Australian Critical Care 33 (2020) 30e38

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Australian Critical Care

journal homepage: www.elsevier.com/locate/aucc

Research paper

The effect of physical restraint on neurovascular complications in

intensive care units

rul, MSc *
Büşra Ertug
€
Dilek Ozden, PhD, MSc
Dokuz Eylul University, Institute of Health Sciences, Nursing Faculty, Izmir, Turkey

article information a b s t r a c t

Article history: Background: To reduce the neurovascular complications caused by physical restraint in intensive care
Received 28 May 2018 patients, there is a need to examine the occurrence of neurovascular complications and their rate.
Received in revised form Objectives: The objective of this research was to investigate the effect of physical restraint on the
9 March 2019
occurrence of neurovascular complications and their rate.
Accepted 14 March 2019
Methods: A prospective observational cohort study was carried out. A total of 90 patients from anaes-
thesia and internal intensive care units participated in this study. Patients were assessed at intervals of
Keywords:
24 h for 4 days using the following instruments: Individual Characteristics Form, Richmond Agitation-
Restraint
Physical
Sedation Scale (RASS), Behavioral Pain Scale, and Complication Diagnostic Diary.
Nursing care Results: Redness (p < 0.001), limb movement (p < 0.001), oedema (p < 0.001), and colour complication
Critical care (p < 0.001) increased, whereas pulse strength (p < 0.001) decreased in physically restrained sites on the
Complications arm from day 1 to day 4. Redness was increased in patients physically restrained with all types of ma-
terials (p < 0.001; p < 0.001; p ¼ 0.020). Although there was a statistically significant difference in terms
of movement (p ¼ 0.006; p ¼ 0.003) and oedema (p < 0.001; p < 0.001), both with a roll of gauze and
tough cuff, these complications were not significantly different in patients restrained with green foam tie
(p > 0.05). According to logistic regression analysis, material type, position of the limb, space between
the physical restraint and limb, age, RASS, and pain were independent risk factors for neurovascular
complications. RASS and pain were independent protective factors against movement complications.
Conclusions: The duration of physical restraint increases neurovascular complications. This study
revealed that nurses did not regularly check the restrained wrist and did not focus on the peripheral
circulation. It is necessary to develop training programs, standards, and appropriate follow-up strategies
in intensive care units in Turkey.
© 2019 Australian College of Critical Care Nurses Ltd. Published by Elsevier Ltd. All rights reserved.

1. Introduction
Physical restraint refers to the restriction of patients' move-
ments by attaching physical or mechanical devices to their bodies.1
In intensive care units (ICUs), physical restraint is a controversial
method used to control the behaviour of patients with delirium and
agitation, preventing them from removing medical devices
attached to their bodies.2,3 Although physical restraint is used to
prevent the removal of tubes in patients with delirium, it increases
the delirium of these patients even more.4,5 Therefore, to reduce
* Corresponding author at: Dokuz Eylul University, Institute of Health Sciences,
Nursing Faculty, 35340, Izmir, Turkey. Tel./fax: þ90 2324126967.
E-mail address: busra_diker@hotmail.com (B. Ertug
rul).
the use of physical restraint methods in ICUs, other methods such
as early detection of delirium risk factors; management of pain,
agitation, and delirium; reducing the sedation; and focusing on
care are recommended.6e8 Acevedo et al.3 applied pharmacological
and nonpharmacological methods together in patients who had
severe sedation and delirium. In this study, it is stated that vital
support devices (tubes and lines) can be preserved without using
physical restraint on patients.3
Currently, new methods are being developed to reduce the use
of physical restraint.3,9 However, physical restraint is still widely
used.10e12 Studies have estimated the prevalence of physical re-
straint as 50 per 1000 patients in 40 ICUs in the United States10 and
76% in Canada.11 In Taiwan, the use of physical restraint in ICUs has
been reported to be between 39.1% and 69.9%.12 One study con-
ducted in Turkey reported that 95% of nurses applied physical

