Categories of restraints

Three general categories of restraints exist—physical restraint, chemical

restraint, and seclusion.

Physical restraint
Physical restraint, the most frequently used type, is a specific
intervention or device that prevents the patient from moving freely or restricts
normal access to the patient’s own body. Physical restraint may involve:

 applying a wrist, ankle, or waist restraint

 tucking in a sheet very tightly so the patient can’t move
 keeping all side rails up to prevent the patient from getting out of bed
 using an enclosure bed.

Typically, if the patient can easily remove the device, it doesn’t qualify as a
physical restraint. Also, holding a patient in a manner that restricts movement
(such as when giving an intramuscular injection against the patient’s will) is
considered a physical restraint. A physical restraint may be used for either
nonviolent, nonself-destructive behavior or violent, self-destructive behavior.
(See What isn’t a restraint?)
Restraints for nonviolent, nonself-destructive behavior. Typically, these types
of physical restraints are nursing interventions to keep the patient from pulling
at tubes, drains, and lines or to prevent the patient from ambulating when it’s
unsafe to do so—in other words, to enhance patient care. For example, a
restraint used for nonviolent behavior may be appropriate for a patient with an
unsteady gait, increasing confusion, agitation, restlessness, and a known history
of dementia, who now has a urinary tract infection and keeps pulling out his
I.V. line.
Restraints for violent, self-destructive behavior. These restraints are devices or
interventions for patients who are violent or aggressive, threatening to hit or
striking staff, or banging their head on the wall, who need to be stopped from
causing further injury to themselves or others. The goal of using such restraints
is to keep the patient and staff safe in an emergency situation. For example, a
patient responding to hallucinations that commands him or her to hurt staff and
lunge aggressively may need a physical restraint to protect everyone involved.

Chemical restraint
Chemical restraint involves use of a drug to restrict a patient’s movement or
behavior, where the drug or dosage used isn’t an approved standard of treatment
for the patient’s condition. For example, a provider may order haloperidol in a
high dosage for a postsurgical patient who won’t go to sleep. (If the drug is a
standard treatment for the patient’s condition, such as an antipsychotic for a
patient with psychosis or a benzodiazepine for a patient with alcohol-
withdrawal delirium, and the ordered dosage is appropriate, it’s not considered a
chemical restraint.) Many healthcare facilities prohibit use of medications for
chemical restraint.

Seclusion
With seclusion, a patient is held in a room involuntarily and prevented from
leaving. Many emergency departments and psychiatric units have a seclusion
room. Typically, medical-surgical units don’t have such a room, so this restraint
option isn’t available. Seclusion is used only for patients who are behaving
violently. Use of a physical restraint together with seclusion for a patient who’s
behaving in a violent or self-destructive manner requires continuous nursing
monitoring.

Determining when to use a restraint

The patient’s current behavior determines if and when a restraint is needed. A
history of violence or a previous fall alone isn’t enough to support using a
restraint. The decision must be based on a current thorough medical and
psychosocial nursing assessment. Sometimes, addressing the issue that’s
underlying a patient’s disruptive behavior may eliminate the need for a restraint.
Also, caregivers must weigh the risks of using a restraint, which could cause
physical or psychological trauma, against the risk of not using it, which could
potentially result in the patient harming him- or herself or others. Input from the
entire care team can help the provider decide whether to use a restraint.

Alternatives to restraints
Use restraints only as a last resort, after attempting or exploring alternatives.
Alternatives include having staff or a family member sit with the patient, using
distraction or de-escalation strategies, offering reassurance, using bed or chair
alarms, and administering certain medications.
If appropriate alternatives have been attempted or considered but have proven
insufficient or ineffective or are deemed potentially unsuccessful, restraint may
be appropriate. A provider order must be obtained for patient restraint. Be sure
to update and revise the care plan for a restrained patient to help find ways to
reduce the restraint period and prevent further restraint episodes.

