Fundamentals - Practice & Skills, part 11: Fall Prevention and Restraints
by Meris Shuwarger BSN, RN, CEN, TCRN August 02, 2021 Updated: December 07, 2022 7 min read
This article covers fall prevention, both within the hospital and at home, and the use of restraints. You can follow along with our Fundamentals of Nursing flashcards, which are intended to help RN and PN nursing students study for nursing school exams, including the ATI, HESI, and NCLEX.
Fall prevention is an important aspect of nurse training because patient falls can lead to injuries that will complicate their ability to recover and delay their discharge from care. If the patient is at home and suffers a fall, it’s possible they could be incapacitated and unable to receive the help they need, leading to greater trauma and even death.
Fall prevention in healthcare facilities
The following are some of the things nurses can do or look out for in order to prevent patient falls when the patient is in a healthcare facility or acute care facility.
Round hourly on your patients
Rounding hourly means checking regularly and frequently on how the patient is doing. Do they need anything? Are they getting regular opportunities for toileting and nutrition? Most important, check to make sure they are still in their bed.
Move the patient closer to the nurses’ station
If the patient is confused or unable to follow instructions, or if they have difficulties calling for assistance, move them so their room is closer to the nurses' station. This is an effective, non-invasive way to keep an eye on them.
Keep floors clean, dry, and uncluttered
Clean and uncluttered floors allow your patient to get out of bed and move about on their own, without having to step over items on the floor. Keeping the floor dry means an ambulatory patient can avoid slippery, dangerous, wet spots.
Ensure the patient's bed is always locked and set in the lowest position
A patient should be able to move easily onto and off of their bed if the need arises. So make sure the bed cannot move and is set to a height that makes it easy for the patient to access it.
Set the bed alarm for patients who are at a higher risk for falls
For patients who should not be ambulatory, setting an alarm that will go off in the nurses’ station will alert you when a patient gets out of bed on their own. You can then attend to them immediately.
Keep the patient's possessions within easy reach
Keep the patient's possessions — that is, anything they might need (water, their glasses, dentures) — on their overbed table or within easy reach of their bed. A patient who needs something may attempt to get out of bed unsupervised to retrieve that thing, which can lead to a fall. Make sure the call light is always placed within the patient's reach.
Have the patient wear non-slip footwear
If the patient does need to get up and move about, make sure they wear non-slip, well-fitting footwear. This is why hospital socks come with "grippy" soles.
Preventing orthostatic hypotension
Encourage the patient to sit on the edge of the bed and dangle their legs before standing up. This helps prevent orthostatic hypotension, a form of low blood pressure that happens when you stand up suddenly, which could lead to a fall. Having them dangle their legs before getting up will give their blood pressure a chance to catch up to the next move they want to make.
Fall prevention at home
Fall prevention is just as important for a patient who has returned home as it is for when they are under your direct care in the hospital.
There are several things patients or their families can do to prevent falls at home.
Removing scatter rugs
This is a simple and effective way to prevent falls. Small rugs can slip when stepped on. And their edges and corners can roll up, creating trip hazards.
Ensure good lighting
Make sure the patient's home has good lighting, especially over any stairs. Also, encourage the use of nightlights, to illuminate their path when it gets dark in the house.
Mark the edges of steps
Mark the edges of steps with colored or reflective tape, so they are easier to see. And remove clutter that could force the patient to have to step around, or over, anything.
Tape down electrical cords
Ideally, electrical cords should be run against or along a wall or behind furniture, in order to keep them out of the way. If this is not possible, tape them down so the entire cord is taped to the floor. Do not run an electrical cord under a rug or carpet, as this can become a trip hazard.
Install grab bars
Install grab bars in showers and bathtubs and place a non-slip mat on the shower floor.
And, as we have previously discussed, it is important to teach patients the proper use of assistive devices (e.g., grab bars, railings, walkers, canes).
Restraints are means that restrict a patient's freedom and ability to move. Restraints are also covered from a psychiatric mental health nursing perspective in our Psychiatric Mental Health Nursing Flashcards!
Types of restraints
A restraint can be physical or chemical.
Physical restraints are anything physically put on a patient's body. These include:
- Hand mitts: These are the least invasive type of physical restraint. They look like club-shaped oven mitts and they fasten at the wrist.
- Limb restraints: These look like padded cuffs with straps attached.
- Belts: These attach to a bed or other fixed structure.
- Vests: These are similar to belts but restrain the patient's chest or torso.
Patients have a right to the least restrictive environment. That means choosing the least restrictive restraints possible, often meaning hand mittens.
Medications can also be used as a restraint, as they can keep a patient sedated and/or calm. Benzodiazepines and antipsychotics are often administered as restraints.
Note that as with physical restraints, patients have certain rights when it comes to medications, namely the right to refuse medications or other therapies.
Order requirements for restraints
Order requirements for restraints require an in-person assessment by the provider within 24 hours of the restraint order, and restraint orders are only good for 24 hours at a time. That means that if the patient continues to need restraints, a new order must be given every 24 hours.
PRN, orders are not permitted. PRN means pro re nata, Latin for "take as needed." So an order saying "apply restraints as needed" cannot be written. Correct procedure demands that a patient is only restrained until restraints are no longer needed, upon which they are immediately discontinued. If the need arises for a new restraint order, the process begins again, with a new order necessary every 24 hours.
When having to restrain a patient, the documentation process is extremely important and includes the rationale for why the patient is in restraints and the time (how long) they have been in restraints.
Patient assessment findings are another part of the documentation process. What is the patient’s general well-being? Are they calm? Are they breathing? Has their condition improved, or do they still seem agitated?
It is also important to document what care was offered to the patient and what care was provided to the patient. These are two different things! For example, toileting, fluids, and range-of-motion exercises may have been offered, but perhaps the patient only received the ROM exercises and fluids, and declined toileting. All of this gets documented clearly in the patient's chart, including what times any care was given.
Nursing care for a patient in restraints
Restraints, their orders, and their documentation are key elements of nursing care, so it is incumbent on nurses to assess what is really required for the patient. That means choosing the best option, not necessarily the most restrictive. That is, start by assessing whether restraints can be avoided in the first place.
Alternatives to restraints
See if there are alternatives to restraints. For example, try to set clear boundaries that the patient can follow to keep them calm and engaged in their care. Other options include reducing stimuli or providing a diversion or distraction, like giving them a task (e.g., folding washcloths). Move the patient closer to the nurses' station or offer PRN medications (“administered as needed”) if that means avoiding restraints.
If restraints must be used, then choose the least restrictive method to correct the issue.
In an emergency, the nurse can apply restraints. Remember that the order needs to be obtained from the provider as soon as possible after the application of restraints.
How to tie a restraint
When using a physical restraint, it must be tied to a part of the bed frame that moves with the bed, and not to a part of the bed that moves independently (or not at all), like the side rail or head of the bed. Tying the restraint to something that does not move in tandem with the bed can cause unwanted tightening or loosening of the restraint when the bed is adjusted.
When tying a restraint, use a quick-release knot (slip knot). Make sure two fingers fit between the restraint and patient.
When using a belt restraint, place it over the patient’s gown or clothing, not directly across their skin.
Assessing the restrained patient
Assess the patient's status and behaviors every 15 minutes. This is a more frequent assessment than usual. The reason for such frequent assessment is to prevent positional asphyxia. Patients might fight against their restraints and twist or turn until they are in a position where they cannot breathe adequately. This can cause asphyxiation, which can lead to suffocation or even death.
Take vital signs, provide range-of-motion exercises, and offer fluids and toileting every two hours (or per facility policy) for a restrained patient.
Remove the restraints immediately, once the patient is no longer a danger to themselves or to others.
If checking on a patient requires removing restraints, provide the care by removing one restraint at a time. For example, to check skin integrity, take off one restraint, do a range-of-motion check and examine the skin, then replace that restraint. Next, remove the other restraint and assess the other side of the patient before replacing the restraint.
