Policy for

patients under

Nursing Excellence Unit

restraints

JINO JACOB
Deputy
Nursing Superintendent
 Purpose

 To provide guidance on approach and to use appropriate use of restraints to

Nursing Excellence Unit

patients who are assaultive or have other behaviour abnormalities requiring
physical and/or chemical restraint.

 The purpose of this document is to guide the appropriate and safe management of
patients who are restrained.

 To guide on appropriate utilization of alternatives to restraint, as well as

nonphysical interventions.
Scope

 All Departments, Units, Sections and services involved in patient care

Nursing Excellence Unit

Responsibility

 All members of Medical, Nursing and support staff of AIIMS

Nursing Excellence Unit

 Policy for Patients Under Restraint at
AIIMS, Rishikesh
The purpose of this document is to guide the appropriate and safe management of
patients who are restrained. To guide on appropriate utilization of alternatives to

Nursing Excellence Unit

restraint, as well as nonphysical interventions.
Definitions:

 For the purpose of this document restraints are physical or chemical measures
used to control the physical or behavioural activity of a person or a portion of
his/her body. Furthermore, the definitions of restraint may vary depending
on specific practice settings.
TYPES OF
RESTRAINTS

Nursing Excellence Unit

Physical restraints Chemical restraint
 Physical restraints are primarily used to  Chemical restraint includes
limit physical movement. It includes any drugs/medications used to restrict
manual method or physical/mechanical patient’s behavior or freedom of
device, material or equipment attached or movement and is not a standard treatment
adjacent to the patient’s body that he/she or dosage for the patient’s condition.
cannot easily remove and restricts
freedom of movement or normal access
to patient’s body
Guiding philosophy for use of restraint

 Restraints will be used for medical necessity only (situations where there is
appropriate clinical justification) and not as a means of correction, discipline,

Nursing Excellence Unit

convenience, or retaliation.

 Restraints will be selected when alternative interventions have been attempted and
determined to be ineffective.

 Restraints if used should address the principle of minimal restraint on patients,

and apply it for the shortest possible duration.
 Restraint category

 Category of restraint is determined by the situation that the restraint is being used
to address not the diagnosis or treatment setting.
Non-Violent/Non-Self-Destructive: Used to promote medical/surgical healing
(prevent patient from removing tubes, lines or wandering)

Violent/Self-Destructive:
 Emergency measure
 Violent and/or self-destructive behavior that jeopardizes the immediate physical
safety of the patient, staff or others.
Procedural norms for safe use of
restraints
Assessment
 Patient assessment is to be done by at least a Resident Doctor or Staff Nurse (if
the former is not available) prior to application of physical restraint to determine
the justification for the restraint and to select the appropriate restraint
method. Similarly, assessment for chemical restraint is to be done by at least a
Resident Doctor prior to its use.
 These assessments are to be documented in the medical record and should contain
details like; i) rational of use and ii) alternative or less restrictive
interventions attempted.
 Restraint Orders

 Restraint orders can be initiated by the health care personnel responsible for assessment as stated above. The
exact method (including restraint position and/or site) and time of initiation of restraint also should be
documented in medical records, including medication name, dose, route and time of administration.
 If the order is not initiated by attending/treating doctor, then he/she must be consulted at the earliest and obtain
a written order within
i) Eight hours for 18 years or older
ii) Four hours for 10 to 17 years
iii) Two hours for 9 years or younger

 All restraint orders are time limited after which a fresh assessment for need of continuous restraint and
renewal of written restraint order is to be initiated. All forms of restraints are to be discontinued at the
earliest possible time. The validity of restraint orders varies depending on restraint category which are as
follows:
 Restraint Orders


Restraint category Fresh assessment for restraint Renewal of written restraint order

