The Gerontological Nursing Practice Group of the Massachusetts Nurses Association developed the following guidelines in response to practice issues related to restraining elderly patients. Based on an "Educational Needs Assessment" questionnaire that was completed by over 200 nurses in Massachusetts during a three-year period, restraining the elderly, confusion management, and safety and the elderly were identified as priority areas for educational planning. Nurses clearly recognize the special assessment parameters that apply to the geriatric patients and are concerned about the appropriate use of restraints, which allows not only for the safety of the patient, but for the rights of the patient.
The guidelines, which are based on the nursing process, are intended to assist the nurse in her/his decision making and care planning for those elderly patients who may need temporary restraints to ensure their safety. The importance of continual assessment, re-evaluation, and excellent documentation can not be overemphasized.
The professional nurse, as a health team member who monitors the patient's condition 24 hours a day, is in aj central position to assess the potential for injury and evaluate the need for restraints. Restraints should be considered only as a temporary means of intervention, and evaluation of their need should be continuous. The nurse is responsible for knowing policies pertaining to the use of restraints in the clinical setting in which she/he practices.
Restraint is defined as the use of a chemical substance, mechanical device and/or physical restriction by one or more persons which limits the activity of another.
A. Assessment of Risk Factors:
1. Physiological Data
a. Neurologic deficits
b. Alteration in senses
c. Distortion of ability to interpret the environment
e. Medication, including interaction of multiple drugs
2. Behavioral Data
a. History of falls
b. History of confusion; cognitive changes
d. Abusive behavior (past or present)
f. Drug or alcohol abuse
g. Combativeness or aggressive tendencies
B. Determination of Nursing Diagnosis:
1. Potential for injury
a. Harm to self
2. Potential for violence
a. Harm to others
C. Development and Implementation of Plan of Care
1. Emergency use of minimum physical restraint to ensure safety
2. Consideration of alternatives to use of restraint
a. Companionship- staff, family, friends, volunteers
b. Manipulation of the environment - change in room, improved lighting, accessible means of communication (call light or other)
c. Diversion - television, radio, music
d. Transfer home or to familiar surroundings
3. Plan of nursing care is developed for period of restraint and is based on needs which result from the type of restraint applied
a. Patient preparation and teaching regarding the use of restraint
b. Family preparation and teaching regarding rationale and use of restraint
c. Collaboration with the physician as indicated
d. Appropriate choice and application of least restrictive restraint
e. Assessment of skin, cardiovascular, respiratory, neurologic and musculoskeletal integrity as determined by type of restraint
f. Assessment of physiological response to chemical restraint (medications) including therapeutic responses and side effects
g. Assessment of emotional response to restraint
h. Interventions appropriate to maintain physiological integrity, i.e.:
1) Periodic release of restraint
2) Range of motion
3) Protection padding
4) Maintenance of hygiene
1. Evaluation of outcomes of care is continuous and is reflected through documentation in the following areas:
a. Appropriateness and effectiveness of restraint methodology
b. Appropriateness and effectiveness of nursing intervention
c. Mental status and behavioral response
d. Physical response to restraints, i.e., skin, cardiovascular status, respiratory status, response to medication, etc.
e. Patient and family response to use of restraint
f. Continuation of need for restraint or alteration in method
g. Achievement of desired outcome
These guidelines have been prepared by the following members of the Massachusetts Nurses Association Gerontological Committee and the Commission on Nursing Practice:
Terry Fulmer, RN, MS, Chairperson
Gretchen Dix, RN, MS
Anna Yoder, RN, MS
Jessica Terrill, RN, MAPA
in collaboration with
Nancy J. Peterson, RN, MS
Department of Nursing
Massachusetts Nurses Association
Reprinted with permission of the Massachusetts Nurses Association, ©1982.
- American Nurses' Association: Standards of Gerontological Nursing Practice. Kansas City, MO, American Nurses' Association, 1976.
- DiGabio S: Nurses' reaction to restraining patients. American Journal of Nursing. May 1981, pp 973-975.
- Feist R: A survey of accidental falls in a small home for the aged. Journal of Gerontological Nursing, December 1978, pp 15-17.
- Frazier A: A study of clues to potential patient falls. Unpublished paper. Kettering Memorial Hospital, October 1976.
- Massachusetts Department of Mental Health: Restraint and Seclusion Regulations 104, CMR 3.12.
- Massachusetts Department of Public Health: Licensing of Long-Term Care Facilities 105, CMR 150.015.
- Tadsen J and Brandt RW: Rules for restraints: Hygiene and humanity. Modern Nursing Home March 1973, pp 57-58.
- Wolanin, MD and Phillips, L: Confusion, Prevention and Care. St. Louis, CV Mosby Co, 1981.