Applying an Elbow Restraint

Skill 4-6

Applying an Elbow Restraint

Elbow restraints are generally used on infants and children but may be used with adults. They prevent the patient from bending the elbows and reaching incisions or therapeutic devices. The patient can move all joints and extremities except the elbow.

Restraints should be used only after less restrictive methods have failed. Ensure compliance with ordering, assessment, and maintenance procedures. Restraints must be applied safely and appropriately to reduce risks of injury.

Federal guidelines reinforce that in all settings, the primary responsibility is to protect and promote patient's rights, and that restraints may only be used to protect the patient, staff, or others (Taylor et al., 2023). They must be discontinued at the earliest possible time (Taylor et al., 2023).

Review the general guidelines for using restraints in the chapter introduction and Fundamentals Review 4-2 and Box 4-2 in Skill 4-3. See also Evidence for Practice in Skill 4-3 for best evidence on the topic of interventions to be used as alternatives to the use of restraints, as well as minimizing and eliminating the use of restraints.

Delegation Considerations

After assessment of the patient by the RN, the application of an elbow restraint may be delegated to assistive personnel (AP) as well as to licensed practical/vocational nurses (LPN/LVNs). The decision to delegate must be based on careful analysis of the patient's needs and circumstances as well as the qualifications of the person to whom the task is being delegated. Refer to the Delegation Guidelines in Appendix A.

Equipment

Elbow restraint
Padding, as necessary
PPE, as indicated

Assessment

Assess the patient's physical condition and for the potential for injury to self or others. A confused patient who might remove devices needed to sustain life is considered at risk for injury to self and may require the use of restraints. Assess the patient's behavior, including the presence of confusion, agitation, combativeness, and ability to understand and follow directions. Evaluate the appropriateness of the least restrictive restraint device. Inspect the arm where the restraint will be applied. Baseline skin condition should be established for comparison at future assessments while the restraint is in place. Consider using another form of restraint if the restraint may cause further injury at the site. Assess capillary refill and proximal pulses in the arm to which the restraint is to be applied. This helps to determine the circulation in the extremity before applying the restraint. The restraint should not interfere with circulation. Measure the distance from the patient's shoulder to wrist and limb circumference to determine the appropriate size of elbow restraint to apply.

Actual or Potential Health Problems and Needs

Many actual or potential health problems or needs may require the use of this skill as part of related interventions. An appropriate health problem or need may include:

Injury risk
Acute confusion

Outcome Identification and Planning

The expected outcome to achieve when applying an elbow restraint is that the patient is constrained by the restraint and remains free from injury, and the restraint does not interfere with therapeutic devices. Other outcomes that may be appropriate include the following: the patient does not experience impaired skin integrity, and the patient's family/caregivers demonstrate an understanding about the use of the restraint and its role in the patient's care.

