**5. Restraint maintenance**

After the decision to initiate patient restraint, the choice of restrain has been agreed upon, and the patient has been adequately secured, documentation and reassessments are the hallmark components of physical restrain maintenance. Restraint documentation frequency has been cited with intervals ranging from 15 minutes to hourly [5, 7, 31, 33–36]. These time frames are constructed with the intention of prompting frequent reassessments with the desired goal of termination of restraint utilization as soon as possible.

It is paramount that after administration of restraints (both chemical or physical), the patient's vital signs, hydration, and mental status are documented. Documentation should also include the need for continued restraint utilization, failed alternatives that resulted in the initiation of physical restraint, number of limbs restrained, the type of restraint utilized, the time of application, the mental status of the patient (orientation, fear, anger, and aggression before, during, and after restraint), the patient's response to restraint, and the presence/occurrence of any injuries during or after restraint [33]. The patient should also be continually observed if they appear asleep/sedated, have other illicit substance onboard, have a concerning past medical history, or have experienced harm because of the intervention [33].

For patients that are chemically restrained, care should be taken to reassess the patient after each dose of medication. PRN orders should be avoided to prevent oversedation and cumulative effects of medication administration as mentioned in the previous sections. PRN ordering schemes can potentially limit the ability of providers to assess levels of agitation correctly while potentially masking other complications hidden under the guise of sedation.

For those patients that are physically restrained, care should be taken to the areas of restraint fastening. These devices should be unlocked and unfastened one at a time in a sequential order to evaluate for skin break down or extremity trauma secondary to the restraint application. The patient should be able to move and range the extremity every two hours [33]. A detailed examination and evaluation of neurovascular status of this extremity should be performed in conjunction with this extremity assessment while restraints are in place [7, 33].

Physical examination of the patient during reassessment should focus on core areas that include but are not limited to the following systems: respiratory, cardiovascular, integumentary, and nervous. Respiratory evaluation should include comments on respiratory rate, work of breathing, airway patency, and respiratory rhythm. Cardiovascular evaluation should document heart rate and rhythm, presence and palpation of distal pulses, and capillary refill. Integumentary evaluation should comment on skin color, temperature, presence of wounds, or presence of edema. Nervous system documentation should portray the patient's orientation and level of consciousness, mobility, sensation, and presence of nervous deficits.

The patients position and location within the restraints should also be re-assessed during evaluation. The patient's bed should remain at the lowest height and remain locked in position [33]. The size of the restraint device should be proportional to the patients habitus and the patient should be placed in a position that minimizes the occurrence of neurovascular insult. Fasteners should be rechecked to make sure they are appropriately connected and that knots can be rapidly discontinued in emergent situations [33].

Patients should be closely monitored with a preference for direct observation. The presence of a direct observation (sometimes colloquially called "one-to-one") enables continuous assessment of the need for restraint or resolution of an ABD.
