Restraint as a Last Resort

Overview

The registered nurse (RN) collaborates with the Health Care Team to develop a care plan to ensure that restraint is used as a last resort. Care plans help staff understand, prevent, and manage behaviours that may put the patient at risk for restraint use.

In order to create effective and individualized interventions that match the patient’s needs, the Health Care Team tries to understand:

  • The individual
  • Their triggers
  • The meaning of the behaviour(s)

Consult others (e.g. Circle of Support) on knowledge of behaviour, routines, abilities, and triggers. Use forms and assessment tools, as needed, to gather this information (e.g. All About Me, Pieces of My Personhood).

Consult members of the Health Care Team to assess specific concerns or behaviour(s) and incorporate these assessment results in a behaviour care plan (e.g. level of transfer and mobility assistance, ways to engage patient in self-care tasks, strategies patient has used in the past to relieve stress, leisure interests and abilities). Include known strategies to prevent and manage responsive behaviours, and maintain cognitive and physical function while remaining person-centered.

Document the care plan in the health record and inform the family/Substitute Decision Maker (SDM) of the plan of care.

It may take several attempts to find alternative strategies that work best for the patient to prevent or limit the use of restraints.

Continually assess and modify the care plan to reflect:

  • The patient's responses
  • Successful alternative approaches
  • Any remaining unmet needs and behaviour challenges

When a restraint is implemented, update the care plan for the use of restraints. Refer to Elements to Consider in a Restraint Section of a Care Plan (below). 

The Health Care Team is responsible for maintaining their competencies of de-escalation and behaviour management strategies to ensure effective performance in situations involving the risk of restraint (e.g. Communicating with Individuals Who Have Dementia as part of the Elder Care in Hospital subject guide, Gentle Persuasive Approaches Training, Teepa Snow Dementia Education for Professionals). The Health Care Team should also consider their organization’s standardized approach to de-escalation and crisis management when creating a patient’s individual plan of care. 

Additional Resources

Pain Management Resources

Distraction can be a very effective technique for all age groups:

Positioning can provide comfort for all age groups:

Additional pain managment resources:

Elements to Consider in the Restraint Section of a Care Plan

Suggested elements to include in a care plan: 

  • Date of care plan
  • Patient’s name, age
  • Past medical history
  • Medications
  • Medical status
  • Underlying medical causes for clinical symptoms or manifestations
  • Mental status (e.g. oriented, confused, agitated, acute changes, fluctuations)
  • Level of cognitive impairment (e.g. MMSE/MoCA)
  • Ability to communicate (e.g. sensory impairment, aphasia, tools used to communicate)
  • Knowledge of cultural traumas and intergenerational traumas (e.g. residential schools, trauma from slavery, experience of torture, experience of immigrants who lived in war-torn countries)
  • Functional impairments (e.g. eating independently, personal care)
  • Care needs and frequency (e.g. toileting, nutrition, hygiene)
  • Specific behavioural concerns (e.g. cannot write “aggressive”, instead specify the behaviour such as “patient lashes out with arms and legs during peri-care”)
  • When responsive behaviours started
  • How often responsive behaviours occur (e.g. results of Behaviour Tracking)
  • Triggers of delirium or mental status decline (e.g. recurrent infections, medications, metabolic imbalances, dehydration, pain, exacerbation of chronic illnesses, time of day)
  • Information from assessments and consultations with patient’s Circle of Support
  • Information and suggestions through assessments done by Health Care Team
  • Likes, dislikes, triggers
  • Positioning devices in use
  • Leisure activities and interests (e.g. what patient finds engaging)
  • Strategies that work/de-escalation interventions (e.g. relaxing music, calming activities, 1:1 time, visitors)
  • Availability and level of involvement of Circle of Support
  • Alternatives to restraints being used/trialed (e.g. monitoring devices)

Consider the following elements to add to a care plan if restraints are initiated: 

  • Specific behaviours or treatment indicating the need for restraint
  • A clear and detailed explanation of triggers/root causes for behaviours
  • What type of restraint is to be used/consented to/ordered 
  • Dosage, as applicable
  • Effectiveness of restraint
  • Frequency and conditions for use of restraint (e.g. when a restraint is to be used)
  • Times initiated or removed for care or intermittent use
  • Reason for intermittent use
  • Effective alternative interventions to be trialed first (e.g. bed alarm, distraction, de-escalation techniques)
  • Expected/intended outcome
  • Potential effects and patient’s response to restraint
  • Frequency and level of monitoring/observation and by whom
  • Clear direction of any delegation by the RN (e.g. CTA application of pelvic belt holder)
  • Tactics to reduce and eliminate the restraint as soon as possible
  • Criteria and timelines to discontinue restraint (e.g. intermittent IV infusion of medication completed)
  • How to minimize potential restraint-related risks (e.g. skin breakdown, venous thromboembolism)
  • Anticipated updates to care plan from previous and ongoing assessments
  • Clear plan for reassessment AND by whom
  • Reassessment frequency

NOTE These are sample care plans. Please follow your local forms procedures.