1. INTER-Interdisciplinary
TITLE: Restraints: Nonbehavioral POLICY NUMBER: INTER-R-118
APPROVED: PAGE 1 of 9
EFFECTIVE DATE: 7/2008 REVISION DATE: 3/01/2010
Policy Statement
The hospital limits its use of restraint for non-behavioral health purposes. Use of restraints
from non-behavior health purposes is initiated either by an individual order or by an approved
written protocol, the use of which is authorized by an individual order. The decision to use a
restraint is not driven by diagnosis, but by a comprehensive individual patient assessment.
Purpose
The use of restraint for non-behavioral health purposes is a restraint that is used for acute
medical and surgical care that directly supports medical healing. Restraints used for acute
medical or surgical care is usually an adjunct to planned care or a component of an approved
protocol.
Patient Alert
All patients’ have the right to be free from restraint of any form, imposed as a means of
coercion, discipline, convenience, or retaliation by staff. Restraint may only be imposed to
ensure the immediate physical safety of the patient, a staff member or others and must be
discontinued at the earliest possible time. Restraint may only be used when less restrictive
interventions have been determined to be ineffective to protect the patient, other patients, or
staff from harm.
Overview
Patients at risk for injury may need to be temporarily restrained. A physical restraint is any
device, garment, material, or object that restricts a person’s freedom of movement or
access to his or her body. The restraint must be clinically justified and a part of the
prescribed medical treatment and plan of care, and all other less restrictive measures
must be tried first.
The use of restraints has been associated with serious complications. The Food and Drug
Administration (FDA), which regulates restraints as medical devices and requires
manufacturer’s to label them ―prescription only‖, estimates that hundreds of restraint-
related injuries occur each year, approximately 100 of them resulting in patient death.
Most patient deaths have resulted from suffocation from a vest or jacket restraint. Numerous
institutions have stopped using vest restraints, including Bloomington Hospital. For these
reasons vest restraints will not be presented here.
Pressure ulcer formation, hypostatic pneumonia, constipation, incontinence, contractures,
and neurovascular impairment can result from the enforced immobility that results from using
restraints. Altered sensory perception and altered thought processes, such as delirium, may
also result. Humiliation, fear, anger, and a decreased sense of self-esteem may occur. For
this reason, a patient’s dignity will be maintained while any patient is restrained or secluded.

2. TITLE: Restraints: Nonbehavioral POLICY NUMBER: INTER-R-118
REVISION DATE: 3/01/2010 Page 2 of 9
When the use of restraints is the only appropriate intervention to maintain the patients’ safety,
the patient should be informed that the restraint is temporary and protective, along with family
when applicable. As with other procedures, the nurse and all other staff must follow specific
institution guidelines when using restraints. Restraints require a physician’s order, which
should specify the type of behavior or condition requiring restraint, the type of restraint, and
time limitations for restraint application. Orders should be renewed according to Bloomington
Hospital policy and based on reassessment and reevaluation of the restrained patient.
Not all patients will be able to accept the use of restraints easily. Cultural values affect how
patient’s and family members perceive the use of restraints. The nurse assesses the
meaning of restraint to the patient and the family (when applicable). Nurse and family
collaboration can help with culturally sensitive care. Removing restraints when family
members are present can be an option if patient safety is not jeopardized.
Procedure
Definitions
A Restraint IS:
The application of physical force to a patient with or without the patients’ permission to
restrict his or her freedom of movement. The physical force may be human,
mechanical devices, or a combination thereof.
Any manual method, physical or mechanical device, material, or equipment that
immobilizes or reduces the ability of a patient to move his or her arms, legs, body, or
head freely.
A Restraint may be used in response to emergent, dangerous behavior; as an adjunct
to planned care; as a component of an approved protocol; or, in some cases, as part
of standard practice. Because a restraint may be necessary for certain patient’s, health
care organizations and providers need to be able to use restraints when essential to
protect patient’s from harming themselves, other patient’s, or staff. They also need to
be aware of the associated risks of both its’ use and nonuse.
Any drug or medication when it is used as a restriction to manage the patients’
behavior or restrict the patients’ freedom of movement and is not a standard treatment
or dosage for the patients’ condition.
A Restraint Does NOT INCLUDE:
Generally, if a patient can easily remove a device, the device would not be considered a
restraint. In this context, ―easily remove‖ means that the manual method, device, material or
equipment can be removed intentionally by the patient in the same manner as it was applied
by the staff.
The specific device used to restrain a patient does not in itself determine whether these
standards apply, it is the device’s intended use (such as physical restriction), its’
involuntary application, and/or the identified patient need that determines whether use of the
device triggers the application of these standards. This also does not include devices, such
as orthopedically prescribed devices, surgical dressings or bandages or other methods that
involve the physical holding of a patient for the purpose of conducting routine physical

