What Counts as a Restraint
A restraint is anything that restricts a patient's freedom of movement and that the patient cannot easily remove.
- Physical
- Vest, limb (wrist/ankle) ties, mitts, or all four side rails up to keep a patient in bed.
- Chemical
- A medication used to control behavior or restrict movement — not to treat a diagnosed medical condition.
- Seclusion
- Confining a patient alone in a room they cannot leave.
If a device or drug is used to limit movement for behavior or safety — not for routine treatment like positioning or post-op immobilization — it's a restraint, and the restraint rules apply. The same item (a side rail, a medication) can be a restraint in one situation and not in another.
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Try Alternatives First
Restraints are a last resort. Always use the least restrictive approach, and exhaust alternatives first — many "agitated" patients are really in pain, need the toilet, or are delirious.
- Find and fix the cause — pain, full bladder, hunger, delirium, fear, or boredom.
- Bed/chair alarms and frequent, scheduled rounding.
- Scheduled toileting and keeping needs within reach.
- Lower the bed, use a floor mat, and move the patient near the nurses' station.
- Family presence, familiar objects, distraction, and activities.
- Reorientation and a calm environment for the confused patient.
Restraints don't prevent falls and can make things worse — deconditioning, agitation, pressure injuries, and even strangulation or death. On the exam, the right answer is almost always an alternative, not a restraint.
The Rules
When a restraint is truly necessary, strict rules apply. These are heavily tested — know the order requirements cold.
- A provider order is required — and it must be specific and time-limited.
- No PRN or standing orders. Each episode needs its own order. In an emergency the nurse may apply a restraint to protect the patient or others, then obtain the order right away.
- Time limits for violent/self-destructive (behavioral) restraint: up to 4 hours (adults), 2 hours (ages 9–17), 1 hour (under 9), renewed within those limits up to 24 hours.
- One-hour face-to-face evaluation by a qualified provider for behavioral restraint or seclusion.
- Non-violent (medical/surgical) restraint — e.g., to protect a needed tube — is renewed per facility policy, commonly every 24 hours.
? A provider writes "apply wrist restraints PRN for agitation." What's wrong with this order?
Safe Application & Monitoring
If a restraint is used, apply it safely and monitor closely — improper application is how restraints injure people.
- Least restrictive
- Use the least restrictive device that meets the need; remove it as soon as it's safe.
- Quick-release knot
- Tie with a quick-release (slip) knot so it can be removed instantly in an emergency.
- Secure to the bed frame
- Attach to the non-movable part of the bed frame — never a side rail (a rail can drop and injure the patient).
- Check the fit
- Two fingers should fit under the restraint — snug but not tight.
- Monitor
- Check circulation, skin, and breathing regularly; keep the call light within reach. Behavioral restraint needs continuous monitoring.
- Release on schedule
- For non-violent restraint, release about every 2 hours for range of motion, toileting, skin care, and food/fluids; reassess the need each time.
? Where should a wrist restraint be secured, and what knot is used?
Documentation
Restraint use must be thoroughly documented — it protects the patient and is a legal requirement.
- The behavior that made the restraint necessary and the alternatives tried first.
- Type of restraint, and the times applied and removed.
- Monitoring — circulation, skin, breathing, and care provided during release (ROM, toileting, fluids).
- Patient response and ongoing reassessment of the need.
- Notification and order details, and patient/family education.
Side Rails & Special Cases
The same device can be a restraint or not — it depends on how and why it's used.
- Side rails
- All four up to keep a patient in bed = a restraint (and an entrapment risk). One or two up to help with turning or getting out of bed = a mobility aid, not a restraint.
- Confused older adults
- Restraints worsen delirium, agitation, and injury — lean hard on alternatives and treat the underlying cause.
- Chemical restraint
- Sedating a patient to control behavior (not to treat a condition) is a restraint and follows the same rules.
Restraint-free care connects directly to fall prevention and managing confusion. See Falls: Risk & Prevention and Delirium, Dementia & Depression for the alternatives that keep older adults safe without restraints.
Frequently Asked Questions
Common student questions on this topic.
What counts as a restraint?
Can a restraint be ordered PRN (as needed)?
How long is a restraint order valid?
How do you safely apply a physical restraint?
Are side rails considered a restraint?
Quick-Reference Cheatsheet
Every key point from this guide on a single printable page.
Restraints & Safety Cheatsheet
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