https://doi.org/10.1016/j.aucc.2019.03.002
1036-7314/© 2019 Australian College of Critical Care Nurses Ltd. Published by Elsevier Ltd. All rights reserved.
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rul, D. Ozden / Australian Critical Care 33 (2020) 30e38
restraint,13 and another study indicated that the physical restraint
rate was 84.7%.14
Despite the widespread use of physical restraint, previous
research has identified the psychological and physiological com-
plications caused by it.14e16 Circulation problems are one of these
complications17,18 that can be affected by the duration of physical
restraint and properties of the material used.19e21 Previous studies
have revealed that as a consequence of prolonged physical re-
straint, neurovascular complications, such as oedema, redness,
numbness, limitation of movement, increase in temperature, colour
change, and nerve damage, can occur.2,16,17 If neurovascular trauma
is not adequately assessed and treated, it might result in the
development of ischaemia, necrosis, and neurological deficit.22
There are no standardised procedures in the literature regarding
the use of restraint material among hospitals or patients within the
same clinic.2,19,23e25 As a result of the lack of standards and policies,
practices carried out without adequate consent lead to ethical di-
lemmas and the application of physical restraint becomes an in-
dividual decision, resulting in side effects not being controlled.26,27
To develop new standards and control the duration of physical
restraint use, it is necessary to determine the factors that can
generate these complications.
There is no observational cohort study in the literature that has
examined the relationship between the materials used for physical
restraint and the rate of neurovascular complications. The aim of
this study was to investigate the effect of physical restraint on the
occurrence of neurovascular complications and their rate.
2. Methods
2.1. Design
This was a prospective observational cohort study conducted at
the internal medicine and anaesthesia ICUs of a university hospital
in the province of Izmir, Turkey.
2.2. Setting and participants
The study population consisted of patients who were restrained
in anaesthesia and medical ICUs between January 15 and May 10,
2017. Patients who had hemiplegia, extensive haematomas, sur-
gery, or trauma in the restrained part of the limb were excluded
from the sample. Patients with a cast or splint were also excluded
from the sample because these applications may affect patients'
pulse, capillary filling, and oedema.28,29 In the G*Power Version
3.1.9.4 statistical program, power analysis was performed using
complication day rates (19%) and night shift (25.3%) according to
Kandeel and Attia2. The sample size was calculated to be 90 pa-
tients with a power analysis based on type 1 error (0.05) and type 2
error (0.05) (95%). Patients whose restraint application was inter-
rupted between observations were determined by examining the
patient records and were excluded from the sample. A total of 131
patients were evaluated during the study: 26 were excluded
because their physical restraint materials were removed before 4
days, two died within 4 days, nine were discharged, and four were
excluded because their restraint materials were changed. Devel-
opment of neurovascular damage and compartment syndrome can
occur up to 72 h after the injury.30 Therefore, 90 patients were
evaluated for 4 days in this study (details can be seen in Fig. 1).
2.3. Data collection
During data collection, the researcher evaluated patients in the
hospital's ICUs within the first 24 h of their diagnosis. The
descriptive characteristics of patients were recorded in the
31
Individual Characteristics Form during their first evaluation. The
Neurovascular Assessment Form was used to evaluate each
restrained extremity separately, and the Behavioral Pain Scale and
the Richmond Agitation-Sedation Scale (RASS) were used to assess
restrained patients during the 4 days at intervals of 24 h (Fig. 1).
Patients were monitored by the researcher according to the clinical
routine of ICUs. No physical restraint material was used by the
researcher, and no guidance was provided regarding materials'
selection or patient care. The effects of three different material
types applied to patients by healthcare workers (i.e., roll of gauze,
tough cuff, and green foam tie) were evaluated (Fig. 2). Nurses were
informed about the general purpose of the study, and they were
observed between 8 am and 4 pm, but the observation time was not
known by the nurses.
2.3.1. Individual Characteristics Form
The Individual Characteristics Form comprised patients' per-
sonal and clinical information including age, gender, diagnosis,
surgical history, presence of chronic diseases, drugs used, smoking
status, time between hospitalisation and physical restraint practice,
reasons for the use of physical restraint, type of physical restraint,
space between the restraint device and extremity, restraint mate-
rial, and position of the restrained extremity.
2.3.2. Neurovascular Assessment Form
This form was developed by the researchers by reviewing
literature related to neurovascular assessment parameters such as
pain, colour, peripheral pulses, sensation, movement, skin tem-
perature, capillary refill, and oedema.18,28,31,32 In addition to these
parameters, patients' agitation, the space between the extremity
and physical restraint, and the position of the wrist were evaluated
through observation.28,31,32 Four experts' opinions were considered
to complete the Neurovascular Assessment Form. To evaluate the
performance of the prepared evaluation form, a pilot study was
conducted with 10 patients who were restrained in the anaesthesia
and internal medicine ICUs between January 16 and 20, 2017. The
Neurovascular Assessment Form was then reevaluated and edited.
The 10 patients included in the pilot study were excluded from the
study sample.
2.3.3. Assessment of restrained limbs
Redness Assessment: The redness developed as a result of friction
caused by the physical restraint was classified as ‘occur’,
whereas the condition of the wrist when there was no deteri-
oration in tissue integrity was classified as ‘not to occur’.
Colour Assessment: The distal part of the restrained limb (hand
and fingers) was observed. To evaluate the effect of physical
restraint on arterial and venous circulation, pink colour was
classified as ‘normal’, whereas pale cyanotic or red colours were
classified as ‘abnormal’.16,31
Pulse Assessment: The radial and ulnar peripheral pulses at the
distal part of the restrained extremity were evaluated for
1 min and categorised as strong or weak.
Movement Assessment: In the sedated or unconscious critical
care patient, assessment of movement is clearly problematic.32
Therefore, motor and sensory assessments were based on mo-
tor or reflex responses to painful stimuli applied to the nail bed
of the restrained extremity. The movement as the subdimension
of the Behavioral Pain Scale was also used. As a result of the
evaluation, the movement was classified as either ‘occur’ or ‘not
to occur’.
Sensory Assessment: The assessment was performed with a
pencil and a painful stimulus (with pressure) on the nail bed
of the restrained extremity.
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Fig. 1. The chart of patients participating in the study. ICU, intensive care unit; RASS, Richmond Agitation-Sedation Scale.