3. TITLE: Restraints: Nonbehavioral POLICY NUMBER: INTER-R-118
REVISION DATE: 3/01/2010 Page 3 of 9
examinations or tests, or to protect the patient from falling out of bed, or to permit the patient
to participate in activities without the risk of physical harm.
These standards do not apply to the following:
Standard practices that include limitation of mobility or temporary immobilization
related to medical, dental, diagnostic, or surgical procedures and the related post-
procedure care processes (i.e. surgical positioning, intravenous arm boards,
radiotherapy procedures, protection of surgical and treatment sites in pediatric
patient’s), age or developmentally appropriate protective safety interventions
Adaptive support in response to assessed patient need (i.e. postural support,
orthopedic appliances, table top chairs [geriatric/cardiac]).
Helmets
Forensic and correction restrictions used for security (i.e. handcuffs)
Four side rails up would not be a restraint if a patient was on a Stage IV mattress.
Alternatives to Restraints:
Non-physical techniques are always considered the preferred intervention. Such
interventions may include:
Reality orientation (redirecting the patient’s focus)
Review medication regimen
Changes in environment
Optimize positioning/comfort
Velcro Belt
Staff/Family/Patient safety provider present
Physical activity/ambulate patient
Patient education
Lowering beds
Open visitation to elicit family help
Placing a pillow in the lap of the patient who is sitting
Stuffed animal
Involving Occupational/Recreational Therapy to structure patient time
Angled cushions for chairs
Bed Alerts/personal alarms
Arm sleeves (netting)
Verbal De-Escalation
Allowing the patient to voluntarily cooperate
Cardiac chair
Geriatric chair

4. TITLE: Restraints: Nonbehavioral POLICY NUMBER: INTER-R-118
REVISION DATE: 3/01/2010 Page 4 of 9
Non-Behavioral Restraint Orders Time Limited, Medical – Surgical Units
If a registered nurse initiates use of restraint for non-behavioral health purposes, a
licensed independent practitioner (LIP) provides a verbal or written order as soon as
possible, not to exceed 12 hours of initiation.
The patient must be examined by a LIP within 24 hours of initiation of restraints.
If the restraint for non-behavioral health purposes is continued beyond 24 hours, its
use is ordered once each calendar day by a LIP, based on his or her examination of
the patient.
If a significant change in patient’s condition or behavior the attending physician
is to be notified immediately.
Non-Behavioral Restraint Orders – Critical Care Protocol
During treatment of certain specific conditions (i.e. Post-traumatic brain injury) or
certain specific clinical procedures (i.e. intubation), restraints may be necessary to
prevent significant harm to the patient. Protocols for restraint use may be established
based on frequent presentation in those conditions or procedures of behavior by
patients that seriously endangers the patient or seriously compromises the
effectiveness of the procedure.
Restraint protocols include guidelines for assessing the patient; criteria for applying the
restraint and criteria for monitoring the patient and reassessing the need for restraint
and criteria for terminating restraints.
A licensed independent practitioner (LIP) issues a patient specific order authorizing the
use of a restraint protocol. Authorized staff maintains and terminates restraint in
accordance with established criteria based on the individual patient needs and
appropriate clinical justification.
The Non-Behavioral Care Restraint protocol orders at Bloomington Hospital may only
be utilized in the Critical Care Areas (CCE, CCW, CVR). Each patient must be
assessed, and interventions should be tailored to meet the individual patient’s needs.
The protocol is used in the care of patients who are at risk for self-harm secondary to:
o Airway Management
o Feeding/Drainage Tube
o Invasive Lines
The order will remain in effect until selected medical treatments are
discontinued, patient no longer meets criteria for use OR the patient is
transferred to any medical/surgical unit. If none of the above applies, a Time-
Limited Restraint Order must be used.
Monitoring & Documentation of Medical Restraints
All documentation of patient in Non-Behavioral Time Limited & Critical Care Protocol
Restraints is to be noted every 2 hours and be individualized taking into consideration
variables such as the patient’s condition, cognitive status, risks associated with the use of the
chosen intervention and other relevant factors.

