Restraint Use for CNAs and HHAs (2024)

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Author: Berthina Coleman (MD, BSN,RN)

Introduction

Restraints are any actions or devices healthcare workers use to restrict a patient’s freedom (Scheepmans et al., 2017).The doctor or RN, using protocols, who follows up with the doctor, decides to use physical restraints. It is never OK for a CNA or HHA to start restraints without direction from a higher-level professional.

Certain conditions may make restraint use necessary when caring for patients for their safety:

Impaired decision making
Increased dependency
History of falls or patients at increased risk of falling and impaired mobility

Underlying conditions that may make restraint use necessary include:

Psychiatric disease
Alcohol or drug intoxication
Low blood sugar
Head trauma (Boyce et al., 2016).

Other methods of de-escalation should be tried when caring for agitated patients. De-escalation means taking action to try to keep the agitation from increasing. Restraints should be the last resort. Using restraints when caring for patients in healthcare can negatively affect patients and staff. Consequences can be physical, social, and psychological.

Examples of physical consequences of restraint use include:

Pressure ulcers
Incontinence
Bruising
Physical injury up to death

Social consequences include:

Isolation
Feeling withdrawn

Psychological consequences include:

Depression
Anger
Fear

Restraint use can negatively affect family members by evoking feelings of anger, worry, and guilt. Healthcare workers can also be negatively impacted by their feelings of guilt (Boyce et al., 2016).

Joint Commission Requirements for Checking Patient Who are Restrained

The Joint Commission has stringent requirements for using restraints in the healthcare setting. State, hospital, and facility policies usually define how often restrained patients are checked. They define how often the patient’s vital signs are taken. The policies also detail skin integrity, toileting, and range of motion rules. The restraints can and should be removed as soon as the patient is calm and quiet. However, staff should continue to monitor the patient carefully for both the patient’s safety and that of other patients and the staff (Boyce et al., 2016).

While restrained, patients must be watched closely. Some of the checkings may be delegated to the CNA or HHA.

Vital Signs

Vital Signs: Heart rate, blood pressure, temperature, oxygen saturation and respiratory rate.

Comfort

Patient comfort: skin chafing under and around the restraints, hydration, personal hygiene and toileting needs.

De-escalation Techniques

De-escalation techniques should be tried before restraints are used. There are 3 phases of escalating violence. They are:

Anxiety
Defensiveness
Physical aggression

These patterns of aggression are somewhat predictable. Developing violence can be identified before aggression takes place.

One technique is asking the patient, “How can we assist you?” This technique allows the healthcare worker to engage the patient while displaying compassion. Often, this is sufficient to put an agitated patient at ease. Another technique is offering the patient food and drinks and helping with toileting if appropriate.

The goal is to treat the patient with dignity and empathy. If the patient continues to be agitated, untrained staff should immediately enlist the help of a trained staff member who can help defuse a potentially violent patient encounter. If the patient continues to be violent despite these efforts, facility security should be called to help keep the patient, staff, and other patients safe. When security does arrive, they should gather at a safe distance but within the patient’s view. Sometimes, a show of force is all that is required to calm the patient (Boyce et al., 2016).

Restraint Use in the Elderly

Safety in caring for older people sometimes requires the use of restraints. Overall, using restraints and restricting mobility in older adults will result in a loss of function in the long run (Dahlke et al., 2019).

Several things cause problems in safety when caring for elderly patients. These include:

A lack of experience in caring for the elderly
Mistaking functional decline in older people for a normal process of aging
Lack of access to resources

Leaders at the institutional level must address organizational factors that increase the use of restraint; these may be poor staffing.

Types of Restraints:

Seclusion

Seclusion can be used in both inpatient units and specialized psychiatric units. It was used a lot in the 1980s, but its use has declined due to nursing staff shortages. In addition, most hospitals do not have space to provide seclusion to all patients who need it. Seclusion is a very effective technique for use in aggressive patients.

Note that seclusion can be combined with other forms of restraints, including physical or chemical restraints. Patients placed in seclusion must be reassessed as often as those placed in physical restraints (Kowalski, n.d.).

Limb Restraints

Physically restraining a patient’s limbs is the most common form of physical restraint. Limb restraints can be made from different materials, including leather and cotton. In general, restraints must be comfortable and easy to apply, remove, and clean. Of note, leather restraints are difficult to break or tear but difficult to clean if they get soiled from bodily secretions. Sometimes, hard leather restraints have difficult application and removal processes relative to soft-form restraints. Furthermore, that can be problematic when the patient is crashing in an acute setting. Leather limbs are usually reserved for combative and violent patients in whom the need for secure restraints is considered more important and worth the time it takes to apply or remove them (Kowalski, n.d.).

Soft Limb Restraints

Soft limb restraints are single-use devices made from cotton or foam material. They are less rigid than hard restraints and are easier to apply. Soft restraints are reserved for patients who are agitated but are less aggressive. Soft limb restraints are less secure than hard leather restraints(Kowalski, n.d.). Four-point restraints are restraints on both arms and legs.

Fifth Point Restrains or Belts

Fifth-point restraints, or belts, are used as an adjunct to the four-point restraint. It functions by restricting the movement of the patient’s torso, pelvis, or thighs. Fifth-point restraints are reserved for patients who continue to be dangerous to themselves or others while in a four-point restraint. It can also be used in patients whose behavior prohibits the medical staff from administering medically necessary care, including therapeutic interventions (Kowalski, n.d.).

