Basics of Restraints
This is the definition of a physical restraint.
What is any device or method that restricts a patient’s movement and cannot be easily removed by the patient?
This common restraint wraps around a patient’s wrists.
What is a wrist restraint?
Restraints can only be used when this is present.
What is a clear, immediate risk of harm to the patient or others?
Nurses must document this vital sign before and during restraint use.
What is circulation (skin color, warmth, cap refill, pulse)?
This is the most important ethical principle guiding restraint use.
What is patient safety?
This type of restraint uses medications to control behavior or movement.
What is a chemical restraint?
This restraint is often used for patients who slide forward in wheelchairs.
What is a lap belt or pelvic restraint?
A patient in restraints must be visually monitored at least this often in most facilities.
What is every 15 minutes (for violent/self-destructive behavior) or per policy?
This should be documented to justify restraint use.
What is the patient’s behavior or reason for restraint?
Using restraints without a valid reason can be considered this.
What is false imprisonment?
This must always be tried before applying a restraint.
What is a less restrictive intervention (e.g., verbal de-escalation, reorientation)?
This type of restraint involves changing a wheelchair’s position to limit movement.
What is a tilted-back wheelchair
The patient’s physical and emotional status must be assessed at least this often.
What is every 2 hours (or according to facility policy and patient’s condition)?
Nurses must document this each time restraints are released.
What is range-of-motion exercises or patient’s response?
This is the best way to prevent the need for restraints.
What is early intervention with de-escalation and environmental modifications?
This type of order is needed for restraint use in healthcare facilities.
What is a physician’s or authorized provider’s order?
This restraint is sometimes mistaken for a blanket or bedsheet tucked tightly around a patient’s arms.
What is a blanket restraint
A new order for restraints must be obtained within this time frame after emergency application.
What is as soon as possible, typically within 1 hour?
This type of monitoring is required for a patient in seclusion with restraints.
What is continuous video and/or in-person observation?
Restraints should always be tied to this part of the bed.
What is the immovable portion of the bed frame (not the side rails)?
This is the maximum initial time limit for an adult’s violent/self-destructive restraint order.
What is 4 hours
This type of restraint is used to prevent a patient from pulling out IV lines or tubes without restricting mobility
What is a mitt restraint
Restraints must be discontinued as soon as this occurs.
This documentation detail is required by law and facility policy for every restraint episode.
What is the exact time of application, type of restraint, alternatives tried, patient’s response, and ongoing assessments?
This ethical principle protects a patient’s right to make their own healthcare decisions, even when restraints are considered.
What is respect for autonomy?