Addison was called to the holding area of the large city jail in which she worked to evaluate Mr. Jackson, a man who was just put into a restraint chair after banging his head against the concrete wall of his cell and refusing to follow the direction of the deputies. She arrived to find him secured to a padded metal chair with belts around shoulders, forearms, lower legs, and torso. He had on a ‘spit mask’ as the officers reported that he was spitting at them while they restrained him. It was a distressing sight and she stopped for a moment to take a deep breath and organize her thoughts.

Physical restraints are still used in the criminal justice system to manage unruly inmates; most often mentally ill or substance-involved individuals who are not willing or able to follow instruction or control themselves, and as a result, could harm themselves or others. The risk of self-harm or the harm to others may be valid reasons for a limited use of physical restraint, but the least restrictive options are recommended. Restraint such as this example, especially when it follows a violent take-down, use of an electronic control device or the use of pepper spray, can result in death.  Cases in Florida, Kentucky, Georgia and other states emphasize the concern over the use and misuse of physical restraint in corrections.

However, sometimes a restraint chair is necessary to keep both the incarcerated individual and staff safe for a short period of time, for example, to administer medication or to take a “time out” before moving forward. Most problems with the use of restraint chairs occur because it is used as the solution to a problem rather than a short-term intervention in a larger treatment plan.

Restraint Risks

The use of force necessary to establish control of a violent and combative person, especially if this person is large, can result in broken bones or neck or back injury. Death during physical restraint can result from asphyxiation, aspiration, cardiac arrest, seizures, and other reasons. That is why continuous monitoring of a restrained person’s health status is important and should be initiated early in the process.

Immediate Nursing Action Needed

Correctional nurses are called upon to evaluate the health status of inmates once they are restrained, such as the situation above. It can be very distressing to come upon a fully restrained person, especially if the nurse is new to the process. Although nurses can disagree with the choice of action taken, they must provide the health care required in the situation. Addison needed to act immediately in the best interest of her patient. Here are the actions she needed to take:

• Determine if the patient is in distress – take initial vital signs, especially respirations and heart rate, and assess level of consciousness
• Check that restraints are not so tight as to restrict normal chest expansion
• Check that limb and shoulder restraints do not have the body in a poor alignment that could cause avoidable injury
• Check for any body injury that may have resulted from the takedown. Get a report from the officer in charge about the pre-restraint experience to determine if there are any particular body areas that need specific attention
• Establish that the patient is being continually monitored by custody staff while in restraint – this can be by streaming video but should also include direct visualization every 15 minutes. Respirations and level of consciousness should be monitored
• Establish that the patient is not accessible by other incarcerated persons who could harm him.
• Set up a regular schedule of nursing visits – every 2 hours, at a minimum.

Ongoing Nursing Actions

All the problems of immobility may occur in a fully restrained patient. Even after immediate injury is avoided there remains increasing risk of other perils as time goes on. Just like bed rest, restraint can lead to the following conditions:

• Dehydration
• Deep venous thrombosis (DVT)
• Pulmonary embolism
• Pressure ulcers
• Urinary tract infections
• Neuropathy
• Muscle wasting
• Constipation

To help avoid the hazards of immobility, Addison and the other nurses caring for Mr. Jackson during this time need to, at a minimum, do the following at each two hour check:

• Monitor vital signs and assess level of consciousness
• Check each limb for circulation and neurovascular status
• Release limbs one at a time and move each through a normal range of motion
• Offer fluids and toileting

All of these interventions will likely require officer assistance.

Intervene to Reduce Time in Restraint – Mental Health Consult Stat

Addison is doing her part in monitoring the patient’s health status and preventing physical injury while in restraints, but she has an opportunity to do so much more for this patient. As a patient advocate, correctional nurses can establish rapport with officer colleagues to make suggestions and encourage interventions on behalf of the patient. Even though Mr. Jackson was restrained by order of custody, Addison should get an urgent mental health consult to develop a treatment and management plan to deal with the behaviors that initiated the need for physical restraint.

In Mr. Jackson’s situation, Addison was able to contact the on-call Mental Health provider who ordered lorazepam (Ativan ©) and he was released from the restraint chair after being moved to a seclusion cell in the protective unit. A positive outcome to a risky patient situation.

Have you had to deal with a physically restrained patient in your correctional setting? What did you do?