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Restraints &
Least Restrictive Alternatives

Protecting patient safety and dignity by choosing the least restrictive intervention first.

NCLEX-RN

What Is a Restraint?

A restraint is any method, device, material, or medication that restricts a patient's freedom of movement or normal access to their own body, and which the patient cannot easily remove.

Three Categories of Restraint

Physical
Vests, wrist/ankle ties, mitts, or side rails that limit movement.
Chemical
Medication used to control behavior, not to treat a medical condition.
Seclusion
Involuntary confinement alone in a room the patient cannot exit.

Why It Matters

Restraints carry serious risks: injury, strangulation, loss of dignity, impaired circulation, skin breakdown, and even death. Patients have a legal right to be free from unnecessary restraint.

The Restraint Hierarchy

Least Restrictive Verbal de-escalation, reorientation Environmental Changes Bed alarm, low bed, sitter, family at bedside Less Restrictive Restraints Mitts, single wrist restraint Most Restrictive 4-point restraints, seclusion Increasing Restriction

The Core Rule

In a true emergency, a nurse may apply a restraint to protect the patient, but must obtain a provider order within a short window (typically 1 hour), and the provider must evaluate the patient face-to-face.

Order Time Limits

Adults (18+) Ages 9-17 Under 9
Behavioral restraint max order4 hours2 hours1 hour
Reassessment frequencyEvery 15-30 minEvery 15-30 minEvery 15-30 min
Renewable up to24 hours24 hours24 hours

Behavioral vs. Medical Restraint

Behavioral (Violent) Non-Violent (Medical)
PurposeStop violent / self-harming behaviorSupport medical treatment / safety
ExampleCombative, agitated patientConfused patient pulling at IV
Order renewalEvery 4 hrs (adult)Every 24 hours
Face-to-face evalWithin 1 hourPer facility policy

How to Apply Safely

1
Try alternatives first. Reorient, move closer to nursing station, use a sitter or bed alarm.
2
Obtain a provider order with type, reason, and time limit. Never PRN.
3
Apply correctly: use a quick-release knot tied to the bed frame, never the side rail.
4
Monitor frequently: check circulation, skin, ROM, hydration, and toileting needs.
5
Remove ASAP and document each assessment, behavior, and continued need.

Tying the Restraint

Movable bed frame ✓ Tie to frame Quick-release knot ✕ Side rail Unsafe! Always allow slack for movement & breathing

Example 1: Confused Patient

An older adult is confused after surgery and keeps trying to pull out their IV line. What should the nurse try first?

Example 2: Combative Patient

A patient becomes violent and is hitting staff. De-escalation and medication have failed. A 4-point behavioral restraint is ordered.

1
Provider must evaluate face-to-face within 1 hour.
2
Order valid up to 4 hours for an adult.
3
Reassess every 15-30 minutes for circulation, safety, and continued need.

Example 3: Monitoring Math

A behavioral restraint must be reassessed at least every 15 minutes. Over a 4-hour adult order, the minimum number of checks is:

Common Mistakes

✕ PRN Restraint Orders
Restraints can never be ordered as-needed or as standing orders.
✕ Tying to Side Rail
Knots must go to the movable bed frame, never the rail.
✕ Skipping Alternatives
Restraints are a last resort, not a first response.
✕ Poor Documentation
Failing to record assessments and continued need is a legal risk.

Key Takeaways

PrincipleRemember
First stepTry least restrictive alternatives
Order requiredProvider order with type, reason, time limit
NeverPRN orders, side-rail ties, punishment
MonitoringCirculation, skin, ROM, toileting frequently
GoalRemove restraint as soon as safely possible

Question 1 of 5

A confused patient keeps trying to climb out of bed. What should the nurse do first?

Question 2 of 5

Which restraint order is acceptable?

Question 3 of 5

Where should a restraint be secured?

Question 4 of 5

For a violent adult behavioral restraint, the provider must perform a face-to-face evaluation within:

Question 5 of 5

A restrained patient must be checked at least every 15 minutes. Over a 2-hour order, the minimum number of checks is: