Equipment:
■ Restraint of the appropriate size: belt, vest, wrist, ankle, or mitt.
■ Soft gauze or cotton padding for bony prominences.
Assessment:
■ Assess the need for restraints; that is, that the immediate physical safety of the patient, a staff member, or others is threatened.
■ Assess the patient’s risk for falls, including mobility status and level of awareness.
■ Determine that all less-restrictive measures have been tried unsuccessfully.
■ Identify the appropriate restraint; one that:
■ Is the least restrictive possible.
■ Does not interfere with care or exacerbate the patient’s medical condition.
■ Does not pose a safety risk to the patient.
■ Can be changed easily to keep it clean.
Post-Procedure Reassessment
■ Assess the initial restraint placement, circulation, and skin integrity.
■ Check the restraint every 30 minutes (more often for a behavioral restraint). Observe for pallor, cyanosis, and coolness of extremities.
■ Reassess the restraint, circulation, the patient’s response to the intervention, and the continuing need for the restraint every 2 hours; remove it as soon as it is no longer needed.
Key Points:
■ Follow agency policy, state laws, and professional guidelines.
■ Try alternative interventions first (e.g., bed/chair alarms, patient sitters hired to watch the patient).
■ Use the least restrictive method among the various types of restraints:
■ Verbal.
■ Chemical (e.g., antipsychotic or sedative medication).
■ Seclusion (safe containment to de-escalate).
■ Physical (4-point devices, tie-on, Velcro, leather).
■ Use restraints only to protect a patient and/or caregiver from injury;
not for the convenience of the caregiver or as a punishment.
■ Obtain the required consent form.
■ Obtain a medical order before restraining, except in an emergency.
■ Be Safe! Secure restraints in a way that allows for quick release.
■ Be Safe! Tie bed restraints to the bed frame, not to the siderails.
■ Be Safe! Ensure that restraints do not impair circulation or tissue integrity.
■ Be Safe! Check restraints every 30 minutes.
■ Be Smart! A prescriber must reassess and reorder the restraints every 24 hours.
■ Release restraints and assess every 2 hours (more often for behavioral restraints).
Documentation:
■ Document the following on fall risk assessment sheet, restraint flowsheet, and nursing notes per agency policy:
■ All nursing interventions that were done to eliminate the need for the restraint (e.g., moving patient closer to the nurses’ station, asking a family member to remain with the patient).
■ Reasons for placing the restraint (e.g., patient behaviors).
■ The initial restraint placement, including location, circulation, and skin integrity.
■ Patient and family teaching.
■ Circulation checks, range of motion, and restraint removal per agency protocol.
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| A quick-release knot |
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| A vest restraint |
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