[Fr. restrainte, a tying back]
1. Refraining from any action, mental or physical.
2. The condition of being hindered.
3. In medicine, the use of environmental, pharmacologic, or physical means to prevent patients from harming themselves or others.
The FDA defines restraint as “a device, usually a wristlet, anklet, or other type of strap intended for medical purposes and that limits a patient's movements to the extent necessary for treatment, examination, or protection of the patient.” Protective devices include safety vests, hand mitts, lap and wheelchair belts, body holders, straitjackets, and protection nets.
Restraints should be fitted properly and comfortably. They should be applied so as to protect the patient from accidental self-injury, such as strangling or smothering by slipping down in a bed, wheelchair, or chair.
Caregivers are legally and ethically responsible for the safety and well-being of patients in their care; however, when the patient's protection or the achievement of the therapeutic goal appears to require physical or pharmacological restraint, health care providers must consider that such action limits the patient's legal rights to autonomy and self-determination. Decisions to institute restraint must be based on a clear, identifiable, documented need for their use.
With many patients, effective alternatives to physical restraint include providing companionship and close supervision of activities; explaining procedures to reduce anxiety; when possible, removing indwelling tubes, drains, and catheters to reduce discomfort and the potential for displacement; providing good lighting, ensuring that pathways are clear, and that furniture is adequately secured to minimize potential hazards; maintaining beds in low position and using bed alarm systems that signal if the patient’s body is not in contact with the mattress; using an alarm system when the patient is in a chair or wheelchair; ensuring that the call button is easily accessible to facilitate patient requests for help with ambulation; reducing unwelcome distractions, e.g., background noise; enabling the patient's access to diversions such as music and videos to encourage relaxation; and encouraging ambulation and exercise to meet the patient's needs for mobility.
Informed consent must be obtained from the patient or guardian before restraints are to be used. Restraints should not be used without a specific order from the treating health care provider. Almost any type of restraint has the potential for harming the patient; thus it is extremely important to monitor use and be certain that it is applied correctly and removed periodically.
The nurse records behavior that demonstrates a need for restraint; describes nursing actions to achieve the therapeutic objectives of without resort to restraint and the effects of the restraint; suggests the minimum amount of restraint for achieving the objectives; secures or reviews practitioner orders for specific types of restraints; validates informed consent; explains the use of the specific type of restraint to the patient and family members as a reminder needed for protection; and encourages verbalization of feelings and concerns and provides emotional support.
The nurse follows these guidelines for application of restraints: the device that is most appropriate for the purpose is selected. For example, padded mitts protect against patient removing intravenous or other invasive tubing by limiting his or her ability to manipulate the equipment with his or her fingers, but the mitts do not elicit the restlessness and frustration that occurs when the hands are tied down with wrist restraints. The status of tissues is assessed and documented before application. Bony prominences in contact with the restraining devices are padded before application of restraints. Restraints are applied to maintain a comfortable, normal position, and mobility is limited only as much as is necessary to protect the patient (the nurse may change the position without defeating the objectives of the restraint). The nurse anchors restraint devices securely and ensures that they do not interfere with blood flow to the limbs or trunk; ensures that the restraints can be released quickly in an emergency; documents application and evaluation of current status; assesses and records at frequent intervals, e.g., every 30 min, the effects of the restraint on the patient's behavior and on the neurovascular status distal to the site of the restraint; promptly reports signs of increased agitation; releases restraints (one at a time if the patient is unreliable or combative) and allows or provides range-of-motion exercises two to four times each shift; and evaluates the need for continuing restraint at least once each shift, discontinuing the devices as soon as the patient's status permits.
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