Restraint Practices and Patient Safety

Restraints

• Mechanical restraints restrict or control movement/behavior via attachment to a person's body or creation of physical barriers.
• Examples of mechanical restraints are:
  • Soft limb restraints
  • Broda chairs
  • Chair trays
  • Side rails
  • Pinels

Other Types of Restraints

• Physical restraints involve the direct application of physical holding techniques, involuntarily restricting a patient's movement.
  • Holding one hand gently while talking or singing can be a physical restraint.
  • Holding one hand gently to help the person feel safe is preferable to holding both hands firmly or multiple staff holding limbs.
• Chemical restraints are medications used to modify or restrict behavior, such as tranquilizers and sedatives
  • These can be used for pre-care
• Environmental restraints change or modify a person's surroundings to restrict/control movement such as:
  • Coded doors
  • Wanderguards
  • Locked units
  • These could cause injury from climbing, loneliness, misperception of "jail", and stress from fixation on the obstacle.

Concerns Regarding Restraints on Clients

• Restraints can decrease a client's physical activity level and ability to independently function.
  • Chemical restraints may leave someone sedated and inactive.
  • Physical restraints, for example, a tray on the geriatric chair may prevent a person from moving freely, which can lead to frustration and reduced confidence/self-esteem.
• Restraints can cause injuries.
  • A person may climb over bed rails and fall trying to get to the bathroom.
• Restraints may result in a loss of cognitive and physical abilities.
  • Someone sedated for long periods may lose some abilities.

Restraints: When to Use

• Restraints can be useful when the temporary use of a lap belt supports a person to sit up and participate in a group activity.
• Short-term medication use can minimize disturbing hallucinations.
• A protected garden can allow for safe wandering.
• Using restraints to manage behavior can be harmful and lead to loss of skills, independence, and self-esteem.
• Restraints may prevent caregivers from addressing the root cause of the person's distress.
• The preferred choice is to use no restraints; physical, chemical, and environmental restraints should not be substitutes for safe environments or proper care for dementia patients.

Least Restraint Approach

• Emphasizes using the minimal level of restraint to ensure safety, respecting the person's freedom, dignity, and independence - restraints are always a last resort
  • Use restraints only when all other options are exhausted and there is an immediate risk of harm.
  • Attempt multiple alternatives, like de-escalation techniques or environmental adjustments, first.
  • Use the smallest dose of a medication or the least restrictive physical or environmental measure.
  • Apply restraints for the shortest time frame and remove them when the person is safe.
  • Involve the patient and/or their decision-maker in informed consent discussions about the risks/benefits.
  • Regularly evaluate the need for restraints, prioritize the person's well-being, and discontinue use as soon as it is safe.

Restraint Use in Reality

• Restraints are commonly used for "safety"
  • Protects from falls 82% of the time
  • Maintains therapeutic devices (catheters, dressings, IVs, etc.) 65% of the time
  • Protects others from combativeness 67% of the time
  • Confusion 65% of the time
  • Prevents wandering 22% of the time
  • Prevents bothering other patients 15% of the time
  • Encourages rest 12% of the time.
• These situations are an inappropriate use of restraints, happening more often than expected.

Role as the HCA

• HCAs are generally not authorized to independently apply/remove restraints
• Their involvement is limited to assisting with restraint procedures under the direct supervision/direction of regulated health professionals.
  • Licensed practical nurses (LPNs)
  • Registered psychiatric nurses(RPNs)
  • Registered nurses (RNs)
• HCAs must be familiar with and adhere to their employer's restraint use policies/procedures.
  • These policies should outline when restraints can be used, required documentation, and roles of healthcare team members.

Monitoring & Observation

• HCAs are responsible for monitoring restrained clients and reporting concerns/changes to the supervising nurse, including:
  • Signs of distress
  • Discomfort
  • Potential complications
• Remember ABCs.
• Perform frequent checks per care plan and agency policy.
• Reposition the patient.

Ethical & Safety Considerations

• Restraints raise ethical issues like the client's right to autonomy and potential for harm.
  • HCAs should be aware, advocate for the least restrictive interventions, and prioritize alternative measures.
• Restraint use has associated risks, whether they are used to manage/support personal expressions, positioning needs, or behavioral symptoms related to mental health/substance use.
  • It’s important to ensure culturally safer practices when using restraints.
  • Potential negative outcomes:
    • Asphyxiation.
    • Cognitive decline.
    • Death.
    • Decreased mobility and quality of life.
    • Depression
    • Disorientation.
    • Falls.
    • Head trauma.
    • Increased care needs
    • Increased risk of pressure injury and stroke.
    • Muscle atrophy.
    • Poor sleep.
    • Respiratory depression.
    • Urinary and/or bowel incontinence.

Explore culturally safer restraint practices, hygiene-related issues, and the impact on respiratory function. Learn about identifying disorientation, potential physiological risks, and appropriate/inappropriate restraint use. Understand the role of Health Care Aides in restraint management.