Seclusion and mechanical restraint in psychiatry: a last resort, monitoring and debriefing

What it is

A restraint is any device, method or process that restricts a person's movement without their permission; a drug is a chemical restraint when it is used to control behaviour or movement and is not the standard treatment or dose for the condition. Seclusion is confinement in a room or area the person cannot leave. They protect from immediate harm, but they affect dignity and can cause injury, entanglement, pressure injuries and death, and they are traumatic. The standard of care is a restraint-free environment: they are used only when less restrictive measures have failed, never as punishment, discipline, convenience or retaliation, and they end as soon as possible. Ley 1616 de 2013 gives the right to the least restrictive interventions. General ward restraints for fall risk are on enf_restraints.

Indications

• Imminent risk of serious harm to the patient or others that has not responded to verbal de-escalation and other less restrictive measures.
• Seclusion when the patient is not a danger to themselves while alone; restraint when they would be.
• Ordered and applied according to Colombian norms and the institutional protocol.

Contraindications and precautions

• Never as punishment, discipline, convenience or retaliation, or because there are too few staff.
• Check for treatable causes first: pain, hypoxia, delirium, intoxication, hypoglycaemia.
• Extra caution in older adults, children, pregnancy, obesity, breathing or heart problems and a history of trauma.
• Avoid positions and holds that compress the chest or neck: risk of asphyxia.
• The patient keeps their rights: dignity, privacy, information and humane treatment.

Equipment

• Institutionally approved padded restraint devices, in good condition, of the right size.
• A safe seclusion room with no objects or anchor points and a way to observe the patient.
• Enough trained staff, with one team leader.
• Monitoring sheet, vital-signs equipment and the protocol to hand.

Step by step (and why)

1. Confirm that de-escalation and less restrictive measures were tried and record them: restriction is justified only as a last resort.
2. Get the order according to protocol and gather a trained team with one leader: a coordinated team reduces injuries.
3. Tell the patient calmly what will happen, why and what is needed to end it: information lowers fear and gives a goal.
4. Apply the devices as trained, without compressing chest or neck, and check circulation: struggling and pressure cause injury and asphyxia.
5. Remove objects that could cause harm and keep privacy and dignity: the person stays a patient with rights.
6. Monitor continuously or as often as protocol sets: breathing, colour, circulation, skin and mental state; Open RN cites checks every 15 minutes.
7. Meet basic needs: fluids, food, toileting and changes of position or range of motion: immobility harms skin, muscles and joints.
8. Keep talking and reassess the release criteria; remove restriction as soon as safe: every minute of restriction carries risk.
9. After release, debrief with the patient and with staff: it helps prevent the next episode and repairs the relationship.
10. Record behaviour, alternatives tried, type and time, each check, release and teaching: documentation protects the patient.

Complications

• Asphyxia from chest compression or a prone hold.
• Strangulation or entanglement in the devices, falls while trying to escape.
• Pressure injuries, nerve or vascular damage, contractures and muscle loss.
• Dehydration and complications of immobility.
• Psychological trauma, humiliation, fear, anger and loss of trust in the team.

Next step: when to call for help

• Call for urgent medical help at once: breathing difficulty, change in colour, unresponsiveness or chest pain.
• Notify the doctor promptly: poor circulation in a limb, injury, vomiting, fever or the patient not calming as expected.
• Tell the nurse in charge: release criteria met, a need to renew the order, or not enough staff to monitor safely.
• After the episode: complete the record and the institutional event report if there was injury, and plan prevention with the patient.

Test yourself

Think of the answer, then tap the question to see it.

Add to my cards (4)

Elsewhere in DurgiPedia

• Respect for autonomy

Connections

← All of nursing

Educational content for students; it does not replace your institution's protocols, supervised clinical training or a prescriber's order. Dose-calculation examples use made-up numbers: they are educational, not a clinical order.

Sources: Nursing: Mental Health and Community Concepts, 5.5: Patient rights (restraints and seclusion) (Open RN, Wisconsin Technical College System (CC BY 4.0), LibreTexts, 2022); Nursing Fundamentals, 5.7: Restraints (Open RN, Wisconsin Technical College System (CC BY 4.0), LibreTexts, 2021); Use and avoidance of seclusion and restraint: consensus statement of the American Association for Emergency Psychiatry Project BETA Seclusion and Restraint Workgroup (open access, PMC3298214) (Knox DK, Holloman GH Jr, Western Journal of Emergency Medicine, 2012); Ley 1616 de 2013, art. 6 (derechos de las personas en el ámbito de la salud mental) (Secretaría General del Senado de la República de Colombia, 2013).

Spotted a mistake?We are always improving for the community. Tell us what is wrong and our team will review it.Report a mistake

Send

Representative model, for educational purposes only.