Key Takeaways
- Fall risk factors include advanced age, sedating medications, confusion, mobility impairments, and urinary urgency/incontinence
- Fall prevention interventions include bed alarms, non-skid footwear, low bed position, adequate lighting, and assistive devices within reach
- Restraints are a measure of LAST resort and require a provider order that must be renewed every 24 hours for non-violent situations
- PRN (as needed) restraint orders are NEVER acceptable - each restraint use requires a specific time-limited order
- Patients in restraints require assessment every 30 minutes to 2 hours including circulation, sensation, skin integrity, and release for ROM exercises
Fall Prevention and Restraints
Falls are one of the most common adverse events in healthcare facilities, particularly affecting older adults. The NCLEX tests your understanding of risk assessment, prevention strategies, and the proper use of restraints as a last resort.
Fall Risk Assessment
High-Risk Populations
| Risk Factor | Clinical Examples |
|---|---|
| Age | Adults over 65 years old |
| Medications | Sedatives, opioids, diuretics, antihypertensives |
| Cognition | Confusion, delirium, dementia |
| Mobility | Gait disturbances, weakness, balance issues |
| Vision | Impaired vision, recent eye surgery |
| Elimination | Urinary urgency, incontinence, frequent toileting |
| Environment | Unfamiliar surroundings, clutter, wet floors |
| History | Previous falls within past 3 months |
Standardized Assessment Tools
Most facilities use validated fall risk assessment tools:
- Morse Fall Scale - Most commonly used; scores 6 risk factors
- Hendrich II Fall Risk Model - Includes confusion and symptomatic depression
- STRATIFY - Validated for acute hospital settings
Fall Prevention Interventions
Environmental Modifications
| Intervention | Rationale |
|---|---|
| Bed in lowest position | Reduces injury if patient falls from bed |
| Side rails (1-2) up | Assists with repositioning; not restraint when patient can exit |
| Call light within reach | Enables patient to summon help |
| Non-skid footwear | Prevents slipping on smooth floors |
| Adequate lighting | Improves visibility; nightlights for nighttime |
| Clear pathways | Removes obstacles that could cause tripping |
| Assistive devices nearby | Walker, cane within reach when needed |
Patient-Centered Interventions
| Intervention | Rationale |
|---|---|
| Bed/chair alarms | Alerts staff when patient attempts to stand |
| Frequent rounding | Proactive toileting and needs assessment |
| Toileting schedule | Reduces urgency-related ambulation |
| Hip protectors | Reduces injury severity if fall occurs |
| Fall risk signage | Communicates risk to all staff |
| Patient/family education | Engages patient in prevention |
Medication Review
Evaluate and minimize:
- Sedatives and hypnotics
- Opioid analgesics
- Antihypertensives (orthostatic hypotension)
- Diuretics (urgency, electrolyte imbalances)
- Psychotropic medications
Restraints: Last Resort Only
Restraints are defined as any device, method, or process that restricts a patient's freedom of movement or access to their body. This includes:
- Physical devices (wrist, ankle, vest, belt restraints)
- Medication used primarily for control (chemical restraint)
- Seclusion (confinement in a room patient cannot leave)
Core Principle
Restraints are a measure of LAST resort - used only when less restrictive interventions have failed and the patient poses an immediate threat to self or others.
Types of Restraints
| Type | Description | Example |
|---|---|---|
| Limb restraints | Restrict movement of arms or legs | Wrist restraints, ankle restraints |
| Vest/Jacket | Restrict trunk movement | Vest tied to bed frame |
| Belt restraints | Keep patient in chair or bed | Waist belt |
| Mitt restraints | Prevent hand/finger use | Padded mitts prevent pulling tubes |
| Enclosed beds | Prevent patient from leaving bed | Canopy beds, safety enclosures |
| Chemical restraints | Medications for behavioral control | Haloperidol for acute agitation |
Restraint Requirements
Provider Order Requirements
| Situation | Order Requirements |
|---|---|
| Non-violent (medical/surgical) | Written order within 1 hour; renewed every 24 hours |
| Violent/self-destructive (adult) | Written order within 1 hour; renewed every 4 hours |
| Violent/self-destructive (child 9-17) | Renewed every 2 hours |
| Violent/self-destructive (child under 9) | Renewed every 1 hour |
Critical Rules
- PRN orders are NEVER acceptable - Each restraint use requires a specific, time-limited order
- Face-to-face evaluation required within 1 hour for violent restraints
- Continuous monitoring is required
- Least restrictive device must be used
- Documentation must include alternatives tried and failed
Monitoring Patients in Restraints
Assessment must occur at regular intervals (typically every 30 minutes to 2 hours based on facility policy):
| Assessment Area | What to Check |
|---|---|
| Circulation | Pulses distal to restraint, color, temperature, capillary refill |
| Sensation | Numbness, tingling |
| Skin integrity | Redness, breakdown, abrasions |
| Range of motion | Release periodically for ROM exercises |
| Psychological status | Agitation, distress |
| Vital signs | Temperature, pulse, respirations |
| Nutrition/hydration | Offer fluids, meals |
| Elimination | Toileting needs |
| Continued need | Reassess if restraint is still necessary |
Release Schedule
- Remove restraints at least every 2 hours for:
- Range of motion exercises
- Skin care
- Toileting
- Repositioning
Restraint Alternatives
Before applying restraints, try these alternatives:
| Category | Interventions |
|---|---|
| Environmental | Move closer to nursing station, low bed, floor mats |
| Distraction | Music, television, conversation, activities |
| Comfort | Pain management, toileting, positioning |
| Family | Invite family member to stay with patient |
| Staffing | 1:1 sitter observation |
| Assessment | Treat underlying cause (delirium, pain, infection) |
Legal and Ethical Considerations
- Restraints can be considered false imprisonment if used improperly
- Patient has right to be free from restraint unless necessary for safety
- Least restrictive intervention must always be used first
- Documentation is critical - must show medical necessity and alternatives tried
- Death in restraints is a sentinel event requiring root cause analysis
On the NCLEX
Common testing points:
- Identifying patients at high risk for falls
- Priority interventions for fall prevention
- Understanding that restraints require orders (not PRN)
- Assessment frequency for restrained patients
- Legal implications of restraint use
Exam Strategy: If a question asks about restraints, the answer usually involves trying alternatives first, obtaining a proper order, or assessing circulation/skin integrity.
A patient is confused and repeatedly trying to climb out of bed. The nurse has tried reorientation, keeping the call light within reach, and asking a family member to stay. What is the next appropriate nursing action?
A nurse is caring for a patient in wrist restraints for a non-violent medical reason. How often must the restraint order be renewed?
Which assessment finding in a patient with wrist restraints requires immediate nursing intervention?