Reducing restraint risks: Restraints can cause injury and even death. In 1998,
TJC issued a sentinel event alert on preventing restraint deaths, which identified
the following risks:
  Placing a restrained patient in a supine position could increase aspiration
risk.
 Placing a restrained patient in a prone position could increase suffocation
risk.
 Using an above-the-neck vest that’s not secured properly may increase
strangulation risk if the patient slips through the side rails.
 A restraint may cause further psychological trauma or resurfacing of
traumatic memories.

To help reduce these risks, make sure a physical restraint is applied safely and
appropriately. With all types of restraints, monitor and assess the patient
frequently. To relieve the patient’s fear of the restraint, provide gentle
reassurance, support, and frequent contact. Monitor vital signs (pulse,
respiration, blood pressure, and oxygen saturation) to help determine how the
patient is responding to the restraint.

Changing the culture

The American Psychiatric Nurses Association’s position statement on the use of
restraint suggests a unit’s philosophy on restraint use can influence how many
patients are placed in restraints. Interacting with patients in a positive, calm,
respectful, and collaborative manner and intervening early when conflict arises
can diminish the need for restraint. Facility leaders should focus on reducing
restraint use by supporting ongoing monitoring and quality-improvement
projects.
To help ensure a restraint is applied safely, nurses should receive hands-on
training on safe, appropriate application of each type of restraint before they’re
required to apply it. Such training also should occur during orientation and
should be reinforced periodically.
The goal is to use the least restrictive type of restraint possible, and only as a
last resort when the risk of injury to the patient or others is unacceptably high.
Consider using restraint only after unsuccessful use of alternatives, and only as
long as the unsafe situation occurs. Remember—restraint use is an exceptional
event and shouldn’t be a part of a routine protocol.
THE IMPORTANCE OF PROPER BODY MECHANICS
- KEEPING YOUR SPINE HEALTHY

Body mechanics is a term used to describe the ways we move as we go about

our daily lives. It includes how we hold our bodies when we sit, stand, lift,
carry, bend, and sleep. Poor body mechanics are often the cause of back
problems. When we don't move correctly and safely, the spine is subjected to
abnormal stresses that over time can lead to degeneration of spinal structures
like discs and joints, injury, and unnecessary wear and tear.

That is why it is so important to learn the principals of proper body mechanics.

But don't worry, it's not complicated. And once you get used to them, they can
easily be incorporated into your daily life. You will be glad you learned them as
they can save you from back pain and discomfort.

Posture
We have all been told since childhood to "stand up straight". But it's easy to get
into bad habits. Good body mechanics are based on good posture. Good posture
means the spine is in a "neutral" position - not too rounded forward and not
arched back too far. But what does good posture look like?

It's easy, follow these few steps:

 Stand with your feet apart.

 Create a small hallow in your lower back by tucking the tailbone in and
tilting your pelvic bone slightly forward. This is done by tightening the
muscles of the buttocks and thus, rotating the pelvis into the neutral
position. Be careful not to arch too much.
 Pull the shoulders back and lift your chest.
 Lift your chin until it is level and relax your jaw and mouth.

That's it, proper posture! Feel how balanced the spine is? Very little energy is
now required to keep it that way. Practice this position until it becomes second
nature.

Being aware of your posture during all of your daily activities is the best way to
ensure you are using good body mechanics. Here are a few exercises that can
help improve your posture.

 Chin Tuck:
o Sit or stand using proper posture.
o Gently pull your chin back to a comfortable position
o Perform this exercise in sets of ten, 2-3 times daily.
  Shoulder Squeeze
o Sit or stand using proper posture.
o Bring you elbows behind you while squeezing your shoulder
blades together.
o Hold for 5 seconds
o Perform this exercise in sets of ten, 1-2 times daily.

