Provide a safe environment.
1. Restraints may be physical or chemical and are used only to protect the physical safety of
the client and others.
a. Should be adequate and appropriate for the purpose.
b. Use of a restraint on a client requires a physician’s order that includes the:
(1) Type and location of restraint.
(2) Type of behavior for which restraint is to be used.
(3) Time frame that the order for the restraint covers.
c. In an emergency situation, physical restraints may be used without a doctor’s order for a
limited period of time.
d. Safe nursing practice for the care of a client in restraints includes:
(1) Check a restrained client every 30 minutes and provide for physiologic needs.
(2) Remove restraints and provide a range of motion every 2 hours.
(3) Document the time of each check and the neurovascular status of the client’s
extremities.
(4) Remove restraints as soon as possible.
(5) Secure restraints to the bed frame, not to the side rails.
(6) Discuss with family the rationale for and purpose of restraints.
(7) Investigate all alternatives to restraints: family involvement, methods to increase
client orientation, scheduled toileting activities.
Apply and maintain prescribed restraints, bed alarms, or safety devices according to facility
policy. Monitor client response to restraints. Evaluate the appropriateness of the type of restraint
used.
2. Prevention of falls.
a. Educate the staff on fall reduction protocol.
b. Perform appropriate assessment of a client at increased risk.
c. Orient the client to call light and bathroom; give instructions about calling for
assistance.
d. Keep all personal items within client reach.
e. Keep the bed in a low position.
f. Advise all personnel of clients at high risk for falling.
g. Use side rails appropriately.
h. Obtain adequate assistance for ambulation.
i. Ensure appropriate lighting.
j. Remove all obstacles or dangers on floor or in path.
k. Check and use locks on wheelchairs, beds, stretchers.
l. Establish a toileting schedule.