Patients with a 5-point restraint are at increased risk of aspiration because they cannot turn to their sides if they start vomiting. Also, note that the 5-point restraint must be applied tight enough to prevent the risk of accidental suffocation in case the patient tries to slip under the restraint. These restraints usually require quick-release locks in an emergency (Kowalski, n.d.).

Jackets and Vests

Jacket and vest restraints are reserved for inpatients or patients in longer-term facilities. There are reports of death with the use of jackets or vests related to choking and suffocation (Kowalski, n.d.).In general, jackets and vests are rarely used in emergencies (Kowalski, n.d.).

Leg Restraints

Leg restraints are used in the transportation of patients. Leg restraints are limited in the inpatient or emergency setting (Kowalski, n.d.).

Why Restraints are Used

Restraints prevent agitated or violent patients from harming themselves, other patients, or staff members. Restraints should only be used as a last resort after de-escalation techniques have failed. Patients who are noted to be an immediate danger to themselves or others should be promptly restrained without delay.

Patients may need to be restrained to receive life-saving medical care—for example, patients who are intubated and or patients who are sedated and require life-saving treatment.

In addition, patients at risk for elopement (escaping) may also be restrained in very specific circ*mstances.

Restraints should not be used when de-escalation techniques are adequate. Restraints should not be used on broken limbs, open wounds, or skin infections. Also, restraints should be used cautiously in patients with poor vascular circulation. Fifth-point restraints should be avoided in patients with ostomies, feeding tubes, pelvic fractures, or multiple rib fractures. Finally, patients with severe pulmonary or cardiovascular disease may not tolerate the presence of a fifth-point restraint over their chest.

How to Apply Restraints

Restraints should be applied rapidly and safely by personnel who are trained in the application of restraints. The restraints must be tied to a non-moving part of the bed frame out of the patient’s reach. A slip knot must be used so that restraints can be untied quickly.

When applying restraints to an actively violent patient, a team of five members is recommended: one team leader and one individual for each limb. Occasionally, the presence of multiple team members will be enough to subdue the patient with the need to apply restraints. The patient and family members must be educated about why the restraints are being applied. Also, they should always get clear instructions on the entire procedure.

Problems from Restraint Use

Increased agitation can prevent good communication (Boyce et al., 2016).

Local skin breakdown: physically restricting the patient can prevent them from repositioning and moving. This restriction increases the risk of developing pressure ulcers.

Blood flow problems: If restraints are applied too tight, there is an increased risk of restricting blood flow to a limb.

Breathing problems: Patients with moderate to severe respiratory disease are at risk for breathing problems. For example, a patient with severe obstructive lung disease is at increased risk of respiratory failure if they are in a vest restraint or if they receive certain medication. Tied flat patients cannot easily move to throw up or spit.

That liquid might be sucked back into the lungs, causing pneumonia.

Heart problems: Patients with severe congestive heart failure may be unable to lay flat. If restrained and forced to lay flat, they may be at increased risk of heart and respiratory problems.

Case Study

You are working with a patient in four-point restraints. You are required to toilet the patient every hour while awake. When you re-tie the restraints, you check the tightness to be sure the blood flow is not cut off. If you do not check, a too tight restraint can cut off blood flow to the hand or foot. This cutting off blood flow could cause the patient to lose the use of the hand or have to remove the hand.

Summary

Healthcare workers are responsible for caring for patients even when they cannot make appropriate decisions for themselves. At times, ensuring a patient’s safety and the safety of others will require the use of restraints. Workers must provide compassionate care that follows state, federal, and institutional policy if necessary.

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Implicit Bias Statement

CEUFast, Inc. is committed to furthering diversity, equity, and inclusion (DEI). While reflecting on this course content, CEUFast, Inc. would like you to consider your individual perspective and question your own biases. Remember, implicit bias is a form of bias that impacts our practice as healthcare professionals. Implicit bias occurs when we have automatic prejudices, judgments, and/or a general attitude towards a person or a group of people based on associated stereotypes we have formed over time. These automatic thoughts occur without our conscious knowledge and without our intentional desire to discriminate. The concern with implicit bias is that this can impact our actions and decisions with our workplace leadership, colleagues, and even our patients. While it is our universal goal to treat everyone equally, our implicit biases can influence our interactions, assessments, communication, prioritization, and decision-making concerning patients, which can ultimately adversely impact health outcomes. It is important to keep this in mind in order to intentionally work to self-identify our own risk areas where our implicit biases might influence our behaviors. Together, we can cease perpetuating stereotypes and remind each other to remain mindful to help avoid reacting according to biases that are contrary to our conscious beliefs and values.

References

Scheepmans K, Casterlé BDD, Paquay L, Milisen K. Restraint use in older adults in-home care: A systematic review.International Journal of Nursing Studies. 2018;79:122-136. doi:10.1016/j.ijnurstu.2017.11.008.
Boyce SH, Stevenson RJ, Cline DM. Prison Medicine. In: Tintinalli JE, Stapczynski J, Ma O, Yealy DM, Meckler GD, eds. Tintinalli’sEmergency Medicine: A Comprehensive Study Guide. 8th ed. McGraw-Hill, New York, NY; 2016.
Dahlke SA, Hunter KF, Negrin K. Nursing practice with hospitalized older people: Safety and harm.International Journal of Older People Nursing. 2019;14(1). doi:10.1111/opn.12220.
Kowalski JM. Physical and Chemical Restraint. In: Roberts and Hedges’Clinical Procedures in Emergency Medicine and Acute Care. 3rd ed.; 1481-1498.