Restraint Rita — Restraints & Fall Prevention: Least Restrictive First, and the Order Rules
Everything else is tried before anything is tied — and once it is, the clock and the checks begin
Rita kneels, lowers the bed, puts the call light in a reachable hand, and slides nonslip socks on. The padded wrist band on the blanket stays unused.
Rita is the nurse who exhausts alternatives first: lower the bed, nonslip socks, call light in reach, bed alarm, frequent rounding, familiar objects, redirection, and moving the client closer to the station. Restraints are a last resort requiring a provider order that specifies type, reason and duration — never PRN. In an emergency a nurse may apply restraints and obtain the order promptly after. Restraints are tied with a quick-release knot to the BED FRAME, never the side rail, and are released with circulation, skin, range of motion, toileting and hydration checks on schedule. Falls are the other half of the story: assess risk on admission, after any change, and after every fall.
Read Restraint Rita's full story →The story arc
The setup
A confused older client keeps trying to climb out of bed at night.
The turn
Rita tries the least restrictive options first — bed low, alarm on, rounding every hour, a familiar photo, and toileting on a schedule.
The crisis
The client pulls at a critical line and swings at staff. Restraints become necessary.
The save
The restraint is tied with a quick-release knot to the bed frame, and Rita builds her check schedule: circulation, skin, range of motion, food, fluid, toileting.
NCLEX study section — Restraints & Fall Prevention: Least Restrictive First, and the Order Rules
What this chapter is testing: the recognition cues, the numbers and the priority action.
Study section: Safety & Infection Control
Take this chapter into practice questions on the same topic.