Patient restraints (physical, mechanical, or chemical) are interventions used in healthcare settings to limit a patient’s movement. These measures are strictly considered a last resort, implemented only when a patient poses an immediate and serious physical danger to themselves, staff, or others. Continuous monitoring is an absolute requirement once a restraint is applied. This vigilance prevents potential injuries, such as nerve damage, impaired circulation, or death, that can occur from improper use or prolonged immobility, ensuring the patient remains safe while the underlying crisis is resolved.
Defining Restraints and Authorization
Restraints are broadly categorized into physical and chemical types, each with distinct uses and protocols. Physical restraints include devices such as cuffs, safety vests, or mitts, which restrict physical movement. Chemical restraints involve using medication to control behavior, but only when the drug is not a standard treatment or dosage for the patient’s medical condition. Medications used for standard symptom management, such as an antipsychotic for a diagnosed condition, are not considered restraints.
The application of any restraint requires a formal order from a physician or a licensed independent practitioner (LIP). These orders are never written as standing orders or on an “as needed” (PRN) basis, emphasizing that each instance must be a specific, individualized decision. Regulations impose strict time limits on how long an order can last, particularly for managing violent behavior. For adults, the initial order is typically limited to four hours, with shorter limits for children and adolescents. A new order and reassessment are required for continuation.
A face-to-face evaluation by a physician, LIP, or a trained registered nurse must occur within one hour of applying the restraint. This initial assessment confirms the ongoing need for the restraint and ensures that the least restrictive method is being used effectively. This highly regulated authorization process mandates frequent review of the patient’s condition.
Mandatory Monitoring Frequency
The frequency of checks depends on the reason for the restraint, but the standard for safety is exceptionally high. For patients restrained to manage violent or self-destructive behavior, regulatory bodies like CMS and The Joint Commission require continuous assessment and monitoring. Many hospital policies mandate a face-to-face check at least every 15 minutes. This 15-minute interval is the recognized minimum standard for ensuring immediate patient safety in behavioral health settings.
These frequent checks are necessary because a patient’s physical and psychological status can change rapidly while under restraint. Constant observation may be required for high-risk patients, such as those in four-point restraints or those with a high potential for self-harm. The presence of a staff member in close proximity allows for immediate intervention should the patient experience a medical emergency or attempt to escape the restraint.
For restraints used in a general medical or surgical setting (e.g., preventing interference with life-sustaining treatment), the monitoring frequency is often less stringent but still systematic. A full assessment of circulation, skin integrity, and physical needs is commonly required at least every two hours. The patient’s specific condition and the type of restraint used dictate the precise monitoring schedule, always prioritizing safety and comfort.
Essential Patient Assessment Components
A check of a restrained patient is more than a visual confirmation of placement; it requires a comprehensive assessment of the patient’s physical and psychological well-being. A primary component involves the Circulation, Sensation, and Movement (CSM) check on all restrained extremities. Staff must ensure that blood flow is not compromised by the restraint, that the patient retains feeling, and that the restraint is not causing nerve damage.
Skin integrity is another critical assessment point. Staff must look for signs of redness, chafing, or pressure injuries, particularly over bony prominences. Restraints must be padded correctly and repositioned periodically to prevent tissue breakdown that can occur from sustained pressure. The patient’s basic physiological needs, including hydration, elimination, and nutritional status, must also be addressed during these checks.
The assessment also focuses on the patient’s mental and emotional state to determine the continued need for the intervention. Staff must evaluate the patient’s level of distress, agitation, and mental status, looking for signs of improvement or worsening confusion. Offering opportunities for range of motion exercises or toileting, when safely possible, is required to mitigate the negative physical effects of prolonged immobility. Documentation of these specific assessment components is mandatory to demonstrate compliance and justify the restraint’s continuation.
Safe Discontinuation of Restraint Use
The overarching goal of any restraint application is its discontinuation at the earliest possible time. Restraints are intended as temporary measures to stabilize a situation, not as a form of long-term patient management. The decision to remove restraints is based on an assessment that the patient no longer poses an immediate risk of harm to themselves or others.
A licensed nurse or the prescribing practitioner may discontinue the restraint if the patient meets the established behavioral criteria for release, even if the written order has not yet expired. These criteria often include demonstrating a calmer demeanor, ceasing verbal threats, or being able to follow simple safety instructions. The nurse assesses whether less restrictive interventions, which may have been attempted previously, could now successfully manage the patient’s behavior.
Mandatory documentation is required for every aspect of the restraint process, including the time of final removal. If a restraint is removed but the patient’s behavior warrants its reapplication, a completely new order must be obtained from a physician or LIP. Restraint use must be continuously justified, and the patient’s freedom should be restored immediately upon stabilization.