In this section of the NCLEX-RN examination, you will be expected to demonstrate your knowledge and skills of use of restraints and safety devices in order to:

  • Assess the appropriateness of the type of restraint/safety device used
  • Follow requirements for use of restraints and/or safety device (e.g., least restrictive restraints, timed client monitoring)
  • Monitor/evaluate client response to restraints/safety device

The most common reasons for restraints in health care agencies are to prevent falls, to prevent injury to self and/or others and to protect medically necessary tubes and catheters such as an intravenous line and a tracheostomy tube, for example.

All health care environments adopt the philosophy and goal of a restraint free environment; however, it is not often possible to prevent the use of restraints and seclusion. There are rare occasions when the use of restraints is not preventable because the restraints have become the last resort to protect the client and others from severe injuries.

Commonly Used Terms Associated With Restraints and Restraint Use

  • A "restraint" is defined as any physical or chemical means or device that restricts client's freedom to and ability to move about and cannot be easily removed or eliminated by the client.

For example, a vest restraint to prevent a patient fall is an example of a physical restraint and a sedating medication to control disruptive behavior is considered a chemical restraint. Both restrict the person's ability to move about freely. Other examples of physical restraints are soft padded wrist restraints, a sheet tied around a person to keep them from falling out of a chair, side rails that are used to stop a person from getting out of bed, a mitten to stop a person from pulling on their intravenous line, arm and leg restraints, shackles, and leather restraints.

  • A "physical restraint" is defined as "any manual method or physical or mechanical device, material, or equipment attached to or adjacent to the resident's body that the individual cannot remove easily which restricts freedom of movement or normal access to one's body", according to the Centers for Medicare and Medicaid Services.
  • A "chemical restraint" is defined as "any drug used for discipline or convenience and not required to treat medical symptoms", according to the Centers for Medicare and Medicaid Services.
  • A "safety device", also referred to as a protective device, is defined as a device that is customarily used for a particular treatment. Safety devices are not considered a restraint, even though they limit freedom of movement, because they are a device that is customarily and traditionally used for a particular treatment. An intravenous arm board that is used to stabilize an intravenous line is an example of a safety device which is not considered a restraint.
  • "Preventive measures" is defined as those things that are done to prevent the use of restraints.
  • The "least restrictive restraint" is defined as the restraint that permits the most freedom of movement to meet the needs of the client. For example, mittens are the least restrictive device or restraint that can be used to prevent dislodging of catheters and medically necessary lines such as an intravenous line or a central venous device.

Assessing the Appropriateness of the Type of Restraint Used

Nurses assess and determine the need for a client to be restrained or secluded and they also assess the appropriateness of the type of restraint/safety device that is used in context with the client's current condition and behaviors; they assess and reassess the client in a regular and ongoing basis to insure that the client is safe and that their needs have been met when the use of restraints or seclusion cannot be avoided.

These assessments also explore the client's condition within the context of the appropriateness of the restraint in terms of its being the least restrictive alternative and being used for the shortest possible period of time.

Following the Requirements For the Use of Restraints and Safety Devices

According to the Joint Commission on the Accreditation of Health care Organizations and the Centers for Medicare and Medicaid Services, there are many regulations and requirements that address restraints and restraint use including:

  • The initiation and evaluation of preventive measures that can prevent the use of restraints
  • The use of the least restrictive restraint when a restraint is necessary
  • Monitoring the client during the time that a restraint has been applied
  • The provision of care to clients who are restrained

Alternative Preventive Measures

Some of the preventive, alternative measures that can decrease the need for restraints to prevent a fall include:

  • Accurate client assessment for the risk of falls
  • The immediate initiation of special falls risk interventions when a client is assessed as "at risk" for falls
  • More frequent monitoring
  • Providing frequent reminders to the client to call for help before arising from the bed or chair
  • Using bed and chair alarms
  • Using a companion, sitter, etc.
  • Reorienting the person
  • Placing the client near an activity hub such as the nursing station so that the falls risk client gets more monitoring and observation

Some of the preventive, alternative measures that can decrease the need for restraints in order to prevent the dislodgment of medical tubes, lines and catheters include:

  • Discontinuing or changing the treatment as soon as medically possible
  • More frequent monitoring
  • Using a companion, sitter, etc.
  • Distraction
  • Providing constant reminders about the importance of not touching the tube, line or catheter
  • Keeping the tube, line or catheter out of view
  • Reorienting the person

Some of the preventive, alternative measures that can decrease the need for restraints in order to prevent violent behaviors that place self and/or others at risk for imminent harm include:

  • Behavior management techniques
  • Behavior modification techniques
  • Keeping the client away from triggers
  • Stress management and relaxation techniques
  • Positive and negative reinforcements

Restraint Orders

A complete doctor's order is needed to initiate the use of restraints except under extreme emergency situations when a registered nurse can initiate the emergency use of restraints using an established protocol until the doctor's order is obtained and/or the dangerous behaviors no longer exist. Restraints without a valid and complete order are considered false imprisonment.