5. TITLE: Restraints: Nonbehavioral POLICY NUMBER: INTER-R-118
REVISION DATE: 3/01/2010 Page 5 of 9
Time of the initiation of the restraints
Reason for the restraint
Alternatives used prior to placing the patient in restraints AND ongoing alternatives to
ensure the use of restraint is discontinued at the earliest possible time
Restraint placement
Restraint type
Intervention/Assessment – for continued use of restraints
Capillary refill
Food & Fluid
Toileted
Released – note if released temporarily, directly supervised, for the purpose of caring
for a patient’s needs (toileting, feeding, range of motion exercises)
Reapplied - after caring for patient’s needs
Range of Motion
Repositioning
Any injuries noted during restraint episode or related to continuation of restraints –
chart in comment section
Significant changes in patient’s condition – chart in comment section
Vital Signs
Discontinued – restraints removed, requires new order to re—start
Application and Staff Training Requirements
The person applying and monitoring of the patient in restraints must have received education,
training, and demonstrated knowledge based on the specific needs of the patient population
in the following:
Techniques to identify behaviors, events, and environmental factors that may trigger
circumstances that require the use of restraint.
Use of nonphysical skills.
Choosing the least restrictive intervention based on an individualized assessment of
the patients medical, or behavioral status.
The safe application and use of all types of restraints used at Bloomington Hospital,
including training in how to recognize and respond to signs of physical and
psychological distress (i.e. positional asphyxia).
Physical and psychological assessment of the patient who is restrained.
Use of first aid techniques (i.e. management of minor scrapes/bleeding) CPR
Certification, monitoring and establishing vital signs of the patient in restraints.
Application of restraints
Maintain annual competency in all of the above.
Hospitals must report deaths associated with the use of restraints according to the
following CMS guidelines:
Each death that occurs while the patient is in Non-Behavioral Restraints
Each death that occurs within 24 hours after the patient has been removed from

6. TITLE: Restraints: Nonbehavioral POLICY NUMBER: INTER-R-118
REVISION DATE: 3/01/2010 Page 6 of 9
Non-Behavioral Restraints
Each death known to the hospital that occurs within 1 week after Non-Behavioral
Restraint where it is reasonable to assume that use of restraint contributed directly or
indirectly to a patient’s death
Bloomington Hospital Patient Care Directors will be responsible for reporting the above
circumstances to the CMS no later than the close of business the next day following
knowledge of the patient’s death
The Patient Care Director will document in the patient’s medical record the date and
time the death was reported to the CMS
Patient Assessment and Preparation
Assessment
a. Determine patient’s need for restraint if other less restrictive measures fail to
prevent interruption of therapy or injury to self or others. Confer with psychiatrist or
primary health care provider.
b. Assess patient’s behavior, such as confusion, disorientation, agitation,
restlessness, combativeness, or inability to follow directions.
c. Review institution policies regarding restraints. Check physician’s order for purpose
of restraint and type, location, time and duration of restraint.
d. Review manufacturer’s instructions for restraint application before entering
patient’s room. Determine the most appropriate restraint.
e. Inspect area where restraint is to be placed. Note if there is any nearby tubing,
jewelry, or devices. Assess condition of skin, sensation, and joint range of motion,
if applicable, of underlying area on which restraint is to be applied.
Preparation
a. Identify patient by checking armband and having patient state name, if applicable.
b. Approach patient in a calm, confident manner. Explain what the plan is and what
staff will be doing.
c. Gather equipment, and perform hand hygiene.
Procedure
a. Provide privacy and maintain patient’s dignity, as the situation permits. Position and
drape patient as needed.
Rationale: Prevents lowering of patient’s self-esteem
b. Adjust bed to proper height, and lower side rails.
Rationale: Allows nurse and staff to use proper body mechanics
and prevent injury
c. Maintain patient’s comfort and in correct anatomic position.
Rationale: Prevents contractures and neurovascular impairment
d. Pad skin and bony prominences (as necessary) that will be under the restraint.
Rationale: Reduces friction and pressure from restraint on skin and
underlying tissue

7. TITLE: Restraints: Nonbehavioral POLICY NUMBER: INTER-R-118
REVISION DATE: 3/01/2010 Page 7 of 9
f. Apply appropriate size restraint and refer to manufacturer’s directions.
1. Extremity (ankle or wrist) restraint: Restraint designed to immobilize one or
all extremities. Restraints are composed of foam padding. Limb restraint is
wrapped around wrist or ankle with soft part toward skin and secured snugly
in place with Velcro straps and/or locks.
Rationale: Maintains immobilization of extremity to prevent
patient injury from fall or accidental removal of therapeutic
device (i.e. IV tubing, Foley catheter). Tight application may
interfere with circulation.
Patient with wrist and ankle restraints is at risk for aspiration if placed in a
supine position. Place patient in lateral position rather than supine.
g. Attach restraint straps to bed frame and to an area that does not cause the
restraint to tighten when head of bed is raised or lowered. (movable part of the
bed). Do not attach to side rails. In the use of soft wrist restraints the straps may
be attached to chair frame for patient in a chair or wheelchair.
Rationale: Patient may be injured if restraint is secured to side rail
And it is lowered.
h. Secure restraints with a quick-release tie.
Rationale: Allows for quick release in emergency.
i. Insert two fingers under secured restraint
Rationale: Checking for constriction prevents neurovascular injury.
A tight restraint may cause constriction and impede circulation.
j. Restraints should be removed at least every 2 hours. If patient is noncompliant,
remove one restraint at a time and/or have staff assistance while removing
restraints.
Rationale: Provides opportunity to change patient’s position,
perform full range of motion, toileting, and exercise; and
provide food or fluids. Restraints restrict movement; making patient’s unable to
perform their activities of daily living (ADLs) without assistance. Providing
food/fluids and assisting with toileting and other activities is essential.
k. Secure call light or intercom system within reach.
Rationale: Allows patient, family, or caregiver to obtain assistance
quickly.
l. Leave bed or chair with wheels locked. Bed should be in the lowest position.
Rationale: Locked wheels prevent bed or chair from moving if
patient attempts to get out. If patient falls when bed is in lowest
position, chances of injury is reduced.
m. Perform hand hygiene.

8. TITLE: Restraints: Nonbehavioral POLICY NUMBER: INTER-R-118
REVISION DATE: 3/01/2010 Page 8 of 9
Rationale: Reduces transmission of microorganisms.
Post Procedure
a. Evaluate proper placement of restraint, skin integrity, pulses, temperature, color, and
sensation of the restrained body part at least every 2 hours or sooner, according to
need and Bloomington Hospital policy.
Rationale: Frequent assessments prevent complications, such as
suffocation, skin breakdown, and impaired circulation
b. Inspect patient for any injury, including all hazards of immobility, while restraints are in
use. Also inspect patient during routine removal of restraint.
Rationale: Patient should be free of injury and not exhibit any
signs of complications from immobility.
c. Observe IV catheters, urinary catheters, and drainage tubes to determine that they are
positioned correctly and that therapy remains uninterrupted.
Rationale: Reinsertion can be uncomfortable and can increase risk
of infection or interrupt therapy.
d. Reassess patients need for continued use of restraint at least every calendar day,
with documentation every 2 hours. A face to face assessment by a physician for Non-
Behavioral Restraints is every calendar day with a new written order for continuation of
the restraints. Patients in Critical Care areas who meet the criteria for the protocol will
remain in effect until selected medical treatments are discontinued, patient no longer
meets criteria for use OR patient is transferred to any medical/surgical unit.
Rationale: The intent is to discontinue restraints at the earliest
possible time.
Expected Outcomes
Patient remains free from injury
Patients therapy is uninterrupted
Patients self-esteem and dignity are maintained
Unexpected Outcomes
Patient experiences impaired skin integrity related to improper or prolonged use of
restraint
Patient has altered neurovascular status of an extremity, such as cyanosis, pallor, and
coldness of skin, or complains of tingling, pain, or numbness
Patient exhibits increased confusion and disorientation
Patient experiences shortness of breath and impaired air exchange
Patient releases restraint and experiences a fall or other traumatic injury
Patient has psychological distress
Patient has death
Patient & Family Education
Thoroughly explain the use of restraints

9. TITLE: Restraints: Nonbehavioral POLICY NUMBER: INTER-R-118
REVISION DATE: 3/01/2010 Page 9 of 9
Caution family against removing, repositioning, or retying restraints in Acute
Medical Surgical situation
Age-Specific Considerations
Pediatrics
The use of restraints should be limited to clinically appropriate and adequately justified
situations after all appropriate alternatives have been used. Restraints are only used
on children to restrict movement when patient’s are at risk of injuring themselves or
others
When a child needs to be restrained for a procedure, it is best that the person applying
the restraint not be the child’s parent or guardian
A mummy restraint is a safe, efficient, short-term method to restrain a small child or
infant for examination or treatment. Open blanket and fold one corner toward the
center, place child on blanket with shoulders at fold and feet toward opposite corner.
With child’s right arm straight down against body, pull right side of blanket firmly
across right shoulder and chest and secure it beneath left side of body. Place left arm
straight against body, and bring left side of blanket across shoulder and chest and lock
it beneath child’s body on right side. Fold lower corner and bring it over body and trunk
or fasten it securely with safety pins.
Geriatrics
Advanced age is not in itself an indication for use of restraints. Promoting functional
restoration by performing individual assessment of risk factors, determining if a need is
not being met, orienting patient as needed, modifying the environment, teaching
muscle strengthening exercises, and meeting older patient’s needs in ADLs will help
prevent falls and other traumatic injuries.
Documentation/ Related Documents
General Information
Ages Served
Neonatal Infant
Pediatric
Adolescent
Adult
Geriatric
References
The Joint Commission reference is: Comprehensive Accreditation Manual (CAMH) - June
2009
CMS Manual System Pub. 100-07 State Operations - October 17, 2008