Standing
Millions of people spend a good deal of their time on their feet. Standing work,
including bending, lifting, carrying and reaching can be tough on the back -
especially if proper body mechanics are not being used. Use the following
guidelines to minimize the risk of injury to your back when doing standing
work:

 Avoid standing in one position for prolonged periods of time. Change

your position as often as you can. This will not only help relieve stress on
your spine, it also helps increase circulation and decrease muscle fatigue.
When you can, stretch. Gentle stretching exercises during a break can
help ease muscle tightness.
 Be aware of your posture. Are you standing correctly? Check and double
check throughout your day.
 Make sure the surface you are standing on is firm and level.
 If possible, lean on a solid support. This can help reduce fatigue during
long periods of standing.

Other important tips to remember:

 When lifting an object, avoid bending and twisting at the same time.
Instead, face the object and bend at the knees (not the back).
 Before lifting, move close to and directly in front of the object. Make sure
your feet are flat on the floor and shoulders are apart. Bend the knees and
lift smoothly. Use the same movement when putting the object down
again.
 Avoid overreaching. If you have to reach up to a high level, make sure
you are standing on a firm level surface. Avoid standing on tiptoes. Not
only is this an unstable position to stand in, for prolonged periods of time
it can place unnecessary strain on the back and neck.

Sitting
Whether sitting at a desk or at home watching television, good body mechanics
are still important to keep in mind. For deskwork, consider investing in an
ergonomically enhanced chair. What does proper sitting look like?
  Place your buttocks at the back of the seat while maintaining a small
space between the back of your knees and the seat of the chair.
 Place your feet flat on the floor with your knees bent at a 90°
angle.
 Pull your shoulders back and lift your chest.
 Lift your chin until it is level and relax your jaw and mouth.

If your chair has armrests, make sure they are positioned to support the weight
of your arms. Not too high to make you hunch or too low to make you reach.
Footrests can also be a helpful way to maintain good posture while sitting.
Make sure the footrest is positioned so that your knees are bent comfortably and
are level with your hips.

For prolonged periods of sitting, make sure you have enough support for your
lower back. Look for a chair that has adjustable lumbar support. If that is not
possible, you can increase your back support by using a lumbar roll or even a
rolled up towel or cushion placed behind your lower back.

Keep in mind that even sitting in the "correct" position for long periods of time
will eventually become uncomfortable. Don't forget to take breaks, get up, move
around and stretch! This will reduce the stress on your spine and help prevent
muscle fatigue and stiffness.

Sleeping
We spend about one-third of our time in bed, so we can't ignore how our bodies
are positioned during sleep. As during our waking hours, the goal is to maintain
a neutral spine even while we are in bed. Here's how:

 Make sure you are sleeping on a firm mattress.

 Avoid sleeping on your stomach or with your head elevated on an
oversized pillow. These positions cause the back to arch and places stress
on the spine.
 The side and back are the best positions for maintaining a neutral position
and a must for anyone with back or neck problems.
 Place a pillow between your knees (for side sleeping) or behind your
knees (for back sleeping). This will help keep your spine in the right
position and help ease stress on the lower back.
 Use a pillow that allows you to keep your head aligned with the rest of
your body. Numerous and/or oversized pillows may look great on a made
bed but do not necessarily benefit your back while sleeping.

Lifting
The process of lifting places perhaps the greatest loads on the low back and
therefore, has the highest risk of injury. Use of proper lifting mechanics and
posture is critical to prevent injury. In the end, it is more important how you lift
than how heavy a weight you lift. Here are a few tips on how to lift safely:

 Place the load immediately in front of you.

 Bend the knees to a full squat or lunge position.
 Bring the load towards your chest.
 Assume a neutral position with your back.
 Tighten the lumbar and buttocks muscles to "lock" the back.
 Lift now from the legs to the standing position.
 DO NOT:
o Lift from a twisted / sideways position.
o Lift from a forward stooped / imbalanced position.

As you can see, proper body mechanics are vitally important for keeping your
spine healthy. And it's easy to incorporate these principals into your daily life. It
may seem unnatural at first, but if you keep at it, they will easily become
routine. Your back will thank you for it!