Fig. 2. (a) Roll of gauze, (b) Tough cuff, and (c) Green foam tie.
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Temperature Assessment: The distal part of the extremity was
slightly touched; when it was warm, it was evaluated as normal,
whereas when it was hot or cold, it was evaluated as a patho-
logical finding.
Capillary Refill Assessment: The assessment was performed by
pressing the nail at the distal part of the restrained extremity
until it was white; return of blood in 3 to 5 s was evaluated as
normal, and when the refill took more than 5 s, it was evaluated
as a pathological finding.
Oedema Assessment: Oedema was evaluated by applying pres-
sure around the lower part of the restrained extremity. The 1-
(2 mm depth), 2- (4 mm), 3- (6 mm), and 4-degree (8 mm)
pitting oedemas were categorised as ‘occur’, whereas it was
categorised as ‘not to occur’ when there was no oedema.31
Space Between the Physical Restraint and Wrist: The distance
between the physical restraint and the patient's wrist was
measured using a ruler. While a measure of less than 2 cm was
categorised as tight, the measure of 2 cm and above was cat-
egorised as normal.
Position Assessment: All patients were evaluated in the supine
position in which the patient lays flat on his or her back on a
bed with arms at the side of the body. To allow the circulation
in the radial artery line of the wrist, a position in which the
patient's wrist was located in a flat plane was considered
suitable, whereas a position in which the patient's wrist comes
out of the bars, is stuck, or is bent was considered
unsuitable.16,18,28,31e34
2.3.4. Behavioural Pain Scale (BPS)
To diagnose pain in intensive care patients, the BPS was used.
This instrument was designed by Payen et al.35 for intensive care
patients and was translated later into Turkish by Vatansever and
Eti36 in 2005; Cronbach alpha coefficient was found to be 0.88. It
consists of three subscales including facial expression, upper limb
movements, and compliance with ventilation. Each subscale has
four items, totalling 12 items. Each subscale is rated on a 4-point
Likert scale (1 ¼ no response to pain; 4 ¼ full response to pain).
The total scale score ranges from three (lowest score) to 12 points
(highest score). An increase in the score indicates an increase in the
level of pain.
2.3.5. Richmond Agitation-Sedation Scale (RASS)
This instrument was developed by Sessler et al.37, and its reli-
ability and validity were evaluated for Turkey by Hepkarşı et al.38.
Its weighted kappa value was found to be satisfactory, ranging
between 0.71 and 0.77, which determined it to be appropriate for
evaluating the sedation level of patients in intensive care during the
monitoring process. The scale consists of a total of 10 points,
evaluating patients' anxiety and agitation at four levels, sedation at
five levels, and alertness at one level. A score of “0” indicates the
ideal level, scores up to “þ4” show increasing agitation, and scores
up to “5” reflect an increasing level of sedation.37,38
2.4. Ethical approval
According to the “Informed Consent Form” written and verbal
permission was taken from each patient's relatives because most
patients were sedated, confused, or agitated. While the neuro-
vascular evaluations of patients were performed, relatives of pa-
tients were informed about the evaluation even if patients were
unconscious. Informed consent was obtained from patients' rela-
tives after informing them about the aim of the study. A written
permission was obtained from the university hospital and the Non-
33
Interventional Clinical Research Ethics Committee (date of deci-
sion: 12.02.2017, Decree No: 2017/01e05).
2.5. Data analysis
Research data were analysed using IBM SPSS Statistics for
Windows, Version 22.0. Armonk, NY: IBM Corp. Descriptive sta-
tistics were reported as means, standard deviations, percentages,
and quartiles. Cochran's Q test was used to determine complica-
tions developing according to days and types of material. McNe-
mar's test was applied to determine the day in which the difference
was caused. P values less than 0.008 were considered to be statis-
tically significant on McNemar's test.39 Multivariate logistic
regression models were established using the statistically signifi-
cant factors in the univariate analysis as independent variables.
Logistic regression analysis was used to assess risk associations
between risk factors and binary outcomes, and estimates are pre-
sented as odds ratios with 95% confidence intervals (CIs).
HosmereLemeshow goodness-of-fit statistics were used to model
fit. P values less than 0.05 were considered to be statistically
significant.39
3. Results
3.1. Patients' demographic and physical restraint characteristics
The mean age of patients was 67.5 ± 17.1 years, and most pa-
tients were male (64.4%) and had chronic diseases (88.9%). It was
found that physical restraint was used on most patients (85.6%) in
the first 24 h of their hospitalisation. Physical restraints were
placed on both wrists in 71.1% of patients, 17.8% of patients had
restraints on the right wrist, and 11.1% of them on the left wrist.
Regarding the type of physical restraint applied on the wrist, 71.6%
was a roll of gauze, 17.6% was tough cuff material, and 10.8% was a
green foam tie. Other characteristics of patients are described in
Table 1.
3.2. Occurrence of neurovascular complications and their rate
Table 2 indicates the occurrence of redness, pulse, movement,
capillary refill time, development of oedema, colour, and temper-
ature complications on patients' wrists physically restrained per
day. A statistically significant difference was found in terms of
redness (p < 0.001), pulse strength (p < 0.001), limb movements
(p < 0.001), oedema (p < 0.001), and colour (p < 0.001) in patients
who were physically restrained by the wrist. No statistically sig-
nificant difference was found from day 1 to day 4 between the
capillary refill time (p ¼ 0.723) and temperature of the wrist
(p ¼ 0.190).
In paired comparison tests to determine which day causes the
difference, it was determined that the redness, pulse, movement,
oedema and colour complications were caused between days 1 and
2 (p < 0.001), days 2 and 4 (p ¼ 0.002), days 1 and 3 (p < 0.001),
days 1 and 2 (p < 0.001), and days 1 and 2 (p < 0.001), respectively.
Table 3 presents the complications developed in patients whose
wrists were restrained over the 4 days according to material type
used. There was a statistically significant difference in the devel-
opment of redness on the physically restrained area with all ma-
terials (p < 0.001; p < 0.001; p ¼ 0.020). While there was a
statistically significant difference in terms of movement (p ¼ 0.006;
p ¼ 0.003) and oedema (p < 0.001; p < 0.001) on the physically
restrained area on the wrist, both with a roll of gauze and tough
cuff, these complications were not significantly different in patients
who were restrained with green foam tie (p > 0.05). In terms of
pulse strength (p ¼ 0.004), there was a statistically significant
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Table 1 difference on the physically restrained area with a roll of gauze;

Clinical and demographic characteristics. however, it was not significantly different in patients who were
Characteristics Number restrained with tough cuff (p > 0.05).
Age
Because there were no significant risk factors in the univariate
Mean 67.41 analysis for pulse, temperature, and capillary refill time, these
Range (minemax) 73.00 (20e93) variables were not included in the regression model. In logistic
Quartilesa: 25 (1st): 56.00; 50 (2nd): 68.00; 75 (3rd): 83.00 regression analysis, the independent risk factors for redness were
Gender (%)
the roll of gauze and tough cuff material type (on the second, third,
Male 32 (35.6)
Female 58 (64.4) and fourth days), position of the wrist (on the first and second
Department (%) days), and space between the physical restraint and wrist (for all
Anaesthesia 59 (65.6) days). The age was identified as a risk factor for oedema on the
Internal diseases 31 (34.4)
second and fourth days. Position of the wrist and space between the
Sedativeb (%)
No 5 (5.6)
physical restraint and wrist were risk factors for colour, whereas
Yes 85 (94.4) RASS was identified as an independent protective factor. Pain and
b
Sedative and analgesic type (%) RASS scores were identified as independent protective factors for
Midazolam 65 (72.2) movement complications. Other results of the logistic regression
Fentanyl 50 (55.5)
analysis are described in the ‘Supplementary material’.
Reason for ICU admissionb (%)
Pneumonia 24 (26.6)
Respiratory failure 33 (36.6) 4. Discussion
Heart failure 11 (12.2)
Postsurgical 18 (20.0)
Cerebral haemorrhage 25 (27.7)
This study was carried out to investigate the rate of develop-
Other 25 (27.7) ment of neurovascular complications during a period of 4 days.
Medicationb (%) The study results demonstrated a significant difference in
Anticoagulant 62 (68.9) development of redness, pulse, movement, oedema, and colour
Steroids 35 (38.9)
complications throughout the 4 days, and there was no signifi-
Antiepileptic 15 (16.7)
Diuretic 48 (53.3) cant difference in capillary refill time and temperature over the 4
Chronic disease (%) days. Most complications increased significantly after the first
Yes 80 (88.9) 24 h (Table 2). Although the objective of restraining therapies in
No 10 (11.1) the ICU is to provide optimal patient safety while maintaining
Postmedical historyb (%)
Diabetic 33 (36.6)
comfort, it is noteworthy that the prevalence of complications can
Hypertension 44 (48.8) increase day by day. While ensuring the safety of patients, nurses
COPD 18 (20) should provide quality evidence-based care for them in a way
ARF/CRF (renal disease) 18 (20) that would not have an adverse effect on their physical and
Smoking (%)
psychological condition.9,18,40,41 However, in Turkey, nurses use
Yes 24 (26.7)
No 66 (73.3) physical restraints as a preventive measure rather than relying on
clinical observations.14
ARF, acute renal failure; CRF, chronic renal failure; ICU, intensive care unit; COPD,
chronic obstructive pulmonary disease.
Results from this study revealed a statistically significant dif-
a
Quartiles median. ference between the restraint period and redness development in
b
Percentages. patients whose wrists were restrained (p < 0.001). The literature
includes studies that have concluded that physical restraints

Table 2
Development of neurovascular complications on patients' wrist per day (n ¼ 148).

Neurovascular complications Day 1 2 3 4 Compared variables according to day

Redness Occur 34 74 88 96 Redness 1 day  redness 2 day

Not to occur 114 74 60 52 p < 0.001a
Cochran's Q¼ 75.448; p < 0.001
Pulse Strong 139 141 138 131 Pulse 2 day  Pulse 4 day
Weak 8 6 9 16 p ¼ 0.002a
Cochran's Q¼ 18,405; p < 0.001
Movement Occur 55 65 79 87 Movement 1 day  Movement 3 day
Not to occur 93 83 69 61 p < 0.001a
Cochran's Q¼ 26,374; p < 0.001
Capillary refill time 3e5 s 137 136 137 139
b
>3e5 s 11 12 11 9
Cochran's Q¼ 1326; p ¼ 0.723
Oedema Not to occur 67 43 33 29 Oedema 1 day  Oedema 2 day
Occur 81 105 115 119 p < 0.001a
Cochran's Q¼ 60.837; p < 0.001
Colour Normal 50 34 30 22 Colour day 1  Colour day 2 p < 0.001a
Abnormal 98 114 118 126
Cochran's Q¼ 31.595; p < 0.001
Temperature Normal 83 88 90 75
b
Abnormal 65 60 58 73
Cochran's Q¼ 4.757; p ¼ 0.190
a
McNemar's test p values which explore the day causing differences.
b
Because there was no significant difference, binary test was not applied.
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Table 3
Development of neurovascular complications in patients with different types of material (n ¼ 148).

