# A nurse is caring for a hospitalized 78-year-old patient with delirium who has repeatedly attempted to remove a chest tube placed for a hemothorax. The provider has ordered soft wrist restraints. Which actions reflect appropriate use of physical restraints? Select all that apply.

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> subject: System-Specific Assessments  
> category: ROR

## Question

A nurse is caring for a hospitalized 78-year-old patient with delirium who has repeatedly attempted to remove a chest tube placed for a hemothorax. The provider has ordered soft wrist restraints. Which actions reflect appropriate use of physical restraints? Select all that apply.

1

Document the specific behavior justifying the restraint, alternatives attempted, type and location, monitoring findings, and patient and family education

2

Assess circulation, skin integrity, range of motion, and toileting needs at least every 2 hours and release the restraint to provide care and reposition

3

Attempt least-restrictive alternatives first such as 1:1 sitter, family presence, mittens, low bed, and environmental modifications before applying restraints

4

Apply the restraint snugly with the intent to prevent any movement of the patient's wrists, thereby protecting the chest tube from accidental dislodgement.

5

Tie the restraint with a quick-release knot to a movable part of the bed frame, not to the side rails, so the strap does not tighten with bed adjustments

6

Renew the restraint order at the start of each shift, without performing a focused reassessment, provided the patient remains confused and at risk for self-harm.

## Explanation

Document the behavior requiring restraint, alternatives attempted, restraint details, monitoring, and education (Choice 1). Assess circulation, skin, range of motion, and toileting at least every 2 hours and release the restraint for care and repositioning (Choice 2). Try and document least-restrictive alternatives before applying restraints (Choice 3). Attach the restraint with a quick-release knot to the movable bed frame, not the side rail (Choice 5). A restraint must allow two fingerbreadths and must not immobilize the wrist without slack (Choice 4). Orders cannot be renewed automatically without focused reassessment merely because confusion persists (Choice 6).

## In-depth explanation

Frame restraints around three CMS/TJC mandates: (1) Last-resort principle — try and document alternatives first. (2) Time-limited orders — non-behavioral medical orders are renewed by the provider at most every 24 hours after re-evaluation; behavioral restraint orders are time-limited (4 hours adults, 2 hours adolescents 9-17, 1 hour children <9) and require an in-person evaluation within 1 hour by a provider/LIP; PRN restraint orders are PROHIBITED. (3) Active monitoring — q2h release/assess circulation, skin, ROM, hydration, and toileting (q15min for behavioral or violent restraints with continuous observation per facility). Other essentials: two-fingerbreadth fit, quick-release knot to movable bed frame, never to side rails, never use sheets/gauze as makeshift restraints, attempt patient/family education, and discontinue at the earliest safe moment. Side-rails-up x4 is also considered restraint when used to prevent voluntary egress.

## Clinical scenario

Medical-surgical unit. Patient: 78-year-old male postoperative day 3 with hospital-induced delirium, chest tube placed for traumatic hemothorax, has pulled at the tube three times in the past 4 hours despite redirection. Sitter unavailable. Family departed. Provider has just ordered bilateral soft wrist restraints.

## Key concepts

- **Least-Restrictive Intervention** — Ethical and legal principle requiring nurses to attempt the lowest-impact strategy that maintains safety before progressing to more restrictive measures; documented alternatives are required by CMS and TJC before applying restraints
- **Two-Fingerbreadth Fit** — Standard for proper restraint cuff fit: the nurse should be able to slip two fingers between the cuff and the patient skin to ensure adequate circulation; tighter than this indicates risk of compression injury and neurovascular compromise
- **Time-Limited Restraint Order** — CMS and TJC requirement that physical restraint orders specify a maximum time and require provider re-evaluation; non-behavioral orders renewable at most every 24 hours; behavioral orders limited to 4 hours adult, 2 hours adolescent, 1 hour child; PRN orders are prohibited

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