RESTRAINING PROCEDURE

Restraint is defined as ‘the intentional restriction of a person’s voluntary movement or

behaviour. (Counsel and Care UK, 2002).

Restraints are physical, chemical or environmental measures used to control the physical or
behavioural activity of a person or a portion of his/her body.

The Mental Health Act 1983 (MHA)-The common law right is encompassed in the
Criminal Justice and Immigration Act 2008. Finally, the Mental Health Act 1983 (MHA)
provides the authority to restrain patients who require treatment for their mental illness.

GENERAL PRINCIPLES FOR USE OF RESTRAINTS

 should be selected to reduce client’s movement only as much as necessary.

 Nurse should carefully explain type of restraint and reason for its use.

 Should not interfere with treatment.

 Bony prominences should be padded before applying it.

 Should be changed when they become soiled or damp.

 Should be secured away from a clients reach.

 Should be able to quickly release the device.

 Should be attached to bed frame not to side rails.

 Should be removed a minimum of every 2 hrs.

 Frequent circulations checks should be performed when extremity are used.

INDICATIONS ✦

 Displaying behaviour that is putting themselves at risk of harm.

 Displaying behaviour that is putting others at risk of harm.

 Requiring treatment by a legal order, for example, under the Mental Health Act 2007.
  Requiring urgent life-saving treatment.

 Needing to be maintained in secure settings.

Alternatives to Restraint
Suggested restraint alternatives & least restrictive forms of restraint.

 Beds that lower to the floor or a mattress in place next to the bed
 Encourage family members or organise volunteers to visit at 'high risk' times
 Consistency in staff and routines
 Limit the number of staff attending to the person
 Reduce noise levels
 Review lighting to ensure it's not too bright or too dim as this may lead to
misinterpretation of objects
 Ongoing explanation of procedures
 Use of distraction/diversional activities
 Calm voice & soothing music
 Assessing and treating problems causing agitation - e.g.; UTI, dehydration
 Concave mattress
 Water noodles as an inexpensive alternative to concave mattress and can be one side
or both
 Foam wedges to improve position & comfort
 Bed poles/ monkey bars for bed mobility
 Cot sides that can be released by the individual (after explanation of cot side risks)
 Half length cot sides
 If a seat belt is necessary, a velcro belt would be first choice rather than a clip belt
 Non-slip mats, e.g.; by the bed
 'Stop' signs, 'No Exit' signs, strips across in front of the exit door - to prevent
absconding
 Snoozelin therapy
 Individual behaviour management strategies
 Aromatherapy - must be prescribed by a qualified clinical aromatherapist
  Validation therapy
 Reminiscence therapy

All alternatives must be tried before restraining

o Offer bedpan or bathroom every 2 hours.

o Offer fluids and nourishment frequently, keep water within reach.
o Provide diversional activity.
o Decrease stimuli and noise.
o Provide change of position, up to chair, ambulation.
o Have patient wear glasses and/or hearing aids.
o Activate bed alarm.
o Increase observation – Ask family to sit with patient – Alert other staff to be
observant – Move patient to a room near the nurse’s station.

o If the patient is interfering with his medical equipment – Educate frequently

not to touch the treatment device – Place the device out of site if possible –
Cover the device (i.e. wrap I.V. site with Coban or Kerlex).

TYPES OF RESTRAINTS-
 Physical restraints limit a client’s movement. Eg: table fixed to a chair or a bed
rail that cannot be opened by the client.


 Environmental restraints control a client’s mobility. Eg:a secure unit or garden,

seclusion. Environmental restraints control a patient’s mobility. Health care
teams use restraints for a variety of reasons, such as protecting patients from
harming themselves or others, after all other interventions have failed.
 Chemical restraints are any form of psychoactive medication used not to treat
illness, but to intentionally inhibit a particular behaviour or movement.

 Soft restraints. This type of physical restraint device is used to limit movement of
patients who are confused, disoriented or combative. The main goal of using this
restraint is to prevent the patient from injuring him or her self and/or others.

 Vest and Belt Restraints. In using this device full movement of arms and legs are
permitted. This is used to prevent the patient from falling from bed or a chair.


 Limb Restraints. Patients who are removing supportive equipments such as I.V.
lines, indwelling catheters, NGTs and etc. are placed on limb restraints. This
device allows only slight limb motion.

 Mitts. This device prevents the patient from removing supportive equipment,
scratching rashes or sores and injuring him or herself and/or others.


 Body restraints. When patients become combative and hysterical they can be
controlled by applying body restraints. This immobilizes almost all of the body.


 Leather Restraints. This restraint is only used when soft restraints are not
sufficient to control the patient and when sedation is either dangerous to the
patient or ineffective.

