How do nurses prevent falls and use restraints safely?
NCLEX-RN topic: Restraints and safety devices
- Assess each client's fall risk every shift.
- Universal precautions: call light in reach, bed low and locked, nonslip footwear.
- Hourly rounding meets needs before the client gets up alone.
- Restraints are a last resort: try alternatives, then the least restrictive device.
- Restraint orders are never PRN; remove the restraint as early as possible.
Key facts
- Key fall risk factors are a fall in the past 3 months, gait problems or assistive devices, sedating or blood-pressure-lowering drugs, confusion, frequent toileting, IV poles or catheters, poor vision and orthostatic hypotension.
- Universal fall precautions apply to every client: orient to the room, call light in reach and demonstrated, bed low with brakes locked, nonslip footwear, night lights, and dry, uncluttered floors.
- Scheduled hourly rounding (pain, toileting, position, belongings in reach) reduces falls because needs are met before the client gets up alone.
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- Analgesics, antipsychotics, anticonvulsants and benzodiazepines carry the highest medication fall risk; antihypertensives, antidepressants and diuretics add risk through orthostasis.
- A restraint is any device, method or drug that restricts a client's movement without permission; side rails count when used to stop a client from leaving the bed.
- Restraint orders are never PRN or standing orders. For violent or self-destructive behavior, each order lasts up to 4 hours for adults (2 hours ages 9–17, 1 hour under 9), up to 24 hours total, with a face-to-face evaluation within 1 hour.
- A restrained client needs frequent checks of circulation and skin, position changes, fluids, food and toileting, and release at the earliest possible time.
Quick check1 question · 2 more at the end
An 80-year-old client admitted with pneumonia becomes confused during the night and twice tries to climb out of bed alone. There is no restraint order. Which action should the nurse take first?
Correct answer: B.
Restraints are a last resort and may be used only after less restrictive measures fail. The nurse starts with fall precautions and alternatives to restraint, such as a low, locked bed and a bed exit alarm, plus closer supervision and an assessment for delirium. Side rails used to keep a client from leaving the bed count as a restraint.
A Side rails raised to stop a client from leaving the bed meet the definition of a restraint, and a confused client may climb over them.
B Correct: a low, locked bed and a bed exit alarm are less restrictive measures that should be tried before any restraint.
C Restraint orders may never be written as PRN (as-needed) orders.
D A vest restraint skips the required trial of less restrictive alternatives and can cause entanglement or strangulation.
Full lesson
Each part starts with its main idea. Open a part when you want the details.
The short answer: Prevent falls by assessing each client's risk every shift, using universal fall precautions (call light in reach, bed low and locked, nonslip footwear, clear floors) and adding risk-based steps such as scheduled toileting and medication review. Restraints are a last resort: try alternatives first, choose the least restrictive device, never accept a PRN order, and remove it early.
1 Who is most likely to fall?Every hospitalized client can fall, and risk climbs with each added factor. 1 min
Every hospitalized client can fall, and risk climbs with each added factor. Most falls have several causes, and many can be changed. Tools such as the Morse Fall Scale help, and the nurse reassesses each shift.
| Risk factor | Why it matters | Nursing response |
|---|---|---|
| Fall in the past 3 months | Signals a higher risk of falling again | Flag as high risk; check for osteoporosis or anticoagulants that raise injury risk |
| Confusion or delirium | Client forgets to call for help | Assess for delirium; closer supervision, such as checks every 15 minutes or a sitter |
| Frequent or urgent toileting | Client rushes to the bathroom alone | Scheduled toileting during rounds |
| Sedating or blood-pressure-lowering drugs | Drowsiness, dizziness, poor balance | Ask the pharmacist or prescriber to review; check orthostatic blood pressure |
| Walker, cane or unsteady gait | Balance problems | Device in reach and in good repair; gait belt for transfers |
Orthostatic hypotension, a blood pressure drop on standing, causes dizziness and light-headedness. Dehydration and drugs such as diuretics can cause it.