Implementation

Action	Rationale
1. Determine the need for restraints. Assess the patient's physical condition, behavior, and mental status. (Refer to Fundamentals Review 4-2 and Box 4-2 in Skill 4-3.)	Restraints should be used only as a last resort when alternative measures have failed, and the patient is at increased risk for harming self or others.
2. Confirm facility policy for application of restraints. Secure an order from the physician or other licensed practitioner who is permitted to order restraint or seclusion in that health care facility, or validate that the order has been obtained within the required time frame (CMS, 2020a).	Policy protects the patient and the nurse and specifies guidelines for application as well as the type of restraint and duration of use. Each order for restraint or seclusion used for the management of violent or self-destructive behavior that jeopardizes the immediate physical safety of the patient, a staff member, or others may only be renewed in accordance with the following limits for up to a total of 24 hours: (A) 4 hours for adults 18 years of age or older, (B) 2 hours for children and adolescents 9 to 17 years of age, or (C) 1 hour for children under 9 years of age. After 24 hours, before writing a new order for the use of restraint or seclusion for the management of violent or self-destructive behavior, a physician or other licensed practitioner who is permitted to order restraint or seclusion in that health care facility who is responsible for the care of the patient must see and assess the patient (CMS, 2006).
3. Perform hand hygiene and put on PPE, if indicated.	Hand hygiene and PPE prevent the spread of microorganisms. PPE is required based on transmission precautions.
4. Identify the patient.	Identifying the patient ensures the right patient receives the intervention and helps prevent errors.
5. Explain the reason for use to the patient and family/caregivers. Clarify how care will be given and how needs will be met. Explain that restraint is a temporary measure.	Explanation to patient and family/caregivers may lessen confusion and anger and provide reassurance. A clearly stated facility policy on application of restraints should be available for the patient and family/caregivers to read. In a long-term care facility, the family/caregivers must give consent before a restraint is applied.
6. Include the patient's family and/or caregivers in the plan of care.	Promotes person-centered, individualized care and engagement, continuity of care and understanding.
7. Inspect the restraint before use. Do not use a restraint that is soiled or damaged (TIDI Products, 2018a).	Always inspect the device before each use, checking for broken stitches or parts, torn, cut or frayed material; or locks, buckles or hook-and-loop fasteners that do not hold securely. Do not use soiled or damaged restraints to prevent injury or death (TIDI Products, 2018a).
8. Apply the restraint according to the manufacturer's directions:	Proper application reduces the risk for injury. Proper application ensures that there is no interference with patient's circulation.
a. Choose the correct size of the least restrictive type of device that allows the greatest possible degree of mobility.	This provides minimal restriction.
b. Pad bony prominences that may be affected by the restraint.	Padding helps prevent injury.
c. Spread elbow restraint out flat. Place the middle of the elbow restraint behind the patient's elbow. The restraint should not extend below the wrist or place pressure on the axilla.	Elbow restraint should be placed in the middle of the arm to ensure that the patient cannot bend the elbow. The patient should be able to move the wrist. Pressure on the axilla may lead to skin impairment.
d. Wrap the restraint snugly around the patient's arm. Secure hook-and-loop straps around the restraint (Figure 1). Ensure that two fingers can be inserted between the restraint and the patient's arm.	Wrapping snugly ensures that the patient will not be able to remove the device. Hook-and-loop straps will hold the restraint in place and prevent removal of the restraint. Being able to insert two fingers helps to prevent impaired circulation and potential alterations in neurovascular status.
e. Ensure that one to two fingers can be inserted between the restraint and patient's extremity.	The restraint must be snug, but not compromise circulation (TIDI Products, 2019). Proper application ensures that nothing interferes with the patient's circulation and potential alteration in the neurovascular status.
f. Apply a restraint to the opposite arm if the patient can move the arm.	Bilateral elbow restraints are needed if the patient can move both arms.
9. Assess circulation to fingers and hand. Refer to Chapter 3.	Circulation should not be impaired by the elbow restraint.
10. Remove PPE, if used. Perform hand hygiene.	Proper removal of PPE reduces the risk for infection transmission and contamination of other items. Hand hygiene prevents transmission of microorganisms.
11. Assess the patient according to facility policy, or more often, based on the individual patient circumstances and nursing judgment. Assessment should include the placement of the restraint, neurovascular assessment of the affected extremity, and skin integrity. Assess for signs of sensory deprivation, such as increased sleeping, daydreaming, anxiety, panic, and hallucinations. Monitor the patient's vital signs.	The condition of the restrained patient must be continually assessed, monitored, and reevaluated (CMS, 2006). The frequency of monitoring should be made on an individual basis which includes a rationale that reflects consideration of the individual patient's medical needs and health status (CMS, 2006). Improperly applied restraints may cause skin tears, abrasions, or bruises. Decreased circulation may result in paleness, coolness, decreased sensation, tingling, numbness, or pain in extremity. The use of restraints may decrease environmental stimulation and result in sensory deprivation. Monitoring vital signs provides information about the status of the patient.
12. Remove restraint at least every 2 hours or according to facility policy, individual patient circumstances, and nursing judgment. Remove the restraint at least every 2 hours for children 9 to 17 years of age and at least every 1 hour for children under 9 years of age, or according to facility policy, individual patient circumstances, and nursing judgment. Perform range-of-motion (ROM) exercises. Provide for hydration, nutritional, and elimination needs.	Removal allows you to assess patient and reevaluate the need for a restraint. Allows interventions for toileting; provision of nutrition and liquids, and exercise; and change of position. Exercise increases circulation in the restrained extremity.
13. Evaluate the patient for continued need of restraint. Reapply the restraint only if continued need is evident and order is still valid.	Continued need must be documented for reapplication.
14. Reassure the patient at regular intervals. Provide continued explanation of rationale for interventions, reorientation if necessary, and plan of care. Keep the call bell within easy reach of the patient.	Reassurance demonstrates caring and provides opportunity for sensory situation as well as ongoing assessment and evaluation. The patient or family/caregiver can use a call bell can use it to summon assistance quickly.

Evaluation

The expected outcome has been met when the restraint prevented injury to the patient or others. In addition, the patient was unable to bend the elbow, skin integrity has been maintained under the restraint, and the family/caregivers demonstrated an understanding of the rationale for the elbow restraint.

Documentation

Guidelines

Document alternative measures attempted before application of the restraint and that less restrictive interventions have been determined to be ineffective. Document patient assessment before application. Record patient and family/caregiver education regarding restraint use and their understanding. Document family/caregiver consent, if necessary, according to facility policy. Document the reason for restraining patient, date and time of application, type of restraint, times when removed, and result and frequency of nursing assessment.

Sample Documentation

Developing Clinical Reasoning and Clinical Judgment

Unexpected Situations and Associated Interventions

Skin breakdown is noted on elbows: Ensure that restraints are being removed routinely for at least 30 minutes and a skin inspection is done. If restraints are still needed, a padded dressing should be applied under the elbow restraint. Ensure restraint is properly applied. Determine possible alternate methods for restraining.
Patient reports discomfort and pain or cries when elbow is moved: Restraints need to be removed more frequently, with active and/or passive ROM. If elbow is not moved, it will become stiff and painful. Ensure restraint is properly applied. Determine possible alternate methods for restraining.
Application of elbow restraint does not control the patient's body movement to allow for needed examination or treatment: Reassess situation and consider continued need for restraint and possible use of a more restrictive type of restraint.

Community-Based Care Considerations

In long-term care facilities, patients have the right to be free from physical or chemical restraint not required to treat the resident's medical symptoms. When the use of restraints is indicated, the facility must use the least restrictive alternative for the least amount of time and document ongoing re-evaluation of the need for restraints (CMS, 2020b).

EVIDENCE FOR PRACTICE
Minimizing Restraint Use Several resources provide current best evidence on the topic of interventions to be used as alternatives to the use of restraints, as well as minimizing and eliminating the use of restraints. Refer to the Evidence for Practice after Skill 4-3.

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Skill 4-6

EVIDENCE FOR PRACTICE