Learning Objectives
By the end of this section, you will be able to:
- Recognize the need for devices that cause limited mobility
- Identify the need for use of restraints
- Describe nursing considerations for restraint management
Devices may sometimes be needed to immobilize a joint or keep a body part in a fixed position for a period of time. This is common in treating various injuries, during medical imaging, and after certain surgeries or procedures. An immobilization device is any device, including casts, braces, slings, traction, and external fixation, that keeps a part of the patient’s body in a fixed position. These devices keep the bone or joint immobile after realignment to aid in proper healing. Restraints are devices used to treat unsafe patient behavior by intentionally limiting the movement of the patient. This unit will discuss the different types of devices used to limit mobility and promote healing. It will also identify different types of restraints, when they are appropriate, and nursing considerations in managing a patient in restraints.
Need for Devices That Cause Limited Mobility
A bone or soft tissue injury may warrant limiting mobility in a joint or limb. The limitation of movement allows the body to repair the injury without the risk of re-injury, complications, or further damage. For example, if a patient breaks their ulna, immobilization of the lower arm will hold the bones together while they heal, reduce pain and swelling, and limit muscle spasms. Another example is that a patient who has a fractured neck may need to wear a cervical collar to ensure proper neck alignment, promote proper healing, and prevent further injury.
Casts and Braces
Immobilization can be completed with casting or bracing. A cast is a hard mold that is set around the limb to prevent it from moving. Casts can be made from plaster or fiberglass. The hardened cast maintains proper alignment of fractured bones or soft tissue injuries while they heal (Figure 9.27). Because the affected limb is immobile, it also promotes continued mobilization of the patient. Casts remain on until the injury heals, which can range anywhere between four and twelve weeks, depending on the injury.
If the cast is too tight or if the limb has swelling, the increased pressure on the capillaries, muscle, and nerves causes a disruption in blood flow, causing compartment syndrome. Left untreated, it can cause permanent tissue damage. It is important that the nurse monitor capillary refill, pulses, temperature, motor function, edema, and sensation of the affected limb and monitor for acute pain. Cast tightness can also cause pressure injury or skin infection.
A functional brace is applied to a limb to heal a fracture, but has the ability to be removed or adjusted. These types of braces are appropriate for a fracture in the tibia or femur. Patients need to remember that if a functional brace is used, the recovery may be delayed; therefore, healing should be in progress with a traditional cast before a functional brace is considered.
Slings and Bandages
A sling is used to support an upper limb by limiting movement or immobilizing the arm to prevent movement in the wrist, elbow, or shoulder. Common injuries that require a sling include surgery; an injured upper arm, wrist, forearm, or shoulder; or a rib or clavicle fracture. A large triangular bandage, or a custom or ready-made sling from cloth, can be used as a sling. The strap of a sling goes around the neck to keep the arm stabilized (Figure 9.28). If the sling is designed to immobilize the arm and shoulder joint, there may be an additional strap that goes around the waist to hold the arm close to the body. Patients should follow provider orders about the frequency of having the sling on and exercises to prevent complications such as frozen shoulder.
Assessment of the arm and hands should be done regularly to monitor for poor circulation or swelling. Symptoms of poor circulation include a change in color of the fingers and hands, cold skin, decreased capillary refill, decreased motor function and sensation, and numbness or tingling in the hands and fingers.
A bandage can be used for slings, to hold splints in place, provide support for the limb or joint, or restrict movement. Bandages should be taut but not to the point of compromising circulation. Skin integrity around the bandage, sensation and color in the extremities, and edema should be monitored closely to prevent complications.
Skeletal Traction
A traction in orthopedics describes the process of pulling on a broken bone or dislocated part of the body, in a slow and steady manner, to realign and stabilize it into the proper position. Generally, this can be done with ropes, pulleys, and weights. A skeletal traction uses pins, wires, or screws inserted distally from the fracture of the bone to create traction by attaching a string and weight (Figure 9.29). The weight pulls the broken bone into place over time. Patients who have been in major trauma accidents where multiple bones are broken may require traction before surgery to align the bones as much as possible and allow the patient to heal from other injuries.
Patients in skeletal traction require safe patient positioning to ensure the weights that create the traction remain suspended at all times. A trapeze should be made available to aid the patient in independent movement and repositioning. Proper cleaning around the skin of the pin sites is also important to prevent infection. Monitor the skin around the pin site for signs or symptoms of infection, such as redness, swelling, warmth to the touch, or drainage.
External Fixation
An external fixation is fixation of a fracture where pins and wires are inserted into the bone percutaneously and held together externally. This type of fixation is commonly done for open fractures, fractures that have exposure to the outside environment, fractures with severe tissue or wound contamination, or pelvic fractures. The fixators can provide alignment and stability to the bones temporarily (Figure 9.30). Ensuring pin care, cleaning the fracture site, and treating the wound can prevent complications such as skin infections or osteomyelitis.
Use of Restraints
A restraint is defined as any measure, physical or pharmacological, that prevents or reduces the full movement of the patient during hospital care (Parkes & Tadi, 2022). The Joint Commission requires that organizations aim to have a restraint-free environment, and if restraints must be used, they are to be used safely (The Joint Commission, 2023a). Restraints should only be used when alternatives cannot meet the needs of the patient or provide the safety of the patient and healthcare staff (The Joint Commission, 2023b). The most common reasons are to prevent injury to self or others, and prevent the patient from dislodging medically necessary IV lines and/or airway tubes from ventilators.
