The use of patient restraints in a healthcare setting is a tightly regulated practice that nurses approach with significant ethical and legal responsibility. Restraints are broadly defined as any physical or mechanical device, material, or equipment that restricts a patient’s ability to move freely. This definition also includes medications used to manage behavior that are not standard treatments for the patient’s condition (chemical restraints). These interventions are reserved only for situations where immediate physical safety is at risk and are never permitted for staff convenience, discipline, or coercion.
Justification for Restraint Initiation
The primary guideline for initiating a restraint is the presence of an imminent danger to the patient or to others. This danger must be severe and immediate, such as a patient attempting to remove life-sustaining medical devices or exhibiting violent, self-destructive behavior. Nurses are first mandated to employ the least restrictive measure possible to manage the situation before resorting to a physical or chemical restraint.
The principle of “Least Restrictive Measure” requires nurses to document the failure of all other non-physical interventions prior to restraint application. These alternatives may include:
- Verbal de-escalation techniques.
- Offering diversions.
- Reorienting a confused patient.
- Moving the patient to a quiet area.
- Moving the patient closer to the nurses’ station for increased observation.
Only after these measures prove ineffective can the nurse proceed with the application of a restraint. The chosen method must also be the least restrictive type that is effective for the situation, such as using a one-point restraint instead of a four-point restraint.
Required Authorization and Documentation
The decision to apply a restraint must be supported by a mandatory order from a Licensed Independent Practitioner (LIP), such as a physician, nurse practitioner, or physician assistant. Orders for restraints can never be written as a standing order or as-needed (PRN). This requirement ensures that each instance of restraint use is a considered response to an acute, specific situation.
Restraint orders are strictly time-limited according to patient age and the reason for the restraint, with regulatory bodies like the Centers for Medicare & Medicaid Services (CMS) and The Joint Commission (TJC) setting maximum durations. For adults in behavioral health restraints, the initial order is limited to a maximum of four hours. Children and adolescents aged 9 to 17 are limited to two hours, and children under nine are limited to one hour.
For restraints applied due to a behavioral health emergency, a face-to-face evaluation by the LIP must occur within one hour of the restraint’s application to assess the patient’s condition and determine the need for continuation. All initial orders, subsequent renewals, and the rationale for restraint use must be immediately and thoroughly documented in the patient’s medical record. If a restraint order expires and the patient still requires the intervention, a new order must be obtained, which often necessitates a new face-to-face evaluation.
Continuous Patient Monitoring Protocols
Once a restraint is applied, nurses must adhere to rigorous monitoring protocols to protect the patient from potential complications. The required frequency of these checks varies depending on the type of restraint and the patient’s condition.
Patients in behavioral health restraints require continuous observation and a documented assessment by a registered nurse at least every 15 minutes. For patients in non-behavioral or medical-surgical restraints, such as those used to prevent dislodgement of tubes, the nurse must assess the patient at least every two hours.
Specific assessments must be documented, including vital signs, respiratory status, and the patient’s level of consciousness. Nurses must check the restrained extremities for circulation, sensation, and motor function, ensuring the restraint is not causing skin breakdown or impairing blood flow.
The nurse is responsible for meeting the patient’s basic needs while restrained. This includes providing for hydration, nutrition, hygiene, and elimination needs, which are typically assessed every two hours. If clinically appropriate, the nurse must temporarily release the restraint device to allow for range of motion exercises and skin care, helping prevent muscle stiffness and pressure injuries.
Criteria for Restraint Discontinuation
Restraints must be discontinued at the earliest possible time, irrespective of whether the written order has expired. The nurse is responsible for continuously assessing the patient’s condition to determine if the safety criteria that necessitated the restraint are still present.
Discontinuation is warranted when the patient no longer poses an immediate threat to themselves or others, or when the underlying condition that required the restraint has resolved. Indicators of readiness for removal include a return to calm behavior, the ability to follow directions, or a cessation of violent or self-destructive acts.
Nurses advocate for the timely removal of the restraint and have the authority to discontinue the restraint if the behavior or condition that was the basis for the order is no longer evident. This ensures the restrictive measure is only used for the shortest duration necessary.