Neurovascular complications Day 1 2 3 4

Redness Roll of gauze Occur 30 56 64 71

Not to occur 76 50 42 35
Cochran’s Q ¼ 42.948; p < 0.001
Tough cuff Occur 4 16 19 20
Not to occur 22 10 7 6
Cochran’s Q ¼ 27.507; p < 0.001
Green foam tie Occur 0 2 5 5
Not to occur 16 14 11 11
Cochran’s Q ¼ 9818; p ¼ 0.020
Movement Roll of gauze Occur 40 43 51 59
Not to occur 66 63 55 47
Cochran’s Q ¼ 12.441; p ¼ 0.006
Tough cuff Occur 10 14 18 19
Not to occur 16 12 8 7
Cochran’s Q ¼ 14.163; p ¼ 0.003
Green foam tie Occur 5 8 10 9
Not to occur 11 8 6 7
Cochran’s Q ¼ 7.000; p ¼ 0.072
Capillary Refill Roll of gauze 3e5 s 100 97 97 98
>3e5 s 6 9 9 8
Cochran’s Q ¼ 3.000; p ¼ 0.392
Tough cuff 3e5 s 21 23 25 25
>3e5 s 5 3 1 1
Cochran’s Q ¼ 6.000; p ¼ 0.112
Green foam tie 3e5 s 16 16 15 16
>3e5 s 0 0 1 0
Cochran’s Q ¼ 3.000; p ¼ 0.392
Oedema Roll of gauze Occur 57 76 80 84
Not to occur 49 30 26 22
Cochran’s Q ¼ 44.739; p < 0.001
Tough cuff Occur 13 18 21 24
Not to occur 13 8 5 2
Cochran’s Q ¼ 18.000; p < 0.001
Green foam tie Occur 11 11 14 11
Not to occur 5 5 12 5
Cochran’s Q ¼ 6.231; p ¼ 0.101
Pulse Roll of gauze Strong 99 101 98 93
Weak 6 4 7 12
Cochran’s Q ¼ 13.452; p ¼ 0.004
Tough cuff Strong 24 24 24 22
Weak 2 2 2 4
Cochran’s Q ¼ 6.000; p ¼ 0.112
a

a
In the evaluation of pulse and capillary refill, the analysis is omitted because the number of sponge material usage is not sufficient.

