Physical restraints: a last resort and their safe use
- Safe practice
A physical restraint limits movement; it is used only when alternatives have failed, with an order, close monitoring and for the shortest possible time.
What it is
A restraint is a device, method or process used to restrict a patient's freedom of movement. A physical restraint may be a wrist device, a belt or a sheet; hand mitts and bed rails also count when they are used to restrict the patient, for example rails raised to stop a patient getting out of bed. A chemical restraint is a medicine used to manage behaviour or restrict movement that is not the standard treatment for the patient's condition. Restraints are used to prevent harm to the patient or others when alternatives have not worked, and they are a last resort. They can cause serious harm: falls and entanglement while the patient struggles, strangulation or chest compression when wrongly fastened, pressure injuries, contractures, muscle loss, humiliation, fear and death. They require an order that is never standing or «as needed», continuous assessment and removal at the earliest possible time.
What it requires
- Look for unmet needs such as pain, and relieve them first.
- Alternatives: a routine daily schedule, regular mealtimes, help with daily activities, pain relief, distraction (television, music, games), supervision near the nurses' station, a bed or chair alarm and a sitter at the bedside.
- A hand mitt counts as a restraint if it is tied to the bed, so tight or bulky that hand use is lost, or if the patient cannot remove it.
- Educate the patient about the restraint and record that education.
- Record the behaviour that led to the restraint, the alternatives tried, and the type, location and time applied.
Components
- Hand mitt: keeps the patient from dislodging tubes or dressings by accident; whether it is a restraint depends on how it is applied.
- Wrist device: limits hand movement; it is applied following the manufacturer's instructions.
- Belt or sheet: when fastened wrongly, without side straps or with the rails down, the patient can slip and be strangled or compressed.
- Chemical restraint: a medicine used to manage behaviour that is not the standard treatment for the patient's condition; it is also a restraint.
How it is applied (and why)
- Try the alternatives first and record them: a restraint is used only when alternatives have not worked.
- If immediate risk persists, tell the doctor so they can assess the patient and order per protocol: the doctor must see the patient and evaluate the need.
- Explain to the patient what will be done and why: a restraint affects autonomy and dignity, and the education is recorded.
- Use the type of restraint that the order and the protocol specify: a wrongly chosen or wrongly applied device causes harm.
- Apply it following the manufacturer's instructions and the protocol: in one case series, most restraint deaths involved incorrectly fastened restraints.
- Assess the patient continually, per protocol (best practice is often every 15 minutes): a restrained patient struggles and can fall or become entangled.
- Remove a mechanical restraint periodically and assess the area: this catches pressure injuries early and limits stiffness.
- Reassess at each check whether it is still needed and remove it as early as possible: orders are time-limited and renewed only after a new assessment.
In nursing practice
- A restrained patient tends to struggle and can still fall or become fatally entangled.
- Raising the side rails to stop a patient getting out of bed voluntarily is a restraint; rails for a patient who cannot get up are not.
- Order time limits in United States textbooks, such as 4 hours for adults, may not apply in Colombia: follow your institution's protocol.
- An injury related to a restraint is an adverse event and is reported.
Common mistakes
- Using a restraint for staff convenience or as punishment: it violates the patient's autonomy and dignity.
- Fastening a restraint incorrectly or not following the manufacturer's instructions.
- Leaving a restraint without continuous assessment or periodic removal.
- Thinking a restraint prevents falls.
- Not recording the behaviour, the alternatives tried, or the type and time of the restraint.
Test yourself
Think of the answer, then tap the question to see it.
When is a physical restraint justified?
To prevent harm to the patient or others when alternatives have not worked, with an order per protocol, and only until it can be discontinued, as early as possible.
Which alternatives are tried before using a physical restraint?
A routine daily schedule, regular mealtimes, pain relief, distraction, supervision near the nurses' station, a bed or chair alarm and a sitter at the bedside.
What is monitored in a patient with a physical restraint?
The patient is assessed continually, often every 15 minutes per protocol; a mechanical restraint is removed periodically to assess the area, and the need for it is reassessed.
Why is an «as needed» restraint order not accepted?
Because each order must be time-limited and based on a current assessment of the patient; it is renewed only after the patient is seen again.
Connections
Educational content for students; it does not replace your institution's protocols, supervised clinical training or a prescriber's order. Dose-calculation examples use made-up numbers: they are educational, not a clinical order.
Sources: Nursing Fundamentals, 5.7 Restraints (Open RN, Wisconsin Technical College System (CC BY 4.0), LibreTexts edition, 2021); Deaths due to physical restraint (Deutsches Ärzteblatt International (PubMed Central), 2012); Safety and efficacy of physical restraints for the elderly. Review of the evidence (Canadian Family Physician (PubMed Central), 1996); Lineamientos para la implementación de la Política de Seguridad del Paciente (Ministerio de la Protección Social (MinSalud), Colombia, 2008).
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Representative model, for educational purposes only.