Restraints and Restraint Alternatives

Key Points

• Restraints restrict freedom of movement and should be used only when safer alternatives are ineffective.
• Restraint use requires provider order, strict policy compliance, and ongoing monitoring/documentation.
• The standard of care is the least restrictive approach that preserves dignity and safety.

Pathophysiology

Restraints can reduce immediate unsafe behavior but introduce secondary harm risks from immobility, entanglement, skin injury, contracture progression, and emotional trauma. The resulting stress response may worsen agitation rather than resolve root causes.

Psychological effects include fear, humiliation, anger, and reduced trust. Physical restraint may also increase injury during struggling attempts.

Because risk-benefit balance can shift rapidly, restraint use requires frequent reassessment and early discontinuation when clinically possible.

Classification

• Physical restraint: Device limiting movement (for example, tied wrist device, restrictive bed setup in certain contexts).
• Chemical restraint: Medication used primarily to restrict behavior rather than treat condition at standard dosage.
• Seclusion: Locked-room confinement where patient cannot exit independently.
• Alternatives-first approach: Behavioral, environmental, and needs-based interventions before restraint.

Nursing Assessment

NCLEX Focus

Priority questions test legal prerequisites, monitoring frequency, and least-restrictive alternative selection.

• Assess immediate safety risk and document behavior triggering concern.
• Identify potentially reversible causes (pain, hunger, toileting need, fear, overstimulation).
• Verify order status, indication, and policy-compliant monitoring requirements.
• Monitor for skin injury, circulation issues, distress, and worsening agitation while restrained.

Nursing Interventions

• Implement alternatives first: frequent toileting, supervised ambulation, calming individual activities, and environmental modification.
• If restraint is required, apply correctly, preserve dignity, and monitor per policy interval.
• Provide fluids, nutrition, toileting, ROM, and skin checks at required frequencies.
• Ensure restraint is removed at earliest safe opportunity and re-evaluated continuously.
• Document behavior, alternatives attempted, restraint details, monitoring, and resident response.

Dignity and Injury Risk

Restraints used for convenience, without valid order, or without required monitoring can cause serious harm and violate resident rights.

Pharmacology

Drug Class	Examples	Key Nursing Considerations
antipsychotics	Behavioral-emergency contexts	Use must reflect clinical indication, not convenience; monitor sedation and adverse effects closely.
benzodiazepines	Acute agitation contexts	Can increase confusion and fall risk in older adults; reassess for de-escalation opportunities.

Clinical Judgment Application

Clinical Scenario

A resident with dementia repeatedly attempts unsafe self-transfer at night and becomes agitated when redirected.

Recognize Cues: Recurrent unsafe movement with escalating agitation. Analyze Cues: Root causes may include toileting need, discomfort, fear, or unmet activity needs. Prioritize Hypotheses: Immediate priority is safety using least restrictive approach. Generate Solutions: Implement hourly toileting, supervised mobility, environmental calming, and targeted redirection before restraint consideration. Take Action: Apply alternative plan and report response trends to nurse. Evaluate Outcomes: Unsafe behavior decreases without restraint or restraint duration is minimized if unavoidable.

Related Concepts

• ethical-and-legal-responsibilities-of-the-nursing-assistant - Restraint practice is governed by rights, scope, and legal standards.
• communication-within-the-health-care-team - Frequent updates are required for reassessment and discontinuation decisions.
• fall-prevention - Alternatives can address unsafe transfer behavior without restricting movement.
• assisting-clients-to-transfer - Proper transfer support reduces behaviors driven by mobility insecurity.
• caregiver-role-strain - Team-based alternatives reduce crisis cycling and stress burden.

Self-Check

1. What conditions must be met before restraint use is considered appropriate?
2. Which alternative interventions can reduce unsafe self-transfer behavior?
3. Why must restraints be removed at the earliest safe opportunity?