This document provides guidance on the safe use of patient restraints. It defines medical and behavioral health restraints and notes that restraints should only be used to prevent harm when less restrictive alternatives have failed. It outlines the patient assessment process for determining restraint need and requirements for physician orders, application, monitoring, documentation and alternatives to restraint use. Competency in proper restraint use is required for certain clinical roles.

1. The Safe
Use of
Patient
Restraints
Mandatory Annual Review Course

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Definitions
RReesstrtraainint ti sis::
Medical
Medical
(Non-behavioral)
(Non-behavioral)
Restraint:
Restraint:
Click each button
for details
 Any method of physically restricting a person’s
freedom of movement, physical activity or normal
access to his or her body.
 Patient immobilization that is a normal component of
a procedure is not considered restraint.
Behavioral Health
Restraint:
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 A manual method, physical or mechanical device,
material, or equipment that immobilizes or reduces
the ability of a patient to move his or her arms, legs,
body or head freely.
 A drug used solely as a restrictions to manage the
patient’s behavior or restrict freedom of movement.
Behavioral Health
Restraint:
 The restriction of patient movement in response to
severely aggressive, destructive, violent or suicidal
behaviors that place the patient or others in
imminent danger.
RReesstrtraainint ti sis n noot: Forensic restriction used by law enforcement for
t: security purposes.

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Side Rails – Restraint or Not?
Click the answer
The use of side rails may pose risk to patient’s safety. Clinical judgment
determines whether or not the use of side rails is considered restraints.
 Raising all four side rails to prevent the
patient from exiting the bed
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Restraint Not
Restraint
 Four or full side rails to prevent the
patient from rolling our of bed
 Patient actively seizing
 Post-op patient recovering from
anesthesia
 Patient on a gurney
Restraint
Not
Restraint
 Raising fewer than four side rails (when
bed has more than two)
Restraint
Not
Restraint

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Alternatives to Restraints
Restraints must never be used as a substitute for good nursing
care or staff convenience. Restrained patients require MORE
CARE and INCREASED DOCUMENTATION.
PHYSICAL MEASURES SPIRITUAL NEEDS
Relaxation techniques
Promote normal sleep patterns
Use of lap belt in chair as a reminder
Provide glasses, hearing aid, dentures
Tape foley to abdomen of male patient
Use Activity Apron
Exercise and activities
Anticipate and provide for basic needs
PSYCHOLOGICAL MEASURES
Provide for companionship: family, friends
Orient to reality
Explain all procedures
Use TV, radio, music
Collaborate w/other healthcare members
Provide pain medication, eliminate itch
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Contact patient’s pastor, minister, priest, rabbi
Offer sacrament of Communion, Reconciliation, Anointing of the Sick
Use sitter or volunteer to read to patient
Use audio tapes, CDs
ENVIRONMENTAL NEEDS
1:1 communication
Use of cushions to maintain safety
Locate patient next to Nurse’s station
Use appropriate lighting
Use Geri chair, position commode, walker, near bedside
Decrease noise, control activity level
Place Call light within reach
Position tubes/drains out of site
PHYSIOLOGICAL MEASURES
Initiate frequent bathroom rounds
Review medications for side effects & interactions

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Patient Assessment
To Determine the NEED for RESTRAINT USE:
 Attempt Alternatives
 Use safe, effective and least restrictive method of restraint
 Clinical Justification based on observed patient actions or behaviors
 Interference with therapy or patient care
 Pulling tubes
 Picking at wounds
 Removing dressings
 Activity or thoughts with a reasonable probability of harm to self
 Wandering
 Unsteady gait (high risk for falls)
 Suicidal
 Activity or thoughts with a reasonable probability of harm to others
 Confused patient striking out at others
 Homicidal attempt or talks about killing/harming someone
 Violent patient in alcohol or drug withdrawal
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Restraint Orders
Restraints will be initiated or continued on the order of a
treating physician. The order must meet the following criteria:
 Reason for the restraint.
 Be time specific
 Include type of restraint.
 Reflect least restrictive manner.
 Be in accordance with safe and
appropriate restraining techniques.
 Be discontinued at the earliest point
in time.
 Never be written as a standing order
or PRN.
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Medical vs. Behavior Health Orders
Medical Behavioral Health
Time
Limitations
24 hours 4 hours 18yrs or older
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2 hours 9-17yrs
1 hour 8yrs and under
RN
Assessment
Every 2 hours or sooner Continuously document every 15
mins
MD
Assessment
Every 24 hours prior to writing
new order
Every 8 hours 18yrs or older
Every 4 hours 17yrs and younger
Emergency
Application by
RN
Notify MD ASAP, within 1 hour
MD must provide telephone or
written order. MD must assess
patient ASAP, within 24 hours.
Notify MD ASAP, within 1 hour MD
must assess patient and write order.
Restraint
Reapplication
Requires new order, and MD assessment. -Even if original order has not
exceeded its “time limit.” This does not include the temporary release that
occurs for patient assessment.

