Restraint—whether physical or chemical—is an intervention considered a measure of last resort in patient care. It involves limiting a patient’s ability to move freely, often to ensure immediate physical safety for themselves, staff, or other individuals. Nursing protocols for the application of restraints are highly regulated, establishing a process for use only after all other less restrictive methods have failed. These guidelines protect the patient’s rights, preserve dignity, and mitigate risks of injury or psychological harm associated with immobilization. Nurses must adhere to procedural steps to maintain patient safety and ensure legal and regulatory compliance.
Assessing Risk and Exhausting Alternatives
The primary guideline requires a thorough assessment of the patient’s behavior before any physical intervention is considered. Nurses must first determine the underlying physiological or psychological cause contributing to the patient’s agitation or dangerous behavior. This initial assessment looks for factors like hypoxia, pain, delirium, or metabolic imbalances which may be driving the unsafe actions. Addressing these root causes, rather than immediately restraining, is the first step toward a safe resolution.
Restraints can only be justified when the patient poses an immediate, substantial physical threat to themselves or to others, not for staff convenience or discipline. Before reaching this threshold, nurses must document less restrictive alternatives that were attempted and failed. These documented interventions include:
- Verbal de-escalation techniques.
- Reorientation.
- Offering comfort measures.
- Changing the environment to reduce stimulation.
- Involving a one-on-one sitter for constant observation.
Only when these measures prove ineffective in managing the immediate danger can a nurse proceed to initiate a restraint.
Requirements for Initiating Restraint Application
When the threshold of immediate danger is met, the nurse must quickly initiate the process while selecting the least restrictive device necessary. This selection must use the minimum necessary force and type of restraint, such as a two-point rather than a four-point restraint, to achieve safety. The guidelines differentiate between two major categories: Medical/Surgical restraints, used to prevent the interruption of life-sustaining treatment, and Behavioral Health restraints, used for violent or self-destructive behavior.
In an emergency involving violent or self-destructive behavior, the nurse may apply the restraint immediately, but a physician or Licensed Independent Practitioner (LIP) order must be obtained promptly, typically within one hour. Behavioral restraint orders for adults are strictly limited to four hours, requiring a face-to-face re-evaluation for renewal after 24 hours. Medical/Surgical restraint orders generally have a maximum duration of 24 hours and can never be written as a standing order or “as needed.” The nurse is also responsible for notifying the patient’s family or legal guardian about the use of restraints as soon as possible.
Ongoing Monitoring and Patient Safety Protocols
Once restraints are applied, nurses must adhere to safety protocols focused on patient advocacy and preventing complications. For patients in Behavioral Health restraints, continuous observation is mandatory, often requiring a dedicated staff member to be present. The patient’s physical well-being must be checked every 15 minutes, assessing neurovascular status, skin integrity at the restraint sites, and emotional response.
Patients in Medical/Surgical restraints require less frequent, though rigorous, checks, typically every two hours. During these checks, the nurse must ensure the patient’s basic needs are met, including:
- Offering hydration.
- Nutrition.
- Hygiene.
- Opportunities for elimination.
Range of motion exercises must also be provided to the restrained limbs at least every two hours to prevent joint stiffness and muscle atrophy.
Frequent documentation is required, detailing the patient’s behavior, the type of restraint used, monitoring check results, and the rationale for continued use. For Behavioral Health restraints, a face-to-face evaluation by a physician or qualified practitioner is mandated within one hour of application to assess the patient’s status. This monitoring and documentation serves as a continuous reassessment, allowing the nurse to constantly evaluate the patient’s condition and readiness for release.
Guidelines for Discontinuation and Post-Restraint Care
The intervention must be discontinued at the earliest possible time. The nurse or the physician may remove the restraints as soon as the patient’s behavior no longer poses an immediate threat to safety. The decision to remove the restraint is based on the nurse’s continuous assessment, looking for sustained behavioral criteria that indicate the patient is safe.
Following the removal of restraints, nurses are responsible for completing a formal post-restraint debriefing with the patient and, if appropriate, their family. This non-punitive discussion reviews the event, identifies potential triggers, and establishes alternative strategies for future care. A separate debriefing session for the staff involved is also recommended to review the incident, ensure proper procedure was followed, and identify system improvements or additional training needs.
Final documentation must detail the time of removal and the behavioral criteria that led to the discontinuation. It must also record the outcome of the patient and staff debriefings. This formally closes the procedural loop for the restraint episode.