Restraint Application

Situations that Requires Restraint Application

  1. Confused client tries to endanger him or herself
  2. Confused client attempts to remove supportive equipments such as necessary tubes, IV lines or protective dressings.
  3. The client is at risk for falls.
  4. The client is suicidal.
  5. The client poses harm or threat of inflicting harm to health care staff, other clients and/or visitors.
  6. A child is unable to remain still during a minor surgical procedure.


Soft restraints

  • Vest restraint
  • Limb restraint
  • Mitt restraint
  • Belt restraint
  • Body restraint as needed
  • Padding if needed (large gauze pads can be used)
  • Restrain flow sheet (washcloth can be used)

Leather restraints

  • Two wrist and two ankle leather restraints
  • Four straps
  • Key
  • Large gauze pads – this is used to cushion each extremity
  • Restraint flow sheet (washcloth can be used)

Restraint Application Key Steps

  1. Make sure that the restraints are correct size for the patient’s build and weight.
  2. Explain the need for restraint to the patient. Assure him or her that they are used to protect him from injury rather than to punish him. It is necessary to inform the patient of the conditions necessary to release him or her from restraints.
  3. Restraints are ONLY used when all other methods have failed to keep the patient from harming himself or others. Restraints used should be least restrictive to the patient.
  4. Obtain adequate assistance to manually restrain the patient.
  5. After an hour of placing a restraint, the patient should be evaluated by a licensed independent practitioner and an order must be written for restraints.
  6. The order must ne time limited: 4 hours for adults; 2 hours for patients ages 9 to 17 years old; 1 hour for patients younger than 9 years old.
  7. The original order expires in 24 hours. Thus, the same order cannot be used the following day.
  8. To promote safety and ensure the patient is not harmed with restraint application, the patient should be assessed every 2 hours or according to the facility policy.
  9. In cases where the client consented to have his family informed of his care, the family should be notified of the use of restraints.

image courtesy of

Daisy Jane Antipuesto RN MN

Currently a Nursing Local Board Examination Reviewer. Subjects handled are Pediatric, Obstetric and Psychiatric Nursing. Previous work experiences include: Clinical instructor/lecturer, clinical coordinator (Level II), caregiver instructor/lecturer, NC2 examination reviewer and staff/clinic nurse. Areas of specialization: Emergency room, Orthopedic Ward and Delivery Room. Also an IELTS passer.

What Do You Think?

Pages: 1 2