The minimal components of orders for restraint include the reason for and rationale for the use of the restraint, the type of restraint to be used, how long the restraint can be used, the client behaviors that necessitated the use of the restraints, and any special instructions beyond and above those required by the facility's policies and procedures.

The Least Restrictive Restraint

The least restrictive restraint to correct the problem like falls and the dislodgment of tubes, lines and catheters is used when restraints are necessary. Restraints, from the least restrictive to the most restrictive, are:

  • Mitten restraints that are used to prevent the dislodgment of tubes, lines and catheters
  • Wrist restraints that are used to prevent the dislodgment of tubes, lines and catheters
  • A vest restraint that is used to prevent falls as well as disturbed violent behavior
  • Arm and leg restraints that are used to prevent violent behavior
  • Leather restraints that are also used to prevent violent behavior

Restraints should NEVER be used for staff convenience or client punishment.

Monitoring the Client During Restraint

When you monitor the patient or resident who is restrained, you must observe and monitor the patient's physical condition, the patient's emotional state, and the patient's responses to the restraint or seclusion.

Is the patient safe? Are the restraints still in place and safely applied? Are the patient's vital signs normal? Are the skin color, intactness of the skin, and circulation good? Is the restraint too tight? Is the patient comfortable and without any physical needs that you can attend to like toileting, food and/or fluids? Is the person confused? Is the patient or resident angry, upset or agitated? Is the person afraid or fearful?

After the restraint is applied, initial monitoring is done whenever necessary but at least every 15 minutes for the first hour by a licensed independent practitioner (LIP) or the qualified registered nurse (RN). When the patient or resident is stable and without significant changes, the monitoring and correlate documentation is then done at least every 4 hours for adults, every 2 hours for children from 9 to 17 years of age, and at least every hour for those less than 9 years of age.

The scope of monitoring must include an evaluation or reassessment of the patient's:

  • Physical status, including vital signs, any injuries, nutrition, hydration, circulation, range of motion, hygiene, elimination and physical comfort
  • Psychological and emotional status, including psychological comfort and the maintaining of dignity, safety and patient rights
  • Restraint need, discontinuation readiness and how the patient or resident acts and reacts when the restraint is temporarily removed for ongoing care. Does the patient's or resident's condition justify the need for the continuation of the current restraint device, a less or more restrictive restraint or the discontinuation of restraints?
  • The correct and safe application, removal and reapplication of the restraint

The Provision of Care to Restrained Clients

The following aspects of care must be provided as needed to a restrained patient or resident and documented at least every two (2) hours when the person is restrained for non behavioral reasons, and at least every four (4) hours when the person is restrained for behavioral reasons and more often for children (every two (2) hours for those 9 to 17 years of age, and at least every hour for those less than 9 years of age, unless the person needs more frequent care.

The components of this care are based on the client's needs and it typically includes:

  • Range of motion exercises to the restrained body part unless the person is sleeping
  • Turning and repositioning the individual
  • Skin care if the skin assessment indicates a need to do so
  • Checking the circulatory status of the affected body part
  • Providing for all other physical needs such as toileting, hydration, nutrition, etc.
  • Providing for the patient's psychological needs, such as their need for as much independence as possible, the need for dignity and respect and freedom from anxiety

Some facilities use restraint flow sheets to document and record the use of restraints, the monitoring of the client, the care provided and the responses of the patient who is restrained or in seclusion. When these flow sheets are not used, the nurse must document all monitoring and care elements in the progress notes.

Monitoring and Evaluating Client Response to Restraints and Safety Devices

When the registered nurse monitors and evaluates the client's responses to the restraints or safety device, the nurse will assess and evaluate the client and their:

  • Mental Status. Is the person afraid or fearful? Is the person confused? Is the patient or resident angry, upset or agitated?
  • Physical Status. Is the person safely restrained and safe from strangulation from a vest restraint, for example? Are the client's respiratory and circulatory systems normal? Is the person clean, comfortable, and dry? Is the skin showing any signs of irritation or breakdown?
  • Response to the Restraint. Has the person improved to the point where they may no longer need of the restraint?

Trial releases from restraints and attempts to control the behavior with appropriate alternatives to restraint provides the registered nurse and/or licensed independent practitioner (LIP) with reassessment data that guides the decision-making process in terms of the:

  • Continuing the use of restraints because the clinical justification and the patient/resident behavior remains the same, or
  • Moving to a less restrictive method, or
  • Using a preventive alternative strategy rather than the restraint, or
  • The discontinuation of the restraint

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