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Nursing Field Notes / Nursing Core · Med-Surg Course

Falls & Restraints 🛡️

Prevention first · alternatives before restraints · the order rules

NG-402 Nursing Core ADHD-friendly visual edition

Restraints are a last resort, and almost every exam question is really asking what did you try first? The correct answer is nearly always an alternative, a reassessment, or moving her closer to the desk.

Always firstTry every alternative before any restraint
The orderProvider order required · never PRN · time-limited
After a fallAssess her first, then vital signs, then notify
The knotQuick-release, tied to the movable bed frame — never the rail

🧨 What starts it

A ladder of alternatives with a restraint at the very top and everything that must be tried first stacked below it, beside the order rules and a knot tied to the movable bed frame rather than the side rail.
Almost every restraint question is really asking what you tried first. The ladder is the answer. Swipe it sideways if it is cut off, or tap to open it full size.
Who falls, and why
  • A previous fall is the strongest predictor.
  • Age over 65, confusion or delirium, impaired vision.
  • Medications: sedatives, opioids, antihypertensives, diuretics (she is rushing to the toilet), and anything anticholinergic.
  • Orthostatic hypotension — a drop of 20 systolic or 10 diastolic on standing.
  • Incontinence or urgency, unfamiliar surroundings, tethers: IV poles, catheters, oxygen tubing.
  • Weakness, gait problems, improper footwear.
Prevention that actually works
  • Hourly rounding covering the four Ps: pain, position, potty, possessions.
  • Bed in the lowest position, wheels locked, call bell in reach.
  • Non-skid footwear, adequate lighting, a clear path to the bathroom, night light.
  • Room near the nurses’ station for high-risk patients.
  • Toilet on a schedule rather than waiting to be asked.
  • Rise slowly: sit on the edge, dangle the legs, then stand.
  • Bed and chair alarms, a low bed, floor mats, a sitter or a family member.
Side rails are a restraint

Four raised side rails count as a restraint. Two raised is usually a safety measure. Rails also cause entrapment injuries. Raising all four to keep someone in bed requires the same order and monitoring as any other restraint.

🔎 What you will see

The restraint rules, in order
  1. Try alternatives first and document what you tried.
  2. A provider order is required — with the type, the reason and a time limit.
  3. In an emergency a nurse may apply one, but the order must be obtained within one hour and the provider must see her face to face.
  4. Never a PRN or standing order. Every restraint episode needs its own order.
  5. Time limits: adults 4 hours, ages 9 to 17 two hours, under 9 one hour. Renewed by a new order, not automatically.
  6. Use the least restrictive type that works.
  7. Informed consent from the patient or family where possible.
Monitoring while one is on
  • Check every 15 minutes for behavior and safety; circulation, sensation and movement below the restraint.
  • Release every 2 hours for at least 10 minutes: range of motion, reposition, toileting, fluids, skin care.
  • Tie the strap to the movable bed frame, never to a side rail — the rail moves and injures her.
  • Use a quick-release knot. Never a square knot or a bow that can tighten.
  • Two fingers should slide under the restraint.
  • Document every check, every release, and continued need.
Chemical restraint

Sedating someone to control behavior, when it is not treating her actual condition, is a chemical restraint and carries the same rules. Giving a sedative because a patient is “difficult” is not a nursing intervention.

🩺 What you do

If she falls — what you do, in this order
  1. Stay with her. Do not move her.
  2. Assess her first — level of consciousness, pain, obvious deformity, head injury, range of motion. Assessment comes before anything else.
  3. Vital signs and a neurological check.
  4. Call for help; only then move her, with enough people and a lift if needed.
  5. Notify the provider and the family.
  6. Monitor closely — neuro observations if the head was hit or she is anticoagulated.
  7. Complete an incident report.
The incident report rules
  • It is a quality and risk-management tool, not part of the medical record.
  • Never chart that an incident report was completed in the nursing notes.
  • Do not put opinion or blame in it. Facts only, and what was observed.
  • The chart records the assessment, the interventions and the notifications — that is separate and it does belong there.
Delegation
  • Unlicensed staff may apply a restraint that is already ordered, check on the patient, and provide the release care — but the nurse assesses, and the nurse decides whether it continues.
  • Unlicensed staff may reposition, toilet and ambulate a stable patient, and set up alarms.
  • Assessment, evaluation and teaching are never delegated.

⚡ Quick recall

Always firstTry every alternative before any restraint
The orderProvider order required · never PRN · time-limited
After a fallAssess her first, then vital signs, then notify
The knotQuick-release, tied to the movable bed frame — never the rail
What comes before any restraint?
Every less restrictive alternative, tried and documented.
Can a restraint be ordered PRN?
No. Never. Each episode needs its own order.
How often do you check, and how often release?
Check every 15 minutes. Release every 2 hours for at least 10 minutes.
Where is the restraint tied?
To the movable bed frame with a quick-release knot. Never to a side rail.
A patient has fallen. What is the very first thing you do?
Stay with her and assess her before moving her.
Do you document the incident report in the chart?
No. It is a risk-management document, not part of the medical record.