1. Non-violent/non-self-destructive 24 hours

2. Violent/self-destructive
i) 18 years or older 4 hours 8 hours
ii) 10 to 17 years 2 hours 4 hours
iii) 9 years or younger 1 hour 4 hours
Selecting the least restrictive type of
restraint
The type or technique of restraint used must be the least restrictive intervention that will
be effective to protect the patient, a staff member, or others from harm.
The following are of the variety of restraints options
 “Freedom” Splints: They are considered a restraint when applied to a patient who
cannot readily remove them, or when applied on both limbs, or if applied to the
functioning arm of someone who does not have use of the other arm.
 Roll belt
 Side Rails: They are considered a restraint when used to prevent a patient from
getting out of bed, or when used to create a barrier with other furniture to prevent a
patient from voluntarily exiting the bed.
 Soft limb holder-wrist and/or ankle (1-4 points)
 Chemical (It may require initial physical restraint)
NOTE: The following are NOT considered restraint:

 Orthopedically prescribed devices, surgical dressings or bandages,

protective helmets or other methods that involve the physical holding of

a patient for the purpose ofconducting routine physical examinations or

tests or to protect the patient from sliding out of bed, or to permit the

patient to participate in activities without the risk of physical harm.

Safe application of restraint

 Restraints will be applied correctly and appropriately according to the

manufacturer’s recommendation by competent, trained staff.

 Soft restraint straps will be secured to the bed frame (not to side rails), in a bow
or knot that can be released quickly and easily in an emergency.

 Sharp objects will be kept away from the patient.

Monitoring of patients in restraint
Monitoring is performed by observation, interaction with the patient, or related direct examination of
the patient by staff nurse or resident doctor.

Monitor and document in medical records (annexure I), the following at the stated intervals or earlier
as appropriate.
Monitor for
1. Orientation/Level of consciousness

2. Restraint site assessment (Pulse, Temp, Colour, Oedema, Skin integrity)

3. Behavioural Status
1. Vital signs (Pulse, BP)

2. Respiratory rate

3. Hydration/Nutrition status

4. Activity/position

5. Toileting

6. Range of movement of the restrained limb(s)

Monitoring of patients in restraint

 The health care staff will meet the patients’ needs while in restraints.
 Any patient in restraints being transported off the ward/nursing unit for testing must have the
staff nurse accompany the patient.
 Each aspect of patient assessment and care is considered complete and may be initiated when
the following criteria have been met:
 Position: Proper alignment of the restrained limb(s) is maintained.
 Circulation: The affected limb(s) has been checked and device application has been determined
not to impair circulation to the extremity:
 Nail bed blanched in less than 3 seconds.
 Pulse is present above and below restraint.
 Skin Integrity: Skin integrity has been checked under and around the device(s), and at all bony
prominences and no pressure or reddened areas have developed.
 The patient is covered either by gown, sheet, or curtain and is protected from public view.
Monitoring of patients in restraint

 Temperature: The patient’s skin is comfortable to the touch. The patient's body temperature is checked as ordered by the physician,
and the room temperature is maintained as appropriate to patient’s condition (generally 68-72° F on the room thermostat).
 Device Application: The device (if any) is applied according to the manufacturer’s guidelines and in a manner that is secure but not
tight. Straps are secured to bed frame (never to side rails or other moveable parts); and quick release is possible.
 Fluid Needs: Fluids are administered as ordered by the physician. If the patient is not on fluid restriction, oral fluids are offered at
least every two hours. If the patient is nothing-by-mouth (NPO), oral care is provided at least daily to maintain integrity of oral
mucosa.
 Toileting Needs: Elimination needs are attended to, either by Foley catheter (only if ordered for other medical necessity) or by
offering the patient the bed pan or assistance to bathroom or bedside commode chair.
 Nutrition Offered: Nutritional needs are met as ordered by the physician. If oral intake is allowed, the patient is offered and assisted
with meals and snacks.
 Range of Motion (ROM): Active or passive range of motion in the affected limb(s) is completed either by the patient or the
caregiver. For patients requiring limb restraints, ROM is recommended at least every 2 hours.
 Evaluation for Restraint Reduction or Removal: Need for the use of restraint(s) is evaluated frequently (at least every two hours)
and restraints are discontinued at the earliest possible time.
 Restraint Status: A plus sign (+) is recorded when restraints are on; a minus sign (-) when they are off.
 A narrative note is recommended for details that deem relevant, e.g., additional assessment data, explanation of patient/family
discussions, exceptional findings in ongoing care and monitoring, etc. Such a note is advised at the time restraints are discontinued
and should reflect any changes in patient condition related to the decision to discontinue the use of restraints.
. Discontinuation of restraint

