Use of safety devices
Introduction
Safety devices are meant to protect, not to punish. They are the guardrails of nursing practice, but if misused, they can cause harm as easily as they prevent it. Nurses must balance autonomy and dignity with the duty to shield clients from injury, using the least restrictive measure first, and reassessing often. The NCLEX will test your ability to choose, monitor, document, and discontinue these devices safely and ethically. This chapter covers a specific subset of safety practice - restraints, fall prevention, and equipment checks; related topics such as transmission-based precautions, hazardous materials, and incident reporting are covered in their own chapters.
Learning objectives
By the end of this section, you should be able to:
- Distinguish between least-restrictive restraint options and know when restraints are permissible
- Implement fall prevention measures and assess equipment safety
- Document, monitor, and evaluate safety device use according to standards
Restraints
There are two types of restraints: physical restraints limit movement (mitts, belts, and vests), while chemical restraints use medications (such as benzodiazepines or antipsychotics) to control behavior or movement when the drug or dose is not a standard treatment for the client’s condition. Use the least restrictive method possible.
Indications & orders: Restraints are used only to prevent harm to self or others, when all alternatives fail. A provider order is required and time-limited. For violent or self-destructive behavior, each order lasts up to 4 hours for adults, 2 hours for ages 9-17, and 1 hour for children under 9, and the client must be seen face-to-face by a primary health care provider, licensed practitioner, or trained RN within 1 hour of initiation. Orders may be renewed within those limits for up to 24 hours; after that, a primary health care provider or licensed practitioner must see and assess the client before writing a new order. A PRN or standing restraint order is never permitted.
Application & monitoring: Restraints must be tied with a quick-release knot to a non-movable part of the bed frame (never side rails). Assess circulation, skin integrity, and client comfort at least every 30 minutes; remove restraints every 2 hours to allow repositioning, toileting, and range of motion.
Discontinuation: As soon as the client no longer poses risk, restraints must be discontinued. Don’t wait for the order to expire. Act proactively.
Nursing interventions
- Try alternatives first (reorientation, sitters, bed/chair alarms)
- Leave enough slack for circulation and comfort
- Document thoroughly: type, reason, time applied, assessments, alternatives attempted
Fall prevention
The most important risk for falls is a previous fall. The idea is to avoid the first one and the disability, pain, and recurrence that usually follow.
Risk factors & assessment: Factors include age, mobility impairment, medications, confusion, history of falls, and environmental hazards. Use validated fall-risk tools on admission and periodically.
Preventive interventions: Keep beds low, wheels locked, call light within reach, and pathway clear of clutter. Use non-slip footwear, adequate lighting, and bed/exit alarms for high-risk clients. Move high-risk clients closer to nurses’ stations and round proactively.
Nursing interventions for fall prevention
- Perform a fall risk assessment on admission and regularly thereafter
- Keep the bed in the lowest position, wheels locked, and call light within reach
- Provide non-slip footwear and adequate lighting
- Eliminate clutter and keep frequently used items nearby
- Use bed or chair alarms when appropriate
- Encourage use of the call light before ambulating
- Involve families in prevention education
Equipment checks
Medical devices can protect life or threaten it if broken. Regular checks ensure they serve the client, not endanger them.
Inspection & safety: Inspect all medical devices and safety equipment before use. Look for frayed cords, alarms, loose connections, and integrity. Never use equipment you suspect is unsafe. Tag malfunctioning equipment “do not use” and remove it from service immediately.
Emergency readiness: Confirm that oxygen, suction, defibrillators, wheelchairs, and monitors are functional at shift start. Secure wheels on stretchers, beds, and chairs before transfer.
Nursing interventions for equipment checks
- Inspect equipment before each use for safety and function
- Tag and remove malfunctioning devices (“do not use”)
- Confirm emergency equipment (oxygen, suction, defibrillator) is functional at the start of each shift
- Lock wheels on beds, stretchers, and wheelchairs before transfers
Clinical vignette: Mrs. P is restless and repeatedly attempts to remove her IV tubing. The nurse first tries reorientation, distraction, and a sitter, but these measures are unsuccessful. Soft wrist restraints are then applied to the bed frame using a quick-release knot. Every 30 minutes, the nurse assesses skin integrity and circulation. Every 2 hours, the restraints are removed for range-of-motion exercises, repositioning, toileting, and reassessment before being reapplied if still necessary. All interventions are documented thoroughly.
Safety considerations and client education
- Restraints can cause injury, impaired circulation, and emotional distress. Use sparingly and reassess often.
- Four raised side rails are generally considered a restraint when used to prevent a client from exiting the bed. Padded side rails are sometimes used for seizure precautions, though current teaching increasingly avoids restraint-like measures during a seizure.
- Families should understand that restraints are temporary safety measures, not punishment.
- Educate clients and families about fall precautions and safe equipment use.