cause redness.14,16,23,26,40 In this study, the number of patients
with redness on the wrist tripled throughout the 4 days (Table 2).
This finding indicates that incomplete nursing care of the
restrained extremity might reflect institutions' inadequate stan-
dards or nurses' inadequate knowledge of caring for physically
restrained patients.18 In the multivariate logistic regression anal-
ysis, roll of gauze and tough cuff material types were identified as
independent risk factors for redness after the first day
(Supplementary material). Regarding the type of material applied
to physically restrained patients in this study, it was found that the
most common material type applied to the wrist was a roll of
gauze. The reason for using this material may be explained by the
fact that physical restraint products are expensive and that there
are no standards and policies regarding the type of material used
in ICUs. Therefore, nurses used the available resources to meet the
needs of patient care.2 Implementing physical restraint methods
with nonergonomic materials may increase the occurrence of
further complications.19 In this study, oedema and movement
complications did not differ significantly in patients restrained
with green foam tie, whereas they differed significantly in patients
restrained with roll of gauze and tough cuff material from day 1 to
day 4 (Table 3). However, in logistic regression analysis, the ma-
terial type was not found to be an independent risk factor for
complications, except for redness (Supplementary material). As
stated previously, if the structure of the textile product is rigid and
rough, it can cause more skin damage than other materials.42
According to these findings, roll of gauzeetype restraint material
may get wet and cause higher vulnerability to tissue damage. On
the other hand, it is less probable that green foam tie gets wet and
deteriorates. Reger et al.43 also reported that wet materials have a
greater risk than dry materials for causing skin damage. However,
studies conducted in this field have been scarce. There is a need
for safety-tested alternative methods to be developed that nurses
can use with patients and there is need to increase nurses' level of
knowledge regarding the appropriate materials to be used for
physical restraint practices.14,19
The space between the wrist and restraint and the position of
the wrist were also independent risk factors for redness and colour
of the extremity (Supplementary material). In this study, the ex-
tremity colour of patients with a physical restraint on their arms
was abnormal on most of the days. Pallor is a complication that
develops as a result of reduced blood circulation in the skin.31 On
the other hand, the development of ischaemia, which is the result
of restricted circulation, was reported by Taha and Ali16 to be a
much less frequent complication than other complications. This
study indicated that a wrong wrist position caused peripheral
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pallor, which supports the fact that inappropriate practice can lead
to an adverse effect on circulation.
As a result of the daily evaluation of patients' pulse strength,
the decrease in pulse strength of the arm was found to be sta-
tistically significant (Table 2). The absence of pulse on the ex-
tremity under restraint is among the early symptoms of
compartment syndrome.28 Pulse evaluation is one of the essential
steps of neurovascular assessment.31,32 Although circulatory
evaluation conducted in the practice of physical restraint is
essential,18 there is a lack of studies regarding pulse evaluation.
Previous research has revealed that physical restraint causes the
development of contracture in joints, nerve injury, and poor
mobility.16,24,44 In their study, Castle and Engberg45 stated that
there was a significant difference between patients who were
physically restrained and those who were not, in terms of being
negatively affected by the development of contracture and loss of
walking independence.
In our study, there was an association between increase of days
and movement, and identifying this is one of the steps of neuro-
vascular assessment. This finding was contrary to the loss of
movement in the affected extremity, and in the logistic regression
analysis, RASS and pain were associated with movement, consistent
with previous studies.16,26 Patients who were physically restrained
were more agitated and made sudden movements to a greater
extent.16,26 Difficulties in calming the intensive care patients and
using different pharmacological strategies with sedative and anal-
gesics contribute to the development of delirium.3 Sedative and
pain-relieving treatment for most patients in our study might have
also caused an increase in their agitation. In addition, restraint is
another factor that increases agitation in intensive care pa-
tients.3,46,47 Although physical restraint has been used to control
the behaviour of patients with delirium, the rate of delirium and
agitation is higher in patients with physical restraint than in pa-
tients who are not restrained and the risk of delirium increases as
the duration of the physical restraint increased.5,45,47,48 Pain is the
most important feature of neurovascular assessment.18,32 However,
evaluating patients in critical care who have been sedated or have a
depressed level of consciousness is frequently problematic.18 In our
study, pain in patients' extremities could not be evaluated and, in
consequence, general pain levels were evaluated instead. Besides
physical restraint, pain is another factor that can cause agitation.49
Therefore, these two values should also be assessed to prevent
physical restraint of patients, and it is recommended to reduce the
duration of restraint if possible. Healthcare workers should pay
close attention to understanding patients' current needs with
empathy.3,5,50
In agreement with previous studies, it was found that oedema is
a common complication caused by physical restraint.2,16,26 Eser
et al. reported that increased levels of agitation in patients may
cause complications such as redness and oedema.23 However, only
age was found to be an independent risk factor for oedema in lo-
gistic regression analysis. As stated in the literature, patients with
peripheral oedema tended to be older.51,52 The high mean age of the
patients (67.41) in this study also supports the literature on the
development of oedema. Besides this, critical care patients' risk for
skin complications is likely to be different than the risk in other
populations because perfusion and general skin status due to
severity of illness and treatments, including vasopressor infusion,