Although restraints are used with the intention to keep a patient safe, they impact a patient’s psychological safety and dignity and can cause additional safety issues and death. A restrained person has a natural tendency to struggle and try to remove the restraint and can fall or become fatally entangled in the restraint. Furthermore, immobility that results from the use of restraints can cause pressure injury, contractures, and muscle loss. Restraints take a large emotional toll on the patient’s self-esteem and may cause humiliation, fear, and anger.
If a restraint is needed, the least restrictive restraint should be selected in order to maintain safety while permitting the most freedom of movement to the patient. For example, to prevent the dislodging of an IV line, padded mitts are less restrictive than wrist ties, because the patient maintains full ROM of their extremities. Another example would be the use of all four side rails of the bed in the upright position, instead of a vest restraint, to prevent the patient from sliding or rolling out of the bed.
Physical Measures
A physical restraint is any manual, physical, or mechanical device, material, or equipment attached to or adjacent to the patient’s body that the individual cannot remove easily and restricts movement or normal access to one’s body. Examples include wrist restraints, padded mitts, and vest restraints (Table 9.7). Nurses should be aware that physical restraints also include common supplies and devices such as sheets, towels, blankets, elbow splints to prevent the patient from bending an arm with an IV, and side rails if they are used in any way to restrict patient movement.
| Restraint Type | Patient Considerations |
|---|---|
| Soft mitt restraint |
|
| Soft wrist restraint |
|
| Vest restraint |
|
| Violent restraint |
|
Link to Learning
This video provides instruction on how to apply different types of physical restraints as well as special considerations for each type.
Pharmacologic Measures
A chemical restraint is any drug that is used to manage a patient’s behavior in order to reduce the safety risk to the patient or others. Drugs used as a chemical restraint should have a rapid onset and minimal side effects to the patient (Parkes & Tadi, 2022). Frequently used drugs include benzodiazepines, first-generation antipsychotics, and second-generation antipsychotics. Examples of situations where chemical restraint would be appropriate include
- a severely violent patient in need of rapid tranquilization,
- agitation from drug or alcohol withdrawal, and
- psychotic or manic episode with severe agitation.
Nursing Considerations for Restraint Management
The American Nurses Association (ANA) has established evidence-based guidelines that state a restraint-free environment is the standard of care. The ANA encourages the participation of nurses to reduce patient restraints and seclusion in all healthcare settings. Restraining or secluding patients is viewed as contrary to the goals and ethical traditions of nursing because it violates the fundamental patient rights of autonomy and dignity. However, the ANA also recognizes there are times when there is no viable option other than restraints to keep a patient safe, such as during an acute psychotic episode when patient and staff safety are in jeopardy due to aggression or assault. The ANA also states that restraints may be justified in some patients with severe dementia or delirium when they are at risk for serious injuries such as a hip fracture due to falling.
The ANA provides the following guidelines: “When restraint is necessary, documentation should be done by more than one witness. Once restrained, the patient should be treated with humane care that preserves human dignity. In those instances, where restraint or therapeutic holding is determined to be clinically appropriate and adequately justified, registered nurses who possess the necessary knowledge and skills to effectively manage the situation must be actively involved in the assessment, implementation, and evaluation of the selected emergency measure, adhering to federal regulations and the standards of The Joint Commission (2009) regarding appropriate use of restraints.” (American Nurses Association, 2012). Nursing documentation typically includes information such as patient behavior necessitating the restraint, alternatives to restraints that were attempted, the type of restraint used, the time it was applied, the location of the restraint, and patient education regarding the restraint.
Any healthcare facility that accepts Medicare and Medicaid reimbursement must follow federal guidelines for the use of restraints. These guidelines include the following:
- When a restraint is the only viable option, it must be discontinued at the earliest possible time.
- Orders for the use of seclusion or restraint can never be written as a standing order or PRN (as needed).
- The treating physician must be consulted as soon as possible if the restraint is not ordered by the patient’s treating physician.
- A physician or licensed independent practitioner must see and evaluate the need for the restraint within one hour after the initiation.
- The patient must be continually assessed. Generally, the best practice is every fifteen minutes for continued use of the restraint, and in the case of an applied restraint, the restraint should be removed and the area assessed every hour. Some agencies require a 1:1 patient sitter when restraints are applied.
- Each written order for a physical restraint is limited to four hours for adults, two hours for children and adolescents ages 9 to 17, or one hour for patients under age 9. The original order may only be renewed in accordance with these limits for up to a total of twenty-four hours. After the original order expires, a physician or licensed independent practitioner (if allowed under state law) must see and assess the patient before issuing a new order.
Alternatives to Restraints
Many alternatives to using restraints in long-term care centers have been developed. Most interventions focus on the individualization of patient care and elimination of medications with side effects that cause aggression and the need for restraints. Common interventions used as alternatives to restraints include routine daily schedules, regular feeding times, easing the activities of daily living, and reducing pain.
Diversionary techniques such as television, music, games, or looking out a window can also be used to help to calm a restless patient. Encouraging restless patients to spend time in a supervised area, such as a dining room, lounge, or near the nurses’ station, helps to prevent their desire to get up and move around. If these techniques are not successful, bed and chair exit alarms or the use of a sitter at the bedside are also considered alternatives to restraints.