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Observation & Monitoring
Assessment will include:
 The patient’s physical and emotional well-being .
 Comfort and care needs, including hygiene, elimination, hydration, nutrition
 The appropriateness of restraint application, removal, and
reapplication
 Assessment of the need for continuing or discontinuing restraint
Patient death associated with
restraint use:
 RN will immediately notify Nurse
Manager or House Supervisor
 Complete a UOR (unusual occurrence
report)
 Hospitals AR&L Director or designee will
notify CMS
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Application of Restraint
 Must have quick-release application
 Use the correct size
 Note “front” and “back” of device
 Secure to bed springs or frame, not mattress or
bed rails
 Do not apply one-sided restraints
 Do not restrain feet while their hands are free
 Place call light and necessary items within
reach
 Do not position pregnant patients 20
weeks or greater on their back, nor should
chest or waist restraints be used
Restraints should be discontinued as soon as it
is no longer indicated by the patient’s actions.
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Documentation
Patient basic needs must be attended to,
including:
 Hygiene
 Elimination
 Hydration
Document the following in Patient’s record in KP
Health Connect:
 Physician’s order
 Initial assessment by the RN and 1 hour in-person evaluation by MD
 Patient’s actions or condition that indicated the initial and continued use of
restraint
 Less restrictive alternatives considered
 Patient monitoring and response to interventions used
 Significant changes in the patient’s condition
 Reassessment/observations, discontinuation of restraints
 Education and information about restraints provided to the patient and family
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 Nutrition
 Circulation
 Range of motion

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POST TEST
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Quiz
Answer True or False
1. Application of restraints should be the initial nursing intervention
when caring for the confused or disoriented patient.
True False
2. Restraints are utilized to prevent disruption of treatment or significant harm
to persons.
True False
3. The care of a patient in restraints requires more nursing time.
True False
4. Once restraints are applied, they are not to be removed by anyone without
a physician’s order.
True False
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Quiz
Answer True or False
5. Bed rails can either be restraints or a protective device, depending on
the intent of use.
True False
6. Use of restraints can be harmful to patients and can result in such outcomes
as impaired skin integrity, incontinence, increased falls, etc.
True False
7. When appropriate, the use of alternatives is attempted in an effort to use
restraints as a last resort.
True False
8. Reassessment is ongoing and occurs at a minimum of q 4 hours for patients
in medical restraints in an effort to discontinue the restraints early whenever
possible.
True False
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Quiz
Answer True or False
9. Four-point soft restraints for an actively suicidal patient requires the
same 15-minute observation checks as leather or hard restraints.
True False
10. A physician’s order for a behavioral health restraint must be time specific
with a maximum limit of 4 hours for the adult, 2 hours for children ages 9-
17, and 1 hour for children 8 and under.
True False
11. RNs may discontinue restraints before the ordered time frame, but must
obtain a new order if the patient again meets indications that justify
restraint.
True False
12. RNs can apply a restraint without a physician order, but must obtain a
verbal phone order within 1 hour of the initiation of the medical restraint.
True False
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Quiz
Answer True or False
13. Bed rails should be used on all patient at all times to keep them
from falling or getting out of bed.
True False
Select the Correct Answer
14. Which of the following observations intervals is incorrect?
A. Every 30 minutes for a patient in four-point restraints to prevent
combative behavior.
B. Every 15 minutes for a patient in leather restraints for violent behavior
to prevent injury.
C. Every 2 hours for a patient with soft wrist ties to prevent dislodgment of
NG tube.
D. Every 2 hours for bed rails up on a patient to prevent them from
continued wandering.
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Quiz
Select the Correct Answer
15. Which of the following are types of protective devices and not considered
restraints?
A. Portable table top chair to prevent the patient from slipping out of the
chair.
B. Safety belt on a gurney.
C. Knee immobilizer.
D. All of the above.
16. The nurse should assess and address which of the following at least every
two hours for patients who are restrained:
A. Hydration and nutrition
B. Hygiene and elimination
C. Continuance or termination of restraint
D. Circulation and ROM
E. All of the above.
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Quiz
Select the Correct Answer
17.Which of the following is not a clinically justified use of restraints?
A. Patient continues to pull at the NG tube after reorientation and
explanation.
B. Combative patient in DTs.
C. Patient is 75 years old and is weak and confused.
D. Patient removes abdominal dressing despite use of abdominal binder.
18.Which of the following is not an example of an alternative to restraint use?
A. Medicate patient to induce sleeping.
B. Tape foley to abdomen of male patient.
C. Provide adequate pain medication.
D. Use TV, radio, or music as diversion.
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Quiz
19. A 9-year-old requires transport via gurney to radiology for a MRI. The
gurney rails are placed in the up position. This is not considered restraint
because:
A. Children are allowed to sit up in gurneys.
B. The child can see through side rails.
C. Side rails are to be up during patient transports of all types regardless of
age and are a protective/safety device.
D. The child will be transferred to an exam table upon arrival so it doesn’t
matter.
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Select the Correct Answer
20. Which of the following employees would need documented competency for
restraints?
A. A transportation aide that unties and reties wrist restraints for transport
to radiology.
B. A physical therapist that releases and reties a patient restraint in order to
exercise a patient.
C. A RN that monitors the patient in restraints.
D. An unlicensed assistant that removes and reapplies restraints to bathe a
patient.
E. All of the above.