Restraint Use
Restraints are legally and clinically a last resort — applying one without meeting strict criteria can constitute false imprisonment, even if your intent was patient safety.
Core Concept
Physical restraints (wrist, vest, mitts, four-point) and chemical restraints (medications given to control behavior, not treat a condition) require that all less-restrictive alternatives have been tried and documented first. A provider order must be obtained — verbal or telephone is acceptable but must be signed within the required timeframe. For behavioral health restraints, orders must be renewed every 4 hours for adults (2 hours for ages 9-17, 1 hour for children under 9). For medical-surgical (nonviolent) restraints, orders are renewed every 24 hours per facility policy. A face-to-face assessment by a licensed independent practitioner is required within 1 hour of applying behavioral restraints. Nursing assessments occur at minimum every 1-2 hours: check circulation, sensation, movement (CSM) distal to the restraint, skin integrity, and provide release for ROM, toileting, nutrition, and hydration. Restraints are tied with quick-release knots to the movable part of the bed frame (never the side rail), and two fingers should fit between the restraint and the client's skin. Restraints must be removed as soon as the behavior or condition warranting them has resolved. Documentation includes the behavior necessitating restraint, alternatives attempted, ongoing assessments, and the client's response. Standing or PRN restraint orders are never acceptable.
Watch Out For
Don't confuse behavioral restraint timelines (4-hour renewal, 1-hour face-to-face) with medical-surgical restraint timelines (24-hour renewal) — NCLEX tests this distinction heavily. Students often think side rails count as restraints only when all four are raised; using four raised side rails on an adult IS a restraint, but two raised side rails on a standard bed is not. Chemical restraint is medication given solely for behavioral control — the same drug given for a diagnosed psychiatric condition is treatment, not restraint.
Clinical Pearl
Quick-release knots, tied to the movable part of the frame — never the rail. Two-finger space. Check CSM every 1-2 hours. If it restricts freedom and isn't treatment, it's a restraint.
Test Your Knowledge
3 quick questions — see how well you understood Restraint Use