Never restrain a patient because it's convenient
Understanding restraints is an important part of nursing school and appears across many parts of training. Familiarity with restraints — and how and when to use them — is not only important to protect a patient's physical safety, but to protect the patient's legal rights. A patient should never have things done to them against their will, unless it is medically necessary because they are a threat to themselves or to others.
Hi, I'm Meris. And in this video, we're going to be talking about fall prevention, both within the hospital and at home, and the use of restraints. I will be following along using our Fundamentals of Nursing flashcards. These are available on our website, leveluprn.com. And if you're following along with your own, I'm starting on card number 75. All right. Let's get started. Okay. So first up, let's talk about fall prevention in the acute care setting, so this is within your facility. As you can see, we've got a lot of bold red text here and key points for you to pay attention to. So let's talk about this, rounding hourly on your patient. It just means poking your head in and making sure that they're doing okay, that they don't need anything, that they are still in their bed. That's going to help to prevent falls. If your patient is confused or can't follow instructions, we want to move their room closer to the nurse's station. That's a really good noninvasive way for us to be able to keep a close eye on them. We of course, want to make sure the floors are clean, dry, and uncluttered. But also, we can set a bed alarm. So your bed for the patient should always be locked and in the lowest position for all patients all the time. But we can also set bed alarms for patients who are at high risk for falls, and that way, if they get out of bed, we can hear it and come running immediately. So we also want to make sure that anything the patient needs, like their water, their glasses, dentures, all of those things, are within reach of their bed on the overbed table. If it's far away, your patient's going to try and get out of bed to get the things that they need, so keep them close to the bed. Another thing is to make sure that the patients are wearing nonslip, well-fitting footwear. This is why all of the socks in the hospital have those grippy things on the bottom. Those are nonslip socks. And then we also want to encourage our patients to sit up and dangle their legs on the edge of the bed before standing up so that we don't have that orthostatic hypotension, which could lead to falls.
Now, let's talk about what to do at home to prevent falls. You'll see here we have some big, bold red things here as well. Very important to know, this is highly testable content for nursing school and for NCLEX because it has to do with patient safety, right? And patient safety is always number one. So first up, we have remove scatter rugs. Scatter rugs make your house look really cute and cozy, but they are a fall risk because you can slip and fall or trip on them. We also want to have good lighting, especially over stairs. We want to mark the edges of our steps with colored tape or reflective tape. We want to tape down electrical cords, so actually tape them down. Don't put them under a rug or just leave them free, right? If we tape them down, it makes them less of a tripping hazard. And we want them to be behind furniture or against a wall, if possible. We want to have grab bars in the shower and bathtub so that we don't slip and fall there, a nonslip mat on the shower floor. And then also, just like we talked about in the last video, we need to make sure that our patients know how to use their assistive devices correctly. So that overs fall prevention measures within the acute care setting and also at home.
Next up, we are talking about restraints. Restraints are very important to understand for nursing school because there is a lot to know about them, when to use them, nursing care, when to stop them, all of those sorts of things. So let's get into it because there is a lot to go over. First and foremost, we have two types, physical restraints and chemical restraints. Physical restraints are anything you physically put on your patient, right? A vest or hand mitts, those are physical. But chemical restraints are things that are going to keep your patient sedated or calm, things like benzodiazepines or anti-psychotics. So don't forget, medication can be a restraint. Order requirements, this is what we need to have an order for restraints. We need the provider to do an in-person assessment of the patient within 24 hours of the order. The order only lasts for 24 hours, which means that after it is up, if the patient continues to need restraints, we need a new order. PRN orders are not allowed, which means I can't have an order that says to restrain the patient PRN or as needed. That's not how it works. We restrain them until restraints are no longer needed, and we immediately discontinue them. And like I said, a new restraint order every 24 hours.
