When are restraints indicated and what guidelines apply?

• A. Use as the first option in all agitation cases.
• B. Remove restraints as soon as patient agrees to calm down.
• C. Use only when less restrictive measures fail, with physician order, ongoing evaluation, and regular reassessment; monitor for safety and rights.
• D. Use without physician order if patient refuses.

Answer: (C)

Restraints should be used only after less restrictive measures have been tried without success and there is real risk of harm. The key is to protect safety while upholding the patient’s rights, using the least restrictive method that will work and with a physician’s order to authorize it.

In practice, start with de-escalation, environmental adjustments, one-to-one observation, and other nonrestrictive strategies. If agitation or unsafe behavior continues and danger remains, apply a restraint only with a physician’s order. Then keep the care plan under ongoing evaluation: reassess regularly to determine if the restraint is still needed, document the rationale, and monitor both safety and rights throughout. Check neurovascular status, skin integrity, circulation, and comfort at frequent intervals; ensure proper hydration, nutrition, and hygiene; and provide back-and-forth checks that respect the patient’s dignity. Remove the restraint at the earliest safe opportunity, and renew the order only if continued need is demonstrated. Use the least restrictive device appropriate, and apply it correctly to prevent complications.

Choices that involve using restraints as a first option, removing them merely on agreement, or applying without an order do not align with these safeguards, which emphasize cautious, rights-respecting intervention only after less restrictive options have failed.