How do you assess if physical restraints (restraints) are too tight on a patient?

How to Check if Restraints Are Too Tight

Assess extremity circulation and range of motion every 15 minutes by checking for signs of neurovascular compromise, including skin color, temperature, capillary refill, pulses, sensation, and the ability to move digits. 1

Structured Assessment Protocol

Mandatory 15-Minute Assessments

The American Academy of Pediatrics and Joint Commission guidelines require comprehensive assessments every 15 minutes for all restrained patients, regardless of age. 1 These assessments must specifically evaluate:

• Extremity circulation and range of motion - the primary indicators of restraints being too tight 1
• Vital signs 1
• Signs of injury due to restraint 1
• Nutrition and hydration status 1
• Physical and psychological status/comfort 1

Specific Signs of Restraints Being Too Tight

Check for neurovascular compromise by assessing each restrained extremity for: 2

• Skin color changes - pallor, cyanosis, or mottling indicating impaired circulation 2
• Temperature differences - coolness compared to non-restrained limbs 2
• Capillary refill - delayed refill (>2 seconds) suggests compromised perfusion 2
• Pulse quality - diminished or absent pulses distal to the restraint 2
• Sensation - numbness, tingling, or loss of sensation 2
• Movement ability - inability to move fingers or toes 2
• Swelling or edema - developing around or distal to the restraint 2

Proper Restraint Application Standards

Each limb should be wrapped with a protective collar before the restraint strap is applied to prevent direct pressure on skin and neurovascular structures. 1 The American Academy of Child and Adolescent Psychiatry emphasizes that restraints must be applied by trained staff who understand proper tension. 1

Critical Safety Considerations

High-Risk Complications

Restraints that are too tight can cause skin breakdown, neurovascular damage, rhabdomyolysis, and potential kidney failure. 2 Deaths have been associated with improper restraint use, particularly when circulation is compromised. 2

Immediate Action Required

If any signs of neurovascular compromise are detected:

• Loosen or remove the restraint immediately 2
• Reassess the clinical need for continued restraint 1
• Consider alternative restraint methods or positions 2
• Document findings and interventions 1

Additional Monitoring Requirements

Beyond checking tightness, continuous monitoring must address: 1

• Airway patency - ensure head can rotate freely in supine position 1
• Respiratory effort - no excessive pressure on chest or back 1
• Positioning - supine with head of bed elevated preferred to minimize aspiration risk 1

Common Pitfalls to Avoid

Never assume restraints are appropriately tight just because they were initially applied correctly. 1 Patient movement, struggling, or changes in position can cause restraints to tighten over time. 1

Avoid relying solely on patient complaints to assess restraint tightness, as patients with altered mental status, intoxication, or psychiatric conditions may not reliably report discomfort. 2 Objective assessment of circulation is mandatory. 1

Do not delay loosening restraints if neurovascular compromise is suspected - err on the side of patient safety. 2 The 15-minute assessment interval represents the maximum time between checks, not a suggestion to wait if problems are suspected. 1