Precautions of Restraint Application

1. Before applying restraints, it is important to try other methods of promoting

patient safety. Alternative methods that might be effective are reorientation of the
patient to the physical surroundings, moving the patient’s room near to the staff
members, teaching relaxation techniques in order to decrease anxiety and fear
and decrease overstimulation.
2. Documentation of any alternative method used is extremely important. Restraint
application should be documented thoroughly.

Situations that require restraint application

1. Confused client tries to endanger him or herself

2. Confused client attempts to remove supportive equipment’s such as necessary
tubes, IV lines or protective dressings.
3. The client is at risk for falls.
4. The client is suicidal.
 5. The client poses harm or threat of inflicting harm to health care staff, other
clients and/or visitors.
6. A child is unable to remain still during a minor surgical procedure.

Equipments

Soft restraints
 Vest restraint
 Limb restraint
 Mitt restraint
 Belt restraint
 Body restraint as needed
 Padding if needed (large gauze pads can be used)
 Restrain flow sheet (washcloth can be used)
Leather restraints
 Two wrist and two ankle leather restraints
 Four straps
 Key
 Large gauze pads – this is used to cushion each extremity
 Restraint flow sheet (washcloth can be used)
Nurse’s responsibility
1. Make sure that the restraints are correct size for the patient’s build and
weight.
2. Explain the need for restraint to the patient. Assure him or her that they are
used to protect him from injury rather than to punish him. It is necessary to
inform the patient of the conditions necessary to release him or her from
restraints.
3. Restraints are ONLY used when all other methods have failed to keep the
patient from harming himself or others. Restraints used should be least
restrictive to the patient.
4. Obtain adequate assistance to manually restrain the patient.
5. After an hour of placing a restraint, the patient should be evaluated by a
licensed independent practitioner and an order must be written for restraints.
 6. The order must ne time limited: 4 hours for adults; 2 hours for patients ages 9
to 17 years old; 1 hour for patients younger than 9 years old.
7. The original order expires in 24 hours. Thus, the same order cannot be used
the following day.
8. To promote safety and ensure the patient is not harmed with restraint
application, the patient should be assessed every 2 hours or according to the
facility policy.
9. In cases where the client consented to have his family informed of his care,
the family should be notified of the use of restraints.
References-

1.www.ncbi.nlm.nih.gov/pmc/articles/PMC6482675/
2. Constitution Act, 1982 [en. by the Canada Act 1982 (U.K.), c. 11, s. 1], pt. 1
(Canadian Charter of Rights and Freedoms).
3. Patient Restraints Minimization Act, 2001, S.O. 2001, c. 16, s. 1 (1).
4. Psychiatric Patient Advocates Office. Review of seclusion and restraint
practices in Ontario provincial psychiatric hospitals. Toronto (ON): Psychiatric
Patient Advocates Office; 2001 Oct.

4. University Hospital Southampton NHS Foundation Trust Restraining

adult patients in hospital

10. References
11. 1. Thara R, Padmavati R, Srinivasan TN. Focus on psychiatry in
12. India. Br J Psychiatry 2004;184:366-73.
13. 2. Mishra N. A Life in Shackles: Mentally Ill in India. The
14. Quint; 2015. Available from: http://www.thequint.com/
15. health-fitness/2015/07/09/a-life-in-shackles-mentally-ill-in-ind
16. ia. [Last cited on 2015 Aug 19
17. References
18. 1. Thara R, Padmavati R, Srinivasan TN. Focus on psychiatry in
19. India. Br J Psychiatry 2004;184:366-73.
20. 2. Mishra N. A Life in Shackles: Mentally Ill in India. The
21. Quint; 2015. Available from: http://www.thequint.com/
22. health-fitness/2015/07/09/a-life-in-shackles-mentally-ill-in-ind
23. ia. [Last cited on 2015 Aug 19
24. References
25. 1. Thara R, Padmavati R, Srinivasan TN. Focus on psychiatry in
26. India. Br J Psychiatry 2004;184:366-73.
27. 2. Mishra N. A Life in Shackles: Mentally Ill in India. The
28. Quint; 2015. Available from: http://www.thequint.com/
29. health-fitness/2015/07/09/a-life-in-shackles-mentally-ill-in-ind
30. ia. [Last cited on 2015 Aug 19
31. References
32. 1. Thara R, Padmavati R, Srinivasan TN. Focus on psychiatry in
33. India. Br J Psychiatry 2004;184:366-73.
34. 2. Mishra N. A Life in Shackles: Mentally Ill in India. The
35. Quint; 2015. Available from: http://www.thequint.com/
36. health-fitness/2015/07/09/a-life-in-shackles-mentally-ill-in-ind
37. ia. [Last cited on 2015 Aug 19