2 What precautions does every client get?Universal fall precautions apply to every client, whatever the risk score, and keep the room safe and familiar. 1 min
Universal fall precautions apply to every client, whatever the risk score, and keep the room safe and familiar.
- Orient the client to the room, and have them show you how to use the call light.
- Keep the call light and personal items within reach.
- Keep the bed low when the client rests, with the brakes locked; lock wheelchair wheels when stopped.
- Use nonslip, well-fitting footwear, night lights, and clean, dry, uncluttered floors.
3 How does hourly rounding prevent falls?Scheduled hourly rounding prevents falls by meeting needs before the client tries to get up alone. 1 min
Scheduled hourly rounding prevents falls by meeting needs before the client tries to get up alone. On each visit, staff check pain, offer toileting, reposition, confirm the bed is low and locked, and put the call light, phone and water in reach. Before leaving, ask if the client needs anything else and say when someone will return.
4 When does a device count as a restraint?A restraint is any device, method or process that restricts a client's movement without their permission. 1 min
A restraint is any device, method or process that restricts a client's movement without their permission. That includes wrist or vest restraints, chemical restraints (a drug used to control behavior that is not standard treatment for the condition) and seclusion.
Purpose decides it. Side rails raised to stop a client from leaving the bed are a restraint; rails raised to help the client reposition are not. Hand mitts become a restraint when they are pinned to the bed or are so tight or bulky that the client cannot use their hands.
Restraints can cause falls, fatal entanglement, pressure injuries, contractures, muscle loss and humiliation. A restraint-free environment is the standard of care.
5 What rules apply once a restraint is used?Restraints are allowed only after less restrictive measures have failed, and the least restrictive effective type must be used. 1 min
Restraints are allowed only after less restrictive measures have failed, and the least restrictive effective type must be used.
- Order: a physician or other licensed practitioner orders it. Never PRN, never a standing order.
- Violent or self-destructive behavior: adult orders last up to 4 hours (2 hours ages 9–17, 1 hour under 9), renewable to 24 hours. Within 1 hour, a physician, other licensed practitioner or trained RN sees the client face to face.
- Monitoring: check circulation, skin and sensation in restrained limbs. Change position regularly and meet hydration, nutrition and toileting needs.
- Removal: release the restraint at the earliest possible time, even if the order has time left.
- Documentation: the behavior, alternatives tried, type and location of the restraint, time applied and client teaching.
6 What the nurse doesThe nurse reassesses fall risk every shift and reaches for alternatives long before a restraint. 1 min
The nurse reassesses fall risk every shift and reaches for alternatives long before a restraint.
- Assess: fall risk each shift, new confusion, toileting needs, medications and orthostatic changes.
- Act first: universal precautions plus alternatives such as bed or chair alarms, a sitter, a seat near the nurses' station, distraction, regular toileting and pain control.
- Teach: call for help before getting up, wear nonslip footwear, and know which medications raise fall risk.
Common mistakes
The traps students fall into most. Read these before you practice.
Watch out: Raising all four side rails to keep a client in bed is a restraint, not a fall precaution.
Watch out: Restraints come after alternatives fail, not first for a confused client who keeps getting up.
Watch out: Restraints can cause falls, entanglement, pressure injuries and death; they do not guarantee safety.
Watch out: Choose the least restrictive device: padded mitts before wrist restraints, because the client keeps range of motion.
Watch out: A drug given to control behavior at a dose that is not standard for the condition is a chemical restraint, not routine care.
How to remember it
Memory hook: "Alternatives, then Least, then Leave early." Try alternatives, use the least restrictive device, and remove it as early as you safely can.
Self-check:
- List four universal fall precautions without looking.
- Explain when side rails are a restraint and when they are not.
- State the adult time limit and the face-to-face rule for a violent-behavior restraint order.