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Application of Physical Restraint (Adult & Pediatric) (13.23)

Application of Physical Restraint (Adult & Pediatric) (13.23) - Policies, Clinical, UWHC Clinical, Department Specific, Nursing Patient Care, Basic Nursing Procedures

13.23

NURSING PATIENT CARE POLICY & PROCEDURE





Effective Date:
November 25, 2015
Amended: April 28,
2017

Administrative Manual
Nursing Manual (Red)
Other _______________

Policy #: 13.23AP

Original
Revision

Page
1
of 9

Title: Application of Physical Restraint
(Adult & Pediatric)

I. PURPOSE

The purpose of this policy is to establish procedures for the safe application of
restraints. See UWHC Hospital Administrative Policy 10.27, UWHC Restraint and
Seclusion, for distinguishing between non-violent and/or non-self-destructive
behavior and violent and/or self-destructive behavior and documentation
requirements.

II. DEFINITIONS
A. A Restraint is any manual method, physical or mechanical device, material or
equipment that immobilizes or reduces the ability of a patient to move the arms,
legs, body or head freely.
1. A restraint does not include devices, such as orthopedically prescribed
devices, surgical dressings or bandages, protective helmets, or other
methods that involve the physical holding of a patient for the purpose of
conducting routine physical examinations or tests, or to protect the patient
from falling out of bed (crib with or without upper shield, emergency
room stretchers, specialty beds) or to permit the patient to participate in
activities without the risk of physical harm (this does not include a
physical escort).
2. This policy does not apply to standard practices that include limitation of
mobility or temporary immobilization related to medical, dental,
diagnostic, or surgical procedures and the related post-procedure care
processes (for example, surgical positioning, IV arm boards, routine
physical exams/tests such as blood draws, radiotherapy procedures).
3. This policy does not include forensic and correction restrictions used for
security purposes. See UWHC Hospital Administrative Policy 4.42, Care
of Patients under Legal Custody. However, when restraints are indicated
for clinical reasons for patients under forensic or correction restrictions,
this restraint policy and procedure must be followed with regard to
additional clinical restraints.
B. Physical Hold: The application of force to physically hold a patient, in order to
administer a medication in emergency situations or against the patient’s wishes by
court order
1. A provider order is needed for a physical hold
2. Medications given during a physical hold cannot be a standing order or a
PRN medication. A one-time order should be received.
3. Can only be administered for violent and/or self-destructive behavior

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4. Documentation should be completed in the restraint flowsheet

III. POLICY
A. The philosophy of caregivers at UWHC is to protect and preserve patients' rights,
dignity and well-being and to provide care that is safe and compassionate. UWHC
is committed to preventing, reducing and eliminating the use of restraint to the
extent possible.
B. Prior to the use of restraint, patients are assessed to determine if alternatives or
less restrictive interventions can be used. Restraints may be used when
alternatives or less restrictive interventions have been determined to be
ineffective. Alternatives or less restrictive interventions include:
1. Distraction
2. Relaxation techniques
3. Skin sleeves
4. Friendly visitors – use volunteer program if needed
5. Regular physical activity
6. Pain control
7. Reality orientation
8. Comfortable room temperature
9. Noise minimization
10. Elimination of unnecessary tubes/drains
11. Low bed
12. Floor mats
13. Bed exit or other alarms
14. Consistent care providers and daily routine when possible
15. Intentional rounding
16. Constant observation
C. UWHC approved restraints (in order of least to most restrictive) include:
1. Lap belts (Inpatient psychiatry only)
2. Mitts (untied)
a. Enclosure bed (American Family Children’s Hospital [AFCH}and
University Hospital- Acute Medical Progressive Care unit (D6/5)
or Hospital Medicine unit (D4/4)and only with approval from
Director, Nursing Quality and Safety or designee.) Related
resource: Enclosure Bed.
3. Elbow immobilizers
4. Wrist and ankle restraints (soft, Neoprene/Velcro and locked)
5. Vests (Neurosurgical Intensive Care Unit and Neurosurgical General Care
Unit and Post-Anesthesia Care Unit [PACU] only)
6. Physical hold
D. Side Rails: Due to the danger of serious injury from entrapment or patients exiting
the bed by going over the top of raised side rails, the use of all four side rails is
prohibited, except in the following situations, four side rail use is considered
necessary to keep a patient safe and is NOT considered restraint:
1. During transport
2. When using a stretcher
3. When the bed needs to be elevated to facilitate care of the patient
4. When a bed is used in the rotational mode
5. When a bariatric specialty bed is being used

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6. When a low air loss mattress is required
7. While recovering from sedation
8. When neurologically impaired patients experience frequent spasms that
could propel them out of bed
9. When seizure precautions are required
10. Raised rails in cribs or radiant warmer
11. When the Hovermatt® is inflated
12. Use of four side rails in situations other than described in 1-11 requires the
approval of nursing leadership, or designee
E. Restraint application is limited to staff trained in safe use of such devices. All
staff who apply restraints must demonstrate safe application in orientation (prior
to using restraint) and annually.

