Non-Violent Restraint Guidelines
1. RN immediately contacts the physician or
PA to evaluate and place the order.
10. To change restraint device:
 Go to Ad Hoc and select Restraint
Monitoring Non-Violent Patient form
 Select “Change device/points”
2. If restraints are applied due to urgent
patient safety concerns, the RN describes
the need for restraints, obtains the order
for the specific restraint type(s) applied,
and documents in Focus Note.



Don’t forget to document on the Restraint
Initiation form via the PAL task as soon as
it is available.
3. To enter verbal order, the nurse enters
Restraint Non-Violent order and uses the
physician’s or PA’s name and POE
VORB/TORB.
Do not use Per Protocol.
4. Restraint Initiation and Monitoring Tasks
will be sent to PAL when the order is
placed.
5. Document using PAL!!! The Restraint
Initiation task form is accessible only
through the task.
6. Restraint device charted must match the
order and fit the circumstances
documented.
7. Restraint Monitoring Tasks are generated
every 4 hours. Monitoring form includes
care plan and interventions.
8. Restraint orders entered by ED physician
automatically D/C when patient is
transferred to inpatient unit or discharged.
The admitting physician must reorder
restraints if the restraints are to be
continued.
9. Each day the physician or PA will renew
the restraint order based on clinical
examination.


Document reason for the change in
Comment field
In the “Discontinue Criteria Met field,
select “Unmet: changed to different
device/points.”
Signing the form discontinues the
original order & all associated tasks.
Notify the physician or PA to obtain a
new order for the change in restraints.
4.
State law requires that a physician or PA
place and renew Non-Violent Restraint
orders, not a NP.
5.
Individualize Restraint Goals and
Interventions. An option of “Other” is
available for both. For example: add
goal “Prevent sensory overload” and
Interventions “Establish a calm
environment, limit room traffic, noise,
bright lights, etc.”
6.
Restraint device charted must match the
order and fit the circumstances
documented.
7.
Document changes in patient condition
or injury related to restraints on the
Focus Note.
8.
Restraint Removal Criteria is on the
Care Plan (Initiation and Monitoring
forms).
9.
Nursing assessment/documentation
should reflect the specific removal
criterion selected when restraints are
discontinued.
10.
The Restraint Plan including Restraint
Removal Criteria is viewed on the Plan
of Care tab. Double click to open cell.
11.
Use of 4 side rails on a patient with
Seizure Precautions does not require a
Restraints Order.
11. To discontinue restraints:





Select Restraint Monitoring Non-Violent
Patient form in Ad Hoc
Click “No” in the “Restraints still needed”
field
Complete the required fields
Remove Restraints from Precaution’s field
Signing the form DC’s all tasks and the
order
If the Dr. or PA enters the DC order, complete
the task.
Restraint Tips
1.
Restraints cannot be PRN.
2.
No Trial Removal of restraints.
3.
Contact physician for a new order when
restraint device or points have changed.
The physician or PA will be electronically
alerted to re-new the restraint order as long as
the RN continues to document on the
Restraint Monitoring form.
Patients who expire within 24 hours of
restraint use, or who expire while restraint in
use, must be reported to risk management at
2-0189. CMS regulations mandate a report be
submitted within 24 hours of the patient’s
death.
Violent Restraint Guidelines
Violent restraints are to be used only as an
emergency measure to manage violent or selfdestructive behavior that jeopardizes the
immediate safety of the patient, staff, or others.
1.
Emergent situation
a. Notify physician/PA at the time of
application to obtain order for specific
restraints to be applied and documents in
Focus Note.
Restraint Guidelines
for Nursing

Non–Violent

Violent
b. Enter verbal order using “POE
VORB/TORB”. DO NOT USE “Per protocol”.
c. Physician/PA must perform face to face
evaluation within one hour of application.
2. Restraint Initiation and Monitoring Tasks will be
sent to PAL when the order is placed.
3. Document using the PAL!!! Patient must be
monitored continuously and assessed every 15
minutes. 1:1 assignment with RN or NA.
a. Document using the PAL Monitoring Task
15 minutes.
b. Restraint device charted must match the
order and fit the circumstances documented.
4. The initial order is valid based on the patient’s
age and must be renewed accordingly:
a.
b.
Adult-every 4 hours
Ages 9-17-every 2 hours
5. A debrief should be completed by the RN. All
staff that was present when the restraint was
initiated will be asked to participate.
6. A debrief task is generated when the
restraint discontinuation form has been
completed.
Note: Use of “Twice as tough” restraints does not
imply the patient needs violent restraint orders.
Twice as tough can be used for non-violent
patients who are strong.
December 2012
Cathy Mowbray BSN, RN, CCRN
Cerner Education