Fundamentals
Patient Safety and Restraints
Overview
Patient safety and restraints focus on maintaining a secure environment while protecting patient rights. Restraints are physical or chemical means used to limit a patient's movement to prevent harm to themselves or others. Nursing practice emphasizes using the least restrictive environment and strictly following legal and ethical guidelines.
Key nursing concepts
- Restraints are a last resort after all alternatives have failed.
- A physician's order is required, and PRN orders for restraints are prohibited.
- Physical restraints include vests, belts, and limb ties.
- Chemical restraints involve medications used to control behavior.
- Improper use of restraints can lead to legal charges of false imprisonment.
- Documentation must include the behavior that necessitated the restraint.
Important nursing considerations
- Always check for skin integrity before and after applying a restraint.
- Ensure the restraint is tied with a quick-release knot.
- Verify that two fingers can fit between the restraint and the patient.
- Assess the patient's neurovascular status every 2 hours or per policy.
- Remove restraints at least every 2 hours for range of motion and toileting.
- Document the clinical justification for restraint use every time.
Patient teaching
- Explain to the family that restraints are for the patient's safety.
- Instruct the patient to use the call light for assistance before getting up.
- Teach the family about the risks of falling and how to mitigate them.
- Explain the temporary nature of restraints to the patient and family.
Related practice questions
Real questions from the NursGuru bank, each with the answer and rationale.
Patient Safety and Restraints flashcards
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Original NursGuru study notes for exam preparation. Pending educator review — always follow your program, current guidelines and institutional policy.