IV. PROCEDURE
A. General Considerations for Application of Restraints
1. Position the patient for greatest safety. If not contraindicated, elevate the
head of bed.
2. Remove or loosen any restrictive clothing.
3. Always secure straps to the bed frame or chair frame that will move with
the patient and ensure that the straps are out of the patient’s reach. Do not
attach to the side rails.
4. Never alter or repair restraints from the manufacturer.
5. To reduce the risk of serious injury or death the use of side rail covers
(seizure pads) help prevent the patient’s body from sliding under, around,
through or between the bed side rails.
B. Types of Restraints
1. Lap Belts (Inpatient psychiatry only)
a. Purpose: Belts used for positioning safety with the intent to maintain
proper positioning in the chair or stretcher are not considered a
restraint. Belts used to restrict or prevent exit are considered a
restraint. Lap belts are for wheelchair use only.
b. Contraindications:
i. Do not use on patients who are or become highly aggressive,
combative, agitated, or suicidal.
ii. Do not use on patients with severe chronic obstructive
pulmonary disease.
iii. Do not use on patients with an ostomy, colostomy, G-tube,
hernia, post-surgical tubes, incisions or monitoring lines,
if/when they could be disrupted.
c. Application: Position patient as far back in seat as possible. Lay the
lap belt across the patient’s thighs and bring the ends down between
the seat and the wheelchair sides. Criss-cross the straps behind the
chair and draw them around the opposite side kick spurs. Kneel next to
the back wheel and adjust the tightness of the slide buckles. Assess
that the straps are secure and will not change position if pulled on or if
the chair is adjusted. Assess for proper fit by sliding an open hand
between the belt and the patient.
2. Mitts

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a. Purpose: To prevent a patient from pulling at tubes or causing self-
injury by scratching at wounds or skin.
b. Contraindications: Do not use on patients who are or become highly
aggressive, combative, agitated, or suicidal. If possible, avoid use of
mitts on a patient if an IV or wound site could be compromised by the
device or with a dislocation or fracture of the affected limb.
c. Application: Insert patient’s hand into mitt palm down against the
padding. Wrap the wrist strap around the smallest part of the wrist,
over the top of wrist, through the plastic ring and secure it onto itself.
Bring the second Velcro strap over the top of the loop strap for a
“double security” closure. Slide one finger between the device and the
wrist to ensure maintenance of circulation.
3. Enclosure Bed:
a. Purpose: To promote a safe, secure, nonthreatening environment with
the use of an enclosure bed for the confused, agitated, impulsive or
extremely restless patient in pediatric and select adult inpatient
settings.
b. Contraindications:
i. Multiple tubes or drains
ii. Halo-traction
iii. External fixator device
iv. Mechanical Circulatory Devices,
v. Combative, violent or extremely aggressive behavior,
vi. Pulling a tracheostomy tube, other tubes/lines/drains,
vii. Suicide Risk
viii. Claustrophobia
c. Application: See Enclosure Bed Resource related resource.
4. Elbow Immobilizers
a. Purpose: The elbow immobilizer fits over the patient’s elbow and is
intended to limit the patient’s arm movement by keeping the elbow in
full extension.
b. Application: Release the adjustment straps to open splint. Position
white side against skin and plastic buckles toward the patient. Center
the splint under the elbow with the opening toward the antecubital
surface. Secure to arm by threading Velcro strap through plastic
buckle and securing back onto itself, assuring that two fingers fit
between the device and limb to maintain circulation. Rotate the device
to ensure strap is away from the patient.
c. Pediatric Elbow Immobilizers: Position the immobilizer with the wider
dimension toward the upper arm. Wrap around patient’s elbow,
securing the arm holder with the Velcro straps. Edges of arm holder
should overlap a minimum of one (1) inch to prevent bending of
elbow. Assure adequate circulation by inserting finger between device
and patient’s skin.
5. Wrist/Ankle Restraints
a. Purpose: Limb restraints are placed to restrict patient ability to harm
self or others with hands or feet. This includes picking, pulling,
scratching or other behavior that interferes with medical care. When

