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Restraint Use for CNAs and HHAs

1.00 Contact Hour
This course is applicable for the following professions:
Certified Nursing Assistant (CNA), Home Health Aid (HHA), Medical Assistant (MA)
This course will be updated or discontinued on or before Monday, June 7, 2021
Course Description
After completing this continuing education course, the participant will be able to Identify consequences of restraint use, Identify de-escalation techniques, Identify types of restraints and Identify how restraint use can negatively affect patients as well as healthcare providers.
CEUFast Inc. did not endorse any product, or receive any commercial support or sponsorship for this course. The Planning Committee and Authors do not have any conflict of interest.

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To earn of certificate of completion you have one of two options:
  1. Take test and pass with a score of at least 80%
  2. Reflect on practice impact by completing self-reflection, self-assessment and course evaluation.
    (NOTE: Some approval agencies and organizations require you to take a test and self reflection is NOT an option.)
Author:    Berthina Coleman (MD, BSN,RN)

Outcomes

The purpose of this course is to enable the participants to use restraints safely.

Objectives

After completing this continuing education course, the participant will be able to meet the following objectives:

  • Identify consequences of restraint use
  • Identify de-escalation techniques
  • Identify types of restraints
  • Identify how restraint use can negatively affect patients as well as healthcare providers

Introduction

Restraints are any actions or devices that healthcare workers use to restrict a patient’s freedom in any way.1 The decision to use physical restraints is made by the doctor, or RN using protocols, who follows up with the doctor. 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 own 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 include2:

  • Psychiatric disease
  • Alcohol or drug intoxication
  • Low blood sugar
  • Head trauma

When taking care of agitated patients, other methods of de-escalation should be tried. De-escalation means to take action to try to keep the agitation from increasing. Restraints should be the last resort. The use of restraints when caring for patients in the healthcare setting can have negative consequences for both the 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.2

Joint Commission Requirements for Checking Patient Who are Restrained

The Joint Commission has stringent requirements for the use of 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 rules on skin integrity, toileting, and range of motion. As soon as the patient is calm and quiet, the restraints can and should be removed. However, staff should continue to monitor the patient carefully for both the patient’s safety as well as that of other patients and the staff.2

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:

  1. Anxiety
  2. Defensiveness
  3. Physical aggression

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

One technique is to simply ask the patient, “how can we assist you?” This 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 to offer the patient food, drinks and help 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 in spite of 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.2

Restraint Use in the Elderly

Safety in caring for the elderly sometimes requires the use of restraints. Overall, using restraints and restricting mobility in elderly people will result in loss of function in the long run.3

There are several things that cause problems in safety when caring for elderly patients. These include:

  • A lack of experience in caring for the elderly
  • Mistaking functional decline in the elderly 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 used in combination with other forms of restraints, including physical or chemical restraints. Patients who are placed in seclusion have to be reassessed as often as those placed in physical restraints.4

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 have to be comfortable, easy to apply, easy to remove and easy to clean. Of note, leather restraints are difficult to break or tear, but they are difficult to clean if they get soiled from bodily secretions. Sometimes hard leather restraints have a difficult application and removal processes relative to soft form restraints. And that can be problematic in an acute setting when the patient is crashing. 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 the restraints.2,4

Soft Limb Restraints

Soft limb restraints are made from cotton or foam material which are a single use device. 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.2,4 Four-point restraints are restraints on both arms and legs.

Fifth Point Restrains or Belts

Fifth point restraint, or belt, 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 a danger to themselves or others while in a four-point restraint. It can also be used in patients whose behavior is prohibiting the medical staff from administering medically necessary care including therapeutic interventions.2,4

Note that patients with a 5-point restraint are at increased risk of aspiration because they are unable to turn to their sides in case they start vomiting. Also, note that the 5-point restraint must be applied tight enough to prevent the risk for accidental suffocation in case the patient tries to slip under the restraint. These restraints usually require quick release locks in case of an emergency.2,4

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.4 In general, jackets and vests are rarely used in the emergency setting.2,4

Leg Restraints

Leg restraints are used in the transportation of patients. There is limited use of leg restraints in the inpatient or emergency setting.2,4

Why Restraints are Used

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

Patients may need to be restrained to ensure that they 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 who are at risk for elopement (escaping) may also be restrained in very specific circumstances.

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 with caution 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 in 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, as well as 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.2

Local skin breakdown: physically restricting the patient can prevent them from repositioning and moving themselves. This 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 restrained or if they receive certain medication. Patients who are tied flat 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 they are restrained and forced to lay flat, they may be at increased risk of heart and eventually respiratory problems.

Case Study

You are working with a patient in four-point restraints. You are required to toilet the patient every 2 hours 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 restraint that is too tight can cut off blood flow to the hand or foot. This could cause the patient to lose the use of the hand or having to remove the hand.

Summary

It is healthcare workers’ responsibility to care for patients even when they are unable to make appropriate decisions for themselves. At times, ensuring a patient’s safety and the safety of others will require the use of restraints. If that becomes necessary, workers must provide compassionate care that follows state, federal and institutional policy.

Select one of the following methods to complete this course.

Take TestPass an exam testing your knowledge of the course material.
OR
Reflect on Practice ImpactDescribe how this course will impact your practice.   (No Test)

References

  1. 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.
  2. Boyce SH, Stevenson RJ, Cline DM. Prison Medicine . In: Tintinalli JE, Stapczynski J, Ma O, Yealy DM, Meckler GD, eds. Tintinalli’s Emergency Medicine: A Comprehensive Study Guide. 8th ed. McGraw-Hill, New York, NY; 2016.
  3. Dahlke SA, Hunter KF, Negrin K. Nursing practice with hospitalised older people: Safety and harm. International Journal of Older People Nursing. 2019;14(1). doi:10.1111/opn.12220.
  4. Kowalski JM. Physical and Chemical Restraint . In: Roberts and Hedges’ Clinical Procedures in Emergency Medicine and Acute Care . 3rd ed. ; :1481-1498.