Restraints require a time-limited provider order specifying type, reason, and duration; behavioral/violent restraint orders are limited and require frequent renewal.
Before you read
Test yourself first: 3 questions
Question 1 of 3
A nurse finds a confused client trying to climb out of bed. The safest immediate action is to:
Answer: B. Stay with the client, lower the bed, and call for help; use the least-restrictive measures. Leaving to find restraints abandons the client at risk for a fall.
Question 2 of 3
A client is in soft wrist restraints. How often does the nurse assess circulation, skin, and need?
Answer: B. Restrained clients are assessed at least every 1–2 hours (circulation, skin integrity, range of motion, toileting, hydration) and released periodically, with an order renewed per policy.
Question 3 of 3
A confused older adult keeps trying to climb out of bed. What should the nurse do FIRST?
Answer: B. Use least-restrictive measures first: a bed alarm, frequent checks, lowered bed, and moving the client near the station. Restraints require an order and are a last resort.
Keep the streak going with more questions like these, each with a full rationale.
What is use of restraints?
They carry serious risks including injury, strangulation, impaired circulation, aspiration, and death. Use requires a current provider order, the least restrictive type, and strict ongoing monitoring. Restraints are never used for staff convenience or punishment.
Key points to remember
- Restraints require a time-limited provider order specifying type, reason, and duration; behavioral/violent restraint orders are limited and require frequent renewal.
- An order can never be PRN (as needed); each episode requires its own order and an in-person evaluation within set timeframes.
- Less restrictive alternatives (sitters, diversion, frequent reorientation, addressing pain/toileting) must be tried first.
- A quick-release knot tied to the movable bed frame (not the side rail) allows rapid removal in an emergency.
- Restrained patients need frequent assessment of circulation, skin integrity, range of motion, toileting, hydration, and nutrition.
- Chemical restraint (sedating medication used to control behavior, not to treat a condition) is also a restraint and follows the same rules.
- Orders for violent or self-destructive behavior are time-limited — up to 4 hours for adults, 2 hours for ages 9–17 and 1 hour under age 9 — and the patient must be seen in person within 1 hour of the restraint being applied.
- In an emergency the nurse may apply a restraint first and obtain the order immediately afterward.
Nursing priorities
- Try and document the least restrictive alternatives before applying any restraint.
- Obtain a current provider order specifying type, reason, and time limit; restraints are never applied PRN.
- Apply the least restrictive device, secure it to the movable bed frame with a quick-release knot, and keep two fingers' space for circulation.
- Monitor circulation, skin, and positioning regularly, and release the restraint per schedule to provide range of motion, toileting, and food/fluids.
- Reassess the continued need each shift and discontinue at the earliest safe opportunity, documenting behavior and interventions.
Patient teaching
- Explain to the patient and family why the restraint is needed, that it is temporary, and the criteria for removal.
- Encourage family presence and involvement, which may reduce the need for restraints.
- Reassure that the patient will be checked frequently and released regularly for movement, toileting, and comfort.
Red flags: report now
- Signs of compromised circulation (cool, pale, cyanotic, numb, or swollen extremity) require immediate removal of the restraint.
- A restraint tied to a side rail or with a fixed knot is unsafe and can cause strangulation or injury; correct it immediately.
- Never use restraints for staff convenience, coercion, or punishment, and never as a substitute for monitoring.
- Applying or continuing restraints without a current valid order is a violation; obtain the order or remove the restraint.
References
Clinical references for this topic