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extremity restraints are applied an assessment is made as to the
number of limbs to be restrained.
i. If a patient is agitated and thrashing around in bed, a minimum
of two (2) opposing extremity restraints are necessary (i.e., left
arm and right leg).
ii. In some cases, restraining only one limb may be enough to
prevent pulling or picking. However, if a patient is agitated or
restless, limb restraints may be applied in pairs to prevent the
patient from becoming entangled during movement.
iii. Patients in limb restraints are at risk for functional decline,
therefore additional exercise, stretching and mobility should be
considered while in restraint. Patient’s limbs are also at risk for
skin or circulatory compromise while in restraint.
iv. Full four-point arm and leg restraints should be used in patients
who are a serious threat to themselves and/or others.
b. Foam (soft) wrist restraint (Restraint Limb Quick Release)
i. Purpose: For patients at risk of disrupting live-saving
treatments or lines, or whose picking, pulling, scratching, or
peeling exacerbates a skin condition and causes self-injury or
compromises a wound.
ii. Contraindications: Do not use on patients who are or become
highly aggressive, combative, agitated, or suicidal. If possible,
avoid use on a patient if an IV or wound site could be
compromised by the device or with a dislocation or fracture of
the affected limb.
iii. Application
• Attach strap with female end of quick release buckle to
the movable portion of the bed frame that moves with
the patient, using defined openings located on the bed.
• Wrap cuff around wrist with foam side against the skin
so the buckle and connecting strap are on the ulnar side
of the wrist (opposite the thumb).
• Secure Velcro and close the quick release buckle on
cuff. Adjust the strap for tightness, ensuring you can
easily insert a finger between the device and the
patient’s limb.
• Insert male end of quick release buckle from strap into
female end of quick release buckle attached to bed.
Adjust bed strap to allow desired freedom of
movement.
c. Neoprene/Velcro Wrist/Ankle Restraint (Posey Non-Locking Twice-
as-Tough Cuffs – Wrist)
i. Purpose: For the combative, agitated patient; to prevent
disruption of IVs, catheters, lines, etc. Use when soft limb
restraints are not effective.
ii. Contraindications: If possible, avoid use on a patient if an IV or
wound site could be compromised by the device or with a
dislocation or fracture on the affected limb.
iii. Application for wrist:

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• Blue restraints are intended for wrists. Attach the
connecting strap to the bed frame.
• Position the cuff underneath the limb with the
connecting straps extending away from the patient.
Wrap the smooth neoprene piece (blue side against the
skin) around the wrist. Attach the black hook and loop
pieces together, followed by the blue hook and loop
pieces. Sandwich the neoprene piece with fuzzy
material between the two pieces of rough hook. Be sure
to overlap at least one inch.
• Press the hook and loop closure together firmly and
ensure it adheres securely. Slide one finger (flat)
between the cuff and the inside of the patient’s wrist to
ensure proper fit. The cuffs must be snug enough to
prevent escape, but not interfere with circulation.
• Release the quick-release buckle, twist, and reconnect.
• Adjust the range of motion of the extremity by securing
the connecting straps to different locations of the bed
frame.
iv. Application for ankle:
• Red restraints are intended for ankles. Attach the
connecting strap to the bed frame.
• Wrap the neoprene piece (the red side should be
positioned against the skin) around the ankle. Attach
the black hook and loop pieces together, followed by
the red hook and loop pieces. The fuzzy piece should be
sandwiched between the two pieces of hook. Be sure to
overlap at least one inch.
• Press the hook and loop closure together firmly and
make sure it adheres securely. Slide one finger between
the cuff and the inside of the patient’s ankle to ensure
proper fit. The cuffs must be snug enough to prevent
escape, but not interfere with circulation.
• Release the quick-release buckle, twist, and reconnect.
• To limit range of motion:
o Attach the cuff that is secured to the bottom
right corner of the bed to the left ankle.
o Criss-cross the straps and attach the cuff secured
to the bottom left corner of the bed to the right
ankle.
d. Locked Wrist/Ankle Restraint
i. Purpose: Patient behaviors that may result in extreme danger of
injury to themselves or to others. Only staff trained in the
application of locked restraints may apply locked restraints.
Typically, the need for locked restraints is considered an
emergency. To obtain locked restraints for all units other than
Inpatient Psychiatry, call In-Patient Psychiatry at 263-7525 or

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the Behavioral Response Team at 2-0000. Provide constant
supervision when using this type of restraint.
ii. Contraindications: If possible, avoid use on a patient if an IV or
wound site could be compromised by the device or with a
dislocation or fracture of the affected limb.
iii. Application:
• Wrap the cuff around the patient’s limb.
• Bring the tongue through the metal buckle.
• Assess for proper fit by inserting one finger between
the cuffs and the patient’s wrists or ankles. The cuffs
must be snug enough to prevent escape, but not
interfere with circulation.
• Assess that the lock “clicks” shut. If a lock is not
completely closed, it can pop open. Before leaving the
patient’s side, test the lock by trying to open it without
the key.
• Loop the connecting strap through the U-bar on the
cuff.
• Secure straps to bed frame, never to or through side
rails, out of the patient’s reach. Ensure that the strap is
wrapped around the frame at least once before passing
the end of the strap through the lock.
• Cuffs need to be applied with smooth edge toward hand
or foot. Tape key to wall behind bed. Transportation of
the patient in locked restraints is discouraged, but if
transporting the patient becomes necessary, the key
must accompany the patient whenever transported.
Transport the key inside the front cover of the patient
chart.
• To prevent irritation or abrasion, cuffs may be padded
with skin sleeve (available from Central Services).
6. Vest Restraints (Neurosurgical Intensive Care Unit and Neurosurgical
General Care Unit and PACU)
a. Purpose: A vest is considered to restrict a patient’s exit from bed or
chair. Early detection fall prevention alarms should be considered prior
to the use of a vest.
b. Contraindications:
i. Do not use on patients
• Who are or become highly aggressive, combative,
agitated, or suicidal
• With severe chronic obstructive pulmonary disease
• With an ostomy, colostomy, G-tube, hernia, post-
surgical tubes, incisions or monitoring lines, if/when
• they could be disrupted.
ii. Use of vest restraints has led to serious injury and
sometimes death. Refrain from using this restraint type if
possible.

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c. Application: Proper fit is necessary. A vest that is too large or too
small may cause patient discomfort or injury. To ensure proper size
once applied, verify that the side seams are located under the patient’s
arms.
i. Attach strap with the female end of the quick release buckle to
the movable portion of the bed frame using defined openings
located on the bed or to the side kick spurs on wheelchair.
ii. Place vest on patient with zipper in back and close zipper.
iii. For bed use, insert male end of quick release buckle on vest
into the female end of quick release buckle already attached to
bed. A snapping noise should be heard when connected
properly.
iv. For wheelchair use, bring straps over hips at a 45 degree angle
and pass down between the seat and wheelchair sides. Criss-
cross straps and attach to the female end of quick release
buckle on opposite side. A snapping noise should be heard
when connected properly.
v. Slide an open hand between the vest and patient to ensure a
proper fit. The device must be snug, but not interfere with
breathing.
7. Physical Hold
a. Purpose: The application of force to physically hold a patient, in order
to administer a medication in emergency situations or against the
patient’s wishes by court order (i.e. in order to place the patient in
restraints to prevent serious harm to self or others and/or transport the
patient to a safer location).
b. Other less restrictive methods should be used to avoid or reduce the
amount of force, when possible.
c. Consider use of personal protective equipment, such as gloves, face
shield, and eye shield before initiating a physical hold.
d. Application: Application of physical hold will differ according to
whether the patient is in a bed, wheelchair, or ambulatory. If the
patient is not in a bed, attempt to transport patient to a bed or gurney
for safe administration of medications.
i. A provider order is needed.
ii. You need a minimum of two staff members to
physically hold a patient. Firmly grasp the patient
wrists and ankles and hold to mattress. Whenever
appropriate, summon the Behavior Response Team,
who utilize Non-Violent Physical Crisis
Intervention techniques, to assist in physical holds
of violent/self-destructive patients.
iii. Refrain from physically holding patient to
floor/ground if at all possible.
iv. Avoid placing any pressure or weight on patient’s
chest and torso.




Page 9 of 9

V. UWHC CROSS REFERENCES

A. Hospital Administrative Policy 4.42, Care of Patients Under Legal Custody
B. Hospital Administrative Policy 10.27, UWHC Restraint and Seclusion
C. Nursing Practice Guideline: Restraint and Personal Safety Attendant (found on U-
Connect)

VI. REFERENCES

A. Chandler, G. E. (2012). Reducing use of restraints and seclusion to create a
culture of safety. Journal of Psychosocial Nursing, 50(10), 29-36.
B. Federal Register, Department of Health and Human Services, December, 2006.
Accessed at:
http://www.cms.hhs.gov/CFCsAndCoPs/downloads/finalpatientrightsrule.pdf
C. Ludwick, R., O’Toole, R., & Meehan, A. (2010). Restraints or alternatives: safety
work in care of older persons. International Journal of Older People Nursing, 7,
11-19.
D. The Joint Commission, Accreditation Manual for Hospitals, current edition.
Accessed at: www.jointcommission.org
E. Standards of BoosterPak for Use of Restraint and Seclusion for Organizations
Using Joint Commission Accreditation for Deemed Status. (2013). The Joint
Commission.
F. State Operations Manual, Revised 07-10-15. Accessed at:
https://www.cms.gov/Regulations-and-
Guidance/Guidance/Manuals/downloads/som107ap_a_hospitals.pdf


VII. REVIEWED BY

Clinical Nurse Specialist, Quality and Safety
Director, Nursing Quality and Safety
Nursing Patient Care Policy and Procedure Committee, November 2015

SIGNED BY

Beth Houlahan, DNP, RN, CENP
Senior Vice President, Chief Nurse Executive