Restraint Safety

Regulatory and Professional Foundations of Restraint Safety

Restraint safety is a critical component of infection control and patient safety in long-term care and acute care settings. For Certified Nursing Assistants (CNAs), proper restraint use involves understanding when restraints are permissible, how to apply them correctly, and how to minimize harm. The Centers for Medicare & Medicaid Services (CMS) and the Joint Commission have strict regulations to reduce unnecessary restraint use and emphasize patient rights.^[1][2] On the CNA exam, restraint safety questions often focus on the types of restraints, required documentation, and the nursing assistant's role in monitoring and alternatives.

Essential Restraint Classifications and Terminology

• Restraint: Any device, method, or medication that restricts a patient's freedom of movement or normal access to their body.^[1]
• Physical Restraint: Manual devices such as wrist ties, vests, belts, or side rails that limit movement.
• Chemical Restraint: Medications used to control behavior or limit mobility (e.g., sedatives, antipsychotics) – not for treating a medical condition.^[3]
• Environmental Restraint: Using furniture, barriers, or locked doors to confine a patient (e.g., geriatric chairs with trays).
• Alternatives to Restraints: Non-restrictive interventions such as bed alarms, repositioning, scheduled toileting, redirection, and comfort measures.^[4]

Justification, Types, and Safe Application Steps

When Restraints May Be Used

1. Only when less restrictive measures have failed and are documented.^[5]
2. To protect the patient from imminent harm (e.g., pulling out a life-sustaining tube, falling from bed).
3. Under a physician’s order that specifies the type, duration, and conditions of restraint use.

Types of Common Restraints

Key Steps for Safe Application

1. Verify the physician’s order and the specific device/vendor protocol.
2. Apply the restraint snug but not tight – you should be able to insert two fingers between restraint and skin.^[6]
3. Secure the restraint to the bed frame (not the moving side rails) to prevent accidental tightening.
4. Use a quick-release knot (slip knot) that can be released rapidly in an emergency.
5. Never tie restraints to each other or to the mattress.
6. Place the call light within the patient’s reach and monitor every 15 minutes (or per facility policy).^[1]
7. Document every 2 hours: condition of skin, circulation (pulse, color, temperature), range of motion, and the reason for restraint.^[2]

Patient Surveillance and Record-Keeping Protocols

• Initial Assessment: Check skin integrity, neurovascular status (pulses, sensation, movement) before applying restraint.
• Ongoing Monitoring: Every 15–30 minutes – assess for agitation, breathing difficulty, skin breakdown, and that the restraint remains properly placed.^[7]
• Restraint Removal: Must be removed at least every 2 hours for range-of-motion exercises, toileting, and skin care. Remove completely every 2 hours for at least 10 minutes (or per facility protocol).^[5]
• Documentation Requirements: Include date/time, type of restraint, patient behavior warranting use, alternatives attempted, patient response, and signatures.

Care Interventions and Alternative Measures

• Nursing Assistant Role: Assist with applying and removing restraints under nurse supervision. Monitor patient comfort and report any changes immediately.
• Alternatives First: Use scheduled toileting, bed alarms, low beds, repositioning, and verbal redirection before resorting to restraints.
• Communication: Explain to the patient and family why the restraint is used, how it will be monitored, and the plan to discontinue it as soon as possible.
• Hydration and Nutrition: Ensure patient receives food and fluids when restraints are off – dehydration and aspiration are risks.^[3]

Potential Harms and Risk Mitigation Strategies

• Strangulation or Asphyxiation: Can occur if vest restraints shift upward or if side rail gaps are too wide. Never use vests on patients who are at high risk of sliding down.
• Circulatory Compromise: Tight restraints can cause nerve damage, pressure ulcers, and loss of distal pulses. Check fingers/toes for color and warmth.^[6]
• Skin Breakdown: Moisture and friction under restraint can cause maceration; pad bony prominences.
• Psychosocial Harm: Increased agitation, loss of dignity, and depression. Always prioritize dignity and privacy.^[4]
• Infection Risk: Under the restraint, skin can become infected – keep area clean and dry. (This links to infection control.)
• Falls: Improperly applied restraints may actually increase fall risk if the patient tries to climb over side rails or untie knots.

Test-Ready Memorization Aids and Common Scenarios

• Remember the “2 finger rule” – two fingers between restraint and skin for fit.
• Quick-release knot is always the correct answer for how to tie a restraint.
• Alternatives first – any exam scenario will emphasize trying non-restrictive measures before restraint use.
• Documentation is key – expected frequency of assessment (every 15 minutes for safety check, every 2 hours for removal).
• Never use side rails as a restraint unless ordered and part of the plan – raise all four rails only when absolutely needed for safety.
• Patient rights: The patient has a right to be free from unnecessary restraints – know the legal framework (OBRA/CMS).
• Memory aid: “Apply, Monitor, Remove, Document” – A-M-R-D sequence.
• Common CNA test question: “What should you do if a patient in a vest restraint is found cyanotic and struggling?” Answer: Remove the restraint immediately and call for help.^[6]

References & Sources

1. Centers for Medicare & Medicaid Services (CMS). CMS Manual System: State Operations Provider Certification – Restraint and Seclusion. Published 2018. Accessed at https://credenzahealth.com/facilities/resources/using-the-cms-state-operations-manual-facility-guide.
2. The Joint Commission. Standards for Restraint and Seclusion. Updated 2023. Available at https://www.jointcommission.org/standards/.
3. Potter, P. A., Perry, A. G., Stockert, P., & Hall, A. (2022). Fundamentals of Nursing (10th ed.). Elsevier. ISBN 9780323677721.
4. Taylor, C., Lillis, C., Lynn, P., & LeMone, P. (2021). Taylor’s Fundamentals of Nursing: The Art and Science of Person-Centered Care (9th ed.). Wolters Kluwer. Chapter on Restraints and Safety.
5. Nursing Home Regulations. 42 CFR §483.12 – Freedom from unnecessary restraints. U.S. Government Publishing Office. Accessed via https://www.ecfr.gov/current/title-42/chapter-IV/subchapter-G/part-483/subpart-B.
6. Ignatavicius, D. D., & Workman, M. L. (2019). Medical-Surgical Nursing: Concepts for Interprofessional Collaborative Care (9th ed.). Elsevier. Chapter 3: Safety, Restraints, and Fall Prevention.
7. American Nurses Association (ANA). Position Statement: Reduction of Patient Restraint and Seclusion in Health Care Settings. Revised 2020. Available at https://www.nursingworld.org/practice-policy/nursing-excellence/official-position-statements/id/reduction-of-patient-restraint-and-seclusion-in-health-care-settings/.