The documentation portion is very important. We're going to be documenting the rationale. Why is the person in restraints? The time they have been in restraints. The patient assessment findings. What is their general well-being? Are they calm? Are they breathing? Are they doing okay, or do they still seem agitated? We're going to document that and then what care we offered and provided to the patient. So I offered toileting, fluids, range of motion exercises. "The patient received range of motion exercises and fluids, declined toileting." Right? Now, this card right here, this is card number 78. I want you to really, really focus on this card and make sure you understand everything that's being said here because this covers the nursing care, which is always what we are focused on, right? What's my job as the nurse? So there's a lot here, and most of it is bold and red, meaning very important. So alternatives first, right? We go least to most restrictive. So that means if my patient is pulling out their lines, tubes, and drains, I don't just put them in full leather restraints, right? We're going to start by trying to distract them. We're going to move them closer to the nurse's station. We're going to try and use a technique of giving them something to do. "Hey, can you fold these washcloths for me?" We're not going to jump to restraining them. If we have to, we can, but we're going to move incrementally up that ladder.
The restraint needs to be tied-- okay, this is so important, and I'm going to use my hands to show you. And I'm sorry, but very important. The restraint needs to be tied in a slipknot fashion, quick-release fashion, meaning when I pull on the long tail, it's immediately untied. So that's for emergency purposes, right? The other thing is that it needs to be tied to a part of the bed frame. The bed frame moves with the bed, meaning it goes up and down as the bed is raised or lowered, right? So bed frame goes up and down, but the frame itself is unmovable, meaning does not move by itself. So for instance, the side rail, that is going to move by itself, right? I can put it down. I can bring it up independent of the bed moving. That's not where I want to tie it because if I put the bed frame-- put the side rail down, now it's really, really tight, right? And then I put the side rail up, and now it's really slack or loose. So I want to tie it on an unmovable part of the bed frame, but it is moving, meaning that it's going up and down, but not moving independently. I hope that makes sense. That really trips a lot of students up. It can be confusing. So just remember, bed frame, not side rail, not head of the bed that goes up and down, bed frame.
Okay. I'm going to assess my patient's status and behaviors every 15 minutes. That is very fast for assessments, right? That's very frequent, I should say, for assessments. Most of the times, we don't assess things every 15 minutes if you're in general med-surg or something. Every 15 minutes, you need to be checking in on that patient. And the big reason here being something called positional asphyxia. Your patients could fight against these restraints, right, and get themselves all twisted and turned in a position where they cannot breathe adequately. And if they cannot breathe adequately, they can asphyxiate, or suffocate, and die, even while they are restrained. So we check on them every 15 minutes. I really want to hammer that point home. We take vital signs, provide range of motion, and offer fluids and toileting every two hours. That's more consistent with what you're used to. And then as soon as the patient is no longer a risk to themselves or others, we discontinue the restraints. We never restrain a patient because it's convenient for us, because we like having them in restraints, absolutely not. As soon as they no longer meet the requirements for the order, we discontinue, okay? If we need to check skin integrity, we can take off one restraint at a time, do range of motion, check the skin, place that restraint, then come over and remove the other restraint, okay? So that's an important distinction between removing restraints one at a time in order to provide care and removing restraints entirely.
Restraints are very big in nursing school. There's a lot of questions about it because it really is important to protect your patient's legal rights to not have false imprisonment, right, to not have things done to them against their will, unless it is medically necessary because they are a threat to themselves or others. So be sure you're familiar with this. This is going to come up for you in Funds, in med-surg, in mental health. It's going to be very, very common nursing test-taking knowledge for school and for NCLEX, so be familiar with it.
Okay. So that is our review here for fall prevention and restraints. I hope it was helpful. If it was, please like this video and let me know. If you have a really great way to remember something, I super want to hear it, so please leave it in the comments so that I can see. And then be sure to subscribe to our channel so that you are the first to know when our next video drops, which is going to be talking about skin integrity, specifically pressure ulcers, pressure injuries. Very, very, very important stuff for nursing school, so you don't want to miss it. Thanks so much, and happy studying.
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