physical restraint should be monitored frequently, often at least every two hours, to check their circulation, skin integrity, and overall well-being. Protocols can vary by facility, and the patient's condition must be continuously reassessed.