 Patients will be removed from restraints when (on reassessment) the reason for
the use of restraint is no longer present or when alternative strategies have become
successful. Documentation for the same is also necessary.
 If the restraints are removed and the alternatives tried are ineffective, the restraint
may be reapplied. If the restraint is discontinued prior to the expiration of the
original order, and reinitiating of restraint is indicated, a new restraint order must
be initiated.
 .
 Patient/Family education

 To the extent feasible, depending on the emergent nature of the use of a restraint,
the reasons for such use will be explained to the patient and/or to an appropriate
family member/person (nominated representative) acting on behalf of the patient.
 If unable to notify family prior to initiation of restraints, the family will be
notified as soon as possible of the initiation of restraints, as appropriate.
 Education is to be documented in the medical record.
Training of staff

 Training in restraint principles and practices for staff nurses and above and
resident doctors and above, involved in direct patient care is mandatory as part of
orientation and at least annually.
 Staff is trained and demonstrate competency in the application of restraints,
monitoring, assessment, and providing care for a patient in restraint.
 Staff is trained appropriate to their patient population, regarding the safe and
effective use of restraints including, restraint policy of the hospital, assessment
and reassessment of the patient in restraint, and ordering of restraints.
 The hospital will keep record of both training and demonstration of competency.
 Monitoring Chart for Patients under Restrain

Patient’s Age/sex UHID No. Ward/Section Department

Name
Date Purpose Ordered By Type of
Restraint

Nursing Excellence Unit

Signature of Assessor & Time of
Assessment

At Orientation/Level of
least consciousness
ever Restraint site assessment (Pulse,
y 15 Temp, Colour, Oedema, Skin
min integrity, Position)
utes Vital
At signs (Pulse, BP,
least Respiratory rate)
Ever
Hydration & Nutrition
y2
hour Toileting
s
Maintenance of privacy and
comfortable body and room
temperature.
Appropriate
application & positioning of the
device(s).
Position & Range
of motion (Active/Passive,
Complete/Incomplete)
Restraint
reduction or removal
Restraint
Status: A plus sign (+) is
recorded when restraints are on;
a nd a minus sign (-) when
CAREGIVER’S INFORMED
CONSENT FOR PATIENT CAREGIVER’S INFORMED CONSENT FOR PATIENT RESTRAINT

RESTRAINT
This Hospital doesn’t use any type of restraint without the stated written consent. You are hereby requested to provide your consent or refusal in this form. By signing this form, it is validated that the potential benefits and risks associated with the use
of restraint have been explained to you by the appropriate healthcare professional and have been understood by you.

I hereby understand that the following restraint(s) are needed for the specific medical reasons as explained to me.

Restraint type, Frequency, Duration Medical symptoms/ Reason(s) Release/Reassessment Schedule

Type(s):

Frequency:

Duration:

STATEMENT OF CONSENT
I Mr./Ms._____________________________S/o/D/o/W/o ________________________________ R/o ______________________________________ hereby confirm that am the primary caregiver/nominated representative of the patient Mr./Ms.________
_______________________with UHID no. __________________________________ and is responsible for the healthcare related decisions of my patient during his/her admission. I have been informed well about the risks and benefits of use of restraint
for my patient. The healthcare professional(s) have assessed the need for such restraint as part of management plan. I do understand that the type of restraint provided in good faith of my patient and has no malafied intention on the part of anybody. I
understand that I have the right to change/withdraw my permission at any point of time. I/we hereby permit the use of _______________________________________restraint for the welfare and management of my patient. I take the full responsibility of
any untoward outcome related to my decision.

Signatures

Patient’s Representative/Caregiver: ______________________ Date & Time: ______________

Relationship: ____________________________________

Name of staff/authority: _____________________________

Signatures of authority/staff: _____________________Date & Time: ____________________