The CCTC Standard of Care for restraint use has been developed to comply with the LHSC Standard of Nursing Care for Restraint Use.  


Restraints are any mechanical, chemical or environmental means which are intended to prevent injury or bring under control behaviours or physical movements which could cause bodily harm to patients or others.

Ensure that patient and health care provider safety standards are met during this procedure including:

  • Risk assessment and appropriate PPE
  • 4 Moments of Hand Hygiene
  • Procedural Safety Pause is performed
  • Two patient identification
  • Safe patient handling practices
  • Biomedical waste disposal policies


Practice Standard

LHSC and CCTC supports a least restraint policy.


  • Effective restraint reduction requires innovative substitutes for the use of restraints.
  • Research has shown that 81% of patients who remove their endotracheal tube were restrained at the time.
  • Evidence also shows that the use of restraints contributes to depression, anger, nosocomial infection, and pressure ulcers.

An assessment for alternative measures is done prior to the use of restraints.

  • Restraints are used only after other measures have been considered and are either unsuccessful or inappropriate.

See Delirium Protocol for strategies to prevent Delirium and engage family members in the prevention and treatment.

Click to obtain Decision Tree for the use of restraints in CCTC.

Document the alternate methods used and patient’s response.

  • Many reasons for restless and agitation can exist including:
    • Pain (e.g., from incisions, invasive lines, monitoring devices or prolonged bedrest)
    • Anxiety
    • Malfunction of catheters
    • Sleep deprivation
    • Drug reactions, interactions or withdrawal
    • Electrolyte imbalances
  • Restraints may contribute to further agitation and delirium.

Ensure that restraints are applied safely and are approved for use at LHSC.

  • Restraints are indicated in isolated circumstances where there are risks of injury to the patient or others.
  • Restraint measures should allow as much autonomy as possible while promoting patient and staff safety.
4. The Patient/Family/Substitute Decision-Maker must consent to the use of restraints.
  • Prior to the use of restraints or as soon as possible once restraints have been initiated, the Family or Substitute Decision-Maker must be notified and their verbal consent documented in the AI flowsheet.
  • Discussion with the family should include:
    • the reason for the restraints
    • the alternatives that have been attempted or considered
    • the type of restraints to be used
    • the associated risks
    • the time frame for which restraints may be necessary
    • the risks associated with not restraining the patient

If the family refuses the use of restraints despite being made aware of the potential risks to the patient or others, a “Consent for the Refusal of Physical Restraints” must be signed by the Family or Substitute Decision-Makers.


Document the following in the AI record:

  • the behaviour that necessitated the use of the restraint
  • the date and time of initial application
  • the type of restraint used
  • the discussion with the Family/Substitute Decision-Maker
  • the verbal consent or refusal
  • observations regarding the effect of the restraint on the patient's behaviour

The Consent for Refusal for Restraint must be completed and left on the chart.

Careful documentation is important to demonstrate that the patient’s dignity, rights and independence were considered while attempting to maintain a safe environment for patients, visitors and staff.


The patient must be reassessed and observed routinely while restraints are in place.

Injury risks from the use of restraints have been well documented.


During initiation of restraints:

The following assessments must be made q 15-30 minutes X 1 hour , then every 15 – 60 minutes:

  • colour, circulation, sensation and motion of all restrained limbs
  • skin condition

Document findings on the A/I flowsheet.

Reported complications related to restraint use have been reported and include:

  • emotional difficulties
  • increased agitation
  • confusion
  • delirium
  • skin breakdown
  • circulatory dysfunction
  • respiratory compromise
  • brachial plexus injury

During ongoing use of restraints:

  • Remove and reapply restraints q2h.
  • Reposition the patient q2h.
  • Monitor body alignment. Pay particular attention to ensure the shoulder is in proper alignment and not being strained.
  • Perform range of motion exercises q12h and prn.

The following assessments must be made q2h AND documented on the AI flowsheet:

  • colour, circulation, sensation and motion of all restrained limbs
  • skin integrity

Brachial plexus injuries can occur from stretching of the shoulder. This can lead to injuries ranging from arm and hand numbness to paralysis.


Reassess the use of restraints q24h and document daily on the AI 24-hour assessment record.

Patient's restraint requirements will change and need to be regularly reevaluated.  


College of Nurses Of Ontario (2000). A Guide on the Use of Restraints. “Communique” January.

Deprospero, R.P., & Bocchino, N. (1999). Restraint Free Care – Is It Possible? American Journal of Nursing 99(10) 27-34.

Fletcher, K. (1996). Use of Restraints in the Elderly. AACN Clinical Issues, 7(4), 611-620.

Gilbert, M., & Counsell, C. (1999). Planned Change to Implement a Restraint Reduction Program. Journal of Nursing Care Quality, 13(5), 57-64.

Knapp, M.B. (1996). Physical Restraint Use in Critical Care: Legal Issues. AACN Clinical Issues, 7(4), 579-584.

Leith, B. (1998). The Use of Restraints in Critical Care. Official Journal of the Canadian Association of Critical Care Nurses, 9(3), 24-28.

Leith, B. (1998). Do Physical Restraints Prevent Patients form Removing Invasive Therapeutic Devices? Official Journal of the Canadian Association of Critical Care Nurses, 9(3), 31-34.

London Health Sciences Centre (2001; February).Revised February  1, 2010.Policy on the Use of Restraints, PCC020.

Maccioli, G., Mazuski, J., Kuszaj, J., Devlin, J. & Peruzzi, W. (2003). Clinical Practice Guidelines for the Maintenance of Patient Physical Safety in the Intensive Care Unit: Use of Restraining Therapies: American College of Critical Care Medicine Task Force 2001-2002, Critical Care Medicine, 31(11), 2665-2676.

Mion, L. (1996). Establishing Alternatives to Physical Restraint in the Acute Care Setting: A Conceptual Framework to Assist Nurses’ Decision Making, AACN Clinical Issues, 7(4), 592-602.

Reigle, J. (1996). The Ethics of Physical Restraints in Critical Care, AACN Clinical Issues, 7(4), 585-591.

Created Januray 25, 2005
Susan Williams, Charge Nurse: CCTC

Revised: January 20, 2017; Updated: November 5, 2018 Reviewed: February 2, 2020 (BM)