Restraint Policy and Care: Physical and Chemical
Comprehensive Nursing Education Notes
Table of Contents
Introduction and Overview
Restraint use in healthcare settings represents one of the most challenging ethical and clinical decisions nurses face. The primary goal is always patient safety while maintaining dignity, autonomy, and therapeutic relationships. Modern healthcare emphasizes restraint-free environments with evidence-based alternatives being the gold standard of care.
Critical Principle
Restraints should be used only as a last resort when all other interventions have been attempted and failed, and only when there is imminent risk of serious harm to the patient or others.
Key Definitions
Physical Restraint
Any manual method, physical or mechanical device that immobilizes or reduces the ability of a patient to move arms, legs, body, or head freely.
Chemical Restraint
Medication used to control behavior or restrict movement when not required to treat medical symptoms.
Seclusion
Involuntary confinement of a patient alone in a room where the patient is physically prevented from leaving.
Therapeutic Restraint
Restraints used to prevent interference with medical treatment or to prevent falls in high-risk patients.
Physical Restraints
Types of Physical Restraints
Wrist/Limb Restraints
- • Soft cloth restraints
- • Leather restraints
- • Mittens/hand covers
Bed/Chair Restraints
- • Vest restraints
- • Waist belts
- • Wheelchair lap belts
Ambulatory Restraints
- • Ankle restraints
- • Full body restraints
- • Four-point restraints
Physical Restraint Decision Flowchart
Complications and Risks
Physical Complications
- • Skin breakdown and pressure ulcers
- • Circulation impairment
- • Muscle weakness and contractures
- • Aspiration and respiratory compromise
- • Thromboembolism
Psychological Complications
- • Increased agitation and anxiety
- • Depression and withdrawal
- • Loss of dignity and autonomy
- • Post-traumatic stress
- • Decreased trust in healthcare providers
Chemical Restraints
Chemical restraints involve the use of medications primarily to control behavior rather than treat underlying medical conditions. These are often more controversial than physical restraints due to their impact on cognitive function and potential for abuse.
Common Chemical Restraint Categories
Antipsychotics
- • Haloperidol (Haldol)
- • Olanzapine (Zyprexa)
- • Risperidone (Risperdal)
- • Used for severe agitation
Anxiolytics
- • Lorazepam (Ativan)
- • Diazepam (Valium)
- • Alprazolam (Xanax)
- • Used for anxiety-related behaviors
Black Box Warning Considerations
Antipsychotic medications carry FDA black box warnings for increased mortality risk in elderly patients with dementia-related psychosis. Use requires careful risk-benefit analysis and frequent monitoring.
Monitoring Parameters
Neurological
- • Level of consciousness
- • Cognitive function
- • Motor function
- • Extrapyramidal symptoms
Cardiovascular
- • Heart rate and rhythm
- • Blood pressure
- • QT interval (if indicated)
- • Perfusion status
Respiratory
- • Respiratory rate
- • Oxygen saturation
- • Airway patency
- • Aspiration risk
Assessment and Documentation
Pre-Restraint Assessment
Patient Factors
Mental status, cognitive function, physical condition, medication effects, pain level
Environmental Factors
Noise level, lighting, room temperature, visitor presence, staff availability
Risk Assessment
Fall risk, self-harm potential, harm to others, medical device interference
Documentation Requirements
- Reason for restraint application
- Alternative interventions attempted
- Type of restraint used
- Time of application and removal
- Patient’s response to restraint
- Frequency of monitoring
- Circulation, skin integrity checks
- Physician notification and orders
Alternative Interventions
Evidence-Based Alternatives
Research consistently shows that restraint-free approaches are safer and more effective in reducing patient injuries and improving outcomes.
Communication Strategies
- • Active listening
- • Therapeutic communication
- • Reorientation techniques
- • Family involvement
Environmental Modifications
- • Remove triggers
- • Adequate lighting
- • Reduce noise
- • Comfortable positioning
Activity and Engagement
- • Structured activities
- • Music therapy
- • Pet therapy
- • Regular exercise
Pain Management
- • Regular pain assessment
- • Non-pharmacological methods
- • Appropriate medication
- • Comfort measures
Safety Measures
- • Bed/chair alarms
- • Increased supervision
- • Fall prevention strategies
- • Room placement near nurses’ station
Staffing Solutions
- • One-to-one supervision
- • Volunteer companions
- • Family presence
- • Behavioral health consults
Legal and Ethical Considerations
Legal Requirements
CMS Conditions of Participation
Federal regulations governing restraint use in healthcare facilities receiving Medicare/Medicaid funding
Joint Commission Standards
Patient safety goals and performance standards for restraint use and monitoring
State Regulations
Additional state-specific requirements that may be more restrictive than federal standards
Ethical Principles
Beneficence
Acting in the patient’s best interest while minimizing harm
Autonomy
Respecting patient’s right to self-determination and choice
Justice
Fair and equitable treatment regardless of patient characteristics
Key Legal Requirements
- Physician order required within 1 hour
- Face-to-face evaluation within 1 hour
- Continuous monitoring requirements
- Time-limited orders (4-24 hours maximum)
- Informed consent when possible
- Death reporting requirements
- Staff training documentation
- Quality assurance monitoring
Monitoring and Care
Physical Monitoring
Every 15 Minutes
- • Circulation (color, temperature, pulse)
- • Skin integrity
- • Positioning and comfort
- • Respiratory status
- • Neurological status
Every 2 Hours
- • Range of motion exercises
- • Position changes
- • Toileting needs
- • Nutrition and hydration
Psychological Support
Communication
Regular verbal contact, explanation of procedures, emotional support
Environmental Awareness
Maintain visual contact, ensure call light accessibility, provide entertainment
Family Involvement
Keep family informed, encourage presence when appropriate, address concerns
Emergency Situations
Immediately remove restraints and notify physician if:
- • Signs of compromised circulation
- • Respiratory distress
- • Altered mental status
- • Skin breakdown or injury
- • Excessive agitation or panic
- • Medical emergency
- • Equipment malfunction
- • Patient requests removal
Nursing Implementation
Nursing Process Application
Assessment
Comprehensive evaluation of patient condition, risk factors, and environmental triggers
Diagnosis
Risk for injury, impaired physical mobility, anxiety, powerlessness
Planning
Develop individualized care plan with measurable outcomes and timeframes
Implementation
Execute alternative interventions, apply restraints if necessary, continuous monitoring
Evaluation
Assess effectiveness, modify plan, discontinue restraints when appropriate
Quality Improvement Initiatives
Restraint-Free Environment
- • Staff education programs
- • Alternative intervention protocols
- • Regular audits and feedback
- • Interdisciplinary team approach
- • Family education and involvement
- • Environmental safety assessments
Performance Metrics
- • Restraint utilization rates
- • Patient injury incidents
- • Length of stay impact
- • Patient satisfaction scores
- • Staff compliance rates
Best Practice Implementation
Prevention Focus
Prioritize identifying and addressing root causes before behavior escalates
Team Collaboration
Involve physicians, social workers, chaplains, and families in care planning
Continuous Monitoring
Regular reassessment ensures timely discontinuation and prevents complications
Memory Aids and Summary
RESTRAINT Mnemonic
CARE Approach
Key Takeaways for Nursing Practice
- Restraints are always a last resort intervention
- Prevention through alternative strategies is most effective
- Continuous monitoring prevents serious complications
- Documentation must be thorough and timely
- Patient dignity must be maintained throughout
- Team collaboration improves outcomes
- Legal and ethical standards guide all decisions
- Quality improvement focuses on restraint reduction