are unique to critical care patients.53,54
Regarding neurovascular assessment, a warm temperature of
the hand indicates a normal finding, whereas a hot or cold tem-
perature suggests a pathological result.31,32 In the literature, it was
found that physical restraint can cause complications related to
skin temperature.16,40 In contrast to the literature, in this study,
complications related to temperature did not change significantly
according to days. In ICUs, patients' core temperature can be
affected by conditions such as low ambient temperature, drug ef-
fects, severe infections, and endocrine abnormalities, as well as the
critical illness.55,56
Results from this study were quite apparent because prolonged
physical restraint led to a shortage of blood flow and pressure on
nerves and tissues with consequent damage. It is important to note
that these complications had increased significantly after the first
day, which shows the importance of the duration of physical re-
straint. Additionally, physical restraint increased the duration of
immobilisation, with subsequent negative effects on patients'
physical and psychological condition. According to the American
College of Critical Care Medicine Task Force 2001e2002, the
restrained patient must be assessed every 15 min if agitated and
every 2 h when calm.18 The assessment should include evaluating
the circulation in the restrained part, as well as the extremity
movement and sensation.31,32 This study revealed that nurses did
not regularly check the restrained wrist and did not focus on the
peripheral circulation. To reduce the frequency of complications
among restrained patients, it is necessary to develop training pro-
grams and standards that will increase nurses' knowledge levels.16
Therefore, there is an urgent need to improve ICUs in Turkey that
should focus on the continuous care of patients who are physically
restrained, how to document the use of restraints, how often to
assess patients, and when to remove these restraints.9 Further-
more, releasing the restraint at 2-h intervals, along with perform-
ing a massage and range-of-motion exercises on the restrained
joints, is recommended.18
Although it has been reported that physical restraints have been
widely used, alternative practices and standards for physical re-
straint have not been implemented yet.57 In this context, multi-
disciplinary reduction programs, development of appropriate
follow-up strategies, and training in ICUs are needed.9,26
4.1. Implications for clinical practice
The increased redness, limb movements, problematic colour
and oedema, and decreased pulse strength observed in intensive
care patients from day 1 to day 4 could be the result of physical
restraint practices. Roll of gauze and tough cuff material types led to
an increase of redness. This study indicates that the neurovascular
complications caused by physical restraint should be monitored
continuously; furthermore, physical restraint should be removed as
soon as possible, standardised green foam tie material types should
be preferred to prevent redness, and clinical nurses should be
trained on this subject. In this regard, standards for assessing the
restrained limb and recording should be developed. There is a need
for training and implementation of standards and policies
regarding the follow-up of physical restraint, neurovascular
assessment steps, and finalisation criteria.
5. Study limitations
There were some limitations in the study. First, pain assessment,
which is one of the neurovascular system evaluations in intensive
care patients, was a difficult task because patients were under
sedation.32 Although pain assessment was performed using scales,
it is unclear whether an increase in pain was associated with the
use of physical restraint. In addition, because there was no control
group in our study and there are many factors that increase RASS
and pain scores, it is not certain whether this increase resulted from
physical restraint or other factors. Second, the position of the wrist
and space between the wrist and restraint has volatility; routine
monitoring of these variables once a day might have under-
estimated their characteristics. Therefore, the result shall be
 €
B. Ertug
rul, D. Ozden / Australian Critical Care 33 (2020) 30e38
interpreted with caution, and further studies are required to
explore the relationship between application characteristics of re-
straint and neurovascular complications. Nurses may have changed
their maintenance behaviour, although only general information
was provided to them about the purpose of the study. Additionally,
because this study was performed in ICUs, results cannot be
generalised to all physically restrained patients.
6. Conclusions
In conclusion, we found that redness, limb movements, and
oedema increased, whereas pulse strength decreased from day 1
to day 4. The complications that developed throughout these four
days revealed that long-term physical restraint of patients should
be avoided and that neurovascular assessment of physically
restrained patients should be performed. Among physical re-
straint practices, the green foam tie material type should be
promoted because it could prevent redness and other potential
complications in patients. Healthcare institutions should develop
standards regarding physical restraint methods and practices. For
physical restraint practices, it is recommended that the distance
between the restraint and patient's wrist should be more than
two centimetres and that an appropriate position should be
maintained.
Funding
This research did not receive any specific grant from funding
agencies in the public, commercial, or not-for-profit sectors.
Authorship statement
All persons who meet authorship criteria are listed as authors,
and all authors certify that they have participated sufficiently in the
work to take public responsibility for the content, including
participation in the concept, design, analysis, writing, or revision of
the manuscript. Furthermore, each author certifies that this mate-
rial or similar material has not been and will not be submitted to or
published in any other publication before
CRediT authorship contribution statement

rul: Conceptualization, Methodology, Data curation,
Büşra Ertu g
Writing - original draft, Formal analysis, Writing - review & editing,
€
Supervision. Dilek Ozden: Conceptualization, Methodology, Writing
- original draft, Formal analysis, Writing - review & editing,
Supervision.
Appendix A. Supplementary data
Supplementary data to this article can be found online at
https://doi.org/10.1016/j.aucc.2019.03.002.
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