Research has shown that as many as 40% of former inpatients who were restrained while delirious are able to recall the restraint. Twenty to thirty percent of those patients have positive or neutral feelings about being restrained, reporting it as understandable in the circumstances or as providing a sense of security. The remaining 70% to 80% have more decidedly mixed feelings about it. These people describe feeling trapped, powerless, and humiliated. They frequently report a perception that nurses see restraints as routine.

Other studies suggest that restraints can make things worse, increasing a delirious patient’s intent to remove the restraint, increasing sensory deprivation and disorganized behavior, intensifying loss of self-image, and enhancing dependency.

During a focus group of former patients who were restrained while at HMC, one patient stated an understanding of the need for restraints, but vividly described the humiliation and frustration experienced while under the care of a nurse who “clearly didn’t want me to be there that day,” who was “abrupt and disdainful” while applying and removing the restraints during care.

Emotional, as well as, physical variables should be taken into account when evaluating risks & consequences of using restraint. Some may be more easily assessed, such as religious or cultural practices limited by restraint. Others will be less obvious – any patient may have a background that makes restraint a very negative experience.

Restraints may still be necessary to protect delirious patients’ invasive devices. Because of their delirium, however, patients may require repeated explanations. An ungentle touch is remembered. Evaluation for times that the patient may be freed of restraints for brief periods can bring relief.

One reason to consider the use of medical restraints is when a patient is attempting to disrupting a medically necessary device and other interventions have proved ineffective or inappropriate. Each patient must be individually assessed for criteria to apply the “Invasive Device Protocol.” This specifically means that the patient:

1. Has a medically necessary device,
2. Has the capacity to remove the device, AND
3. Has at least one of the following behaviors:

• Makes direct attempts to remove the device(s)
• Is at least intermittently unable to follow directions
• Attempts ambulation without assistance/gait is unsteady
• Is impulsive
• Has LOC altered by medications
• Is confused/agitated

This protocol requires an initial order from a physician or other licensed independent practitioner (LIP = PA, ARNP, etc.), but no daily renewal order is necessary.

Use of the “Invasive Device Protocol” will be discontinued when any of the following conditions apply:

*The patient is no longer at risk for self-removing tubes/devices according to the following behavior criteria:

• The patient is alert and oriented to person, place and time; is able to follow commands consistently; utilizes the call system when in need of assistance, and
• The patient is no longer sedated or drowsy.

-OR-

*Less restrictive interventions have proven effective in preventing removal of devices.

-OR-

*Tubes/devices are no longer in place or removal will not cause injury or harm.

If it is determined that the patient continues to need medical restraint for other criteria, such as prevention of injury from fall when alternatives are unsuccessful, a daily order renewal will be required.

Note:  If a patient in forensic restraints (requested by a law enforcement agent who is guarding the patient) develops a change in clinical condition that would lead you to consider use of the “Invasive Device Protocol,” the patient now meets criteria for that level and must be managed as such. This involves obtaining an initial order and following assessment and documentation requirements for medical restraints. When the patient no longer meets the criteria, and medical restraints could be discontinued, the law enforcement agent will determine if restraints should be continued for forensic reasons. If so, an order would no longer be required, and documentation requirements would revert to those for forensic restraint.

Restraint documentation addresses specific patient assessments done at regular intervals. It also reflects formation, implementation and evaluation of a plan of care directed toward removal of restraints as soon as criteria for release are met. 

Elements include:

1.  Restraint Flow Sheet (found under menu button “Restraint” on the patient’s vitals/treatments screen in CIS).

Medical Restraint: RN to complete all elements at least q 2 hrs.

Behavioral Restraint: RN to complete all elements at least q 2 hrs, plus q 15 minute assessments of safety and ADL needs met. This is charted hourly by the patient monitor providing continuous supervision.

All fields must be completed when a patient is in restraint. If restraints are removed, one of three situations must be documented:

• Restraints discontinued (use pick list choice under “Evaluation” to indicate reason discontinued).

• Trial release in progress (next-to-last item on flow sheet).

• Patient temporarily out of restraint for some reason (e.g. Patient in OR, family present, etc.). Pick list choices found under “Reason for restraint,” “Reason for a blank flow sheet.”

2.  Problem Statement added to the patient’s problem list (found under “Safety/Restraint” section of problem list choices).

3.  Plan of Care addressed each shift, including:

• Assessment of continuing criteria for restraint and patient response to plan of care.

• Interventions specific to patient’s criteria for restraint (choices found under “Safety/Restraints”).

• Appropriate discharge goals.

• Update/modify the plan as needed to reflect changes in patient’s condition/risk factors.

At HMC the patient’s risk for falling is identified by a Morse Fall Scale (MFS). A score of 55 or greater represents a high risk for falling. As always, individual nursing assessment of patient and environmental variables may, in the nurse’s judgment, indicate fall risk even if the MFS is less than 55. JCAHO attention to fall prevention includes a focus on staff awareness of medications that have been associated with fall risk. The Morse Fall Scale can identify side effects of high risk medications, such as confusion or balance difficulty if they occur consistently. However, it does not typically identify transient changes or potential for side effects. 

Although not all studies agree on specific medications, those most frequently associated with patient falls include:

• Benzodiazepines
• Anticonvulsants
• Neuroleptic agents
• Serotonin reuptake inhibitors
• Tricyclic antidepressants
• Class 1A antiarrhythmic agents
• Diuretics, cathartics and laxatives
• Narcotics

The above medication types may particularly contribute to risk of falling if they are new prescription for the patient, or if they are receiving more than one agent. In these situations, carefully evaluate patient response to the medication. Consider reviewing medications with the pharmacist to evaluate alternative choices. If choosing to add fall risk to a patient’s problem list when MFS is < 55, indicate the reasons for risk identification in the "problem statement and shift assessment" note.

Example: Problem Statement: “Patient at risk for falls due to multiple high-risk medications.” Case Note: “Good pain relief from current narcotic dose, but occasionally sleepy after med given. Patient describes feeling of urgency after diuretic given. Does not always call for assistance despite reminders.”

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