Physical Restraint
Reduction for Older Adults
Objectives

Define physical restraint and describe the
characteristics of restraint use.

Identify the older adults most at risk of being
physically restrained.

Discuss myths and facts about physical
restraint use.

Discuss the reasons most frequently given by
health professionals for using physical restraint.
Objectives

Describe morbidity and mortality risks
associated with physical restraint.

Plan the nursing care of older adults,
using restraint-free strategies.

Explain alternatives to the use of
physical restraints.
Definitions
Physical Restraint
Any manual method or physical or
mechanical device, material or
equipment attached or adjacent to the
person’s body that he cannot remove
easily which restricts freedom of
movement or normal access to one’s
body.
Definitions

Medical Immobilization
Temporary
 Performance of and recovery from medical
surgical treatment
 Surgical positioning
 IV arm boards
 Bulky dressing


Forensic Restraint
Types of restraints
 Soft
wrist/ankle
 Straps/belts
 Two- three- or
four-point
 Wheelchair
safety bars
 Mitt
 Chairs
with
lapboards
 Beds with
siderails
 Bedsheets
 Vest/jacket
Restraint Use for Older Adults
Nursing home residents = 15%
 Acute care settings = 6% to 17%
Incidence
 65+ population = 18% to 20%
 75+ and older = up to 22%
 Depression, agitation, confusion,
withdrawal, anger = 20% to 50%

Who are at risk for restraints?
Unsteady mobility or history of falling
 Increased severity of illness
 Multiple debilitating conditions
 Cognitive impairment
 Psychiatric conditions
 Recent surgical procedure
 Medical devices

Myths and Facts

“The old should be restrained because
they are more likely to fall and seriously
injure themselves.”

“The moral duty to protect from harm
requires restraint.”

It doesn’t really bother older people to
be restrained.”

“We have to restrain because of
inadequate staffing.”
Reasons for using restraints
Prevent falls and protect the patient
from harm
 Prevent interference with medical
treatments
 Protect medical devices
 Decrease legal liability and family
pressure
 Control disruptive behavior

Morbidity and Mortality Risks
Short Term Complications
 Hyperthermia
 New-onset bowel and bladder incontinence;
constipation
 Decreased appetite
 Pressure ulcers
 Muscle weakness
 Injury to nerve and joints
 Increased risk of nosocomial infection
 Pneumonia and respiratory complications
Severe or Permanent Injuries
Spiraling immobility
 Risk for strangulation
 Hypoxic encephalopathy
 Deconditioning
 Death from strangulation
 Psychological Effects: anger,
aggressiveness, humiliation,
demoralization, depression, low selfworth, social isolation

Restraint Research

“Perception of Restraint Use
Questionnaire” (PRUQ)- revised 1998

“Subjective Experience of Being
Restrained” (SEBR)
Available at:
http://www.nursing.upenn.edu/centers/
hcgne/H_tools.htm
Hartford Center of Geriatric Nursing
Excellence
University of Pennsylvania
School of Nursing
Available at:
http://www.nursing.upenn.edu/centers/
hcgne/H_tools.htm
Hartford Center of Geriatric Nursing
Excellence
University of Pennsylvania
School of Nursing
Restraint-free guidelines

Establish restraint-free standard

Least restrictive but safest environment

Clinically appropriate situations; not
“routine”; evaluate patient

Rationale must be documented; orders
limited in duration to 24-hours.
Restraint-free guidelines

Monitor for complication every 4 hours and
more frequently

Educate patient and significant others

Medicate to mitigate need for restraints

Consider weaning and early extubation

Use adaptive equipment for impaired mobility

Institute fall prevention strategies
Restraint-free guidelines

Behavioral management strategies

Modify medical devices

Include family / surrogates

Become familiar with statistics and
institutional guidelines, policies and
procedures; evaluate compliance at unit and
institutional level
Alternative to restraints

Pharmacologic agents (NOT CHEMICAL
RESTRAINT) to treat patient’s agitation

Early identification of source of patient’s
discomfort and agitation

Increase patient observations - video
cameras, move closer to nurses station

Music and frequent reorientation

Allow family greater access; visit audiotapes
of family
Alternatives to restraints
Alter the environment
 Reduce noise level
 Turn TV off
 Use bed exit alarms
 Relocate patient near the nurse’s station
 Use family members and sitters
 Lower nurse-to-patient ratio
SUMMARY







Defined physical restraint, medical
immobilization, and forensic restraint
Types of restraints
Who are at risk for being restrained
Myths and facts
Reasons for restraining patients
Morbidity and mortality
Guidelines and strategies in promoting a
restraint-free environment