What does a doctor's order for restraints as needed (Pro Re Nata - PRN) mean for a psychiatric patient?

PRN Restraint Orders Are Not Acceptable in Psychiatric Settings

The nurse should clarify before performing this procedure (Answer C), because PRN restraint orders are not clinically or legally appropriate—restraints require specific evaluation, ordering, and monitoring protocols that cannot be satisfied by a standing PRN order. 1, 2, 3

Why PRN Restraint Orders Are Problematic

Regulatory Requirements Prohibit PRN Use

Restraints require a licensed independent practitioner to evaluate the patient in person within 1 hour of restraint placement, which fundamentally contradicts the concept of a PRN order that nurses can implement independently. 1, 3 This mandatory face-to-face evaluation must occur after the restraint is applied, not as a standing order written in advance. 1

Time-limited orders are mandatory and vary by patient age:

• Every 1 hour for patients <9 years old 3
• Every 2 hours for patients 9-17 years old 3
• Every 4 hours for patients >18 years old 3

These renewal requirements make PRN orders impractical and inappropriate, as each application requires fresh clinical justification and physician involvement. 1, 3

Clinical Criteria Must Be Met at Time of Application

Restraints have only two legitimate indications that must be present at the moment of application:

1. Imminent danger to prevent the patient from harming themselves or others 2
2. Severe disruption to prevent disorganization or serious disruption of the treatment program, including serious property damage 2

Less restrictive measures must be attempted first or documented as impractical before restraints can be applied. 2, 3 A PRN order cannot anticipate whether de-escalation techniques, verbal interventions, or other alternatives have been exhausted at the time the nurse considers using restraints. 2

Prohibited Uses That PRN Orders May Enable

Restraints must never be used for:

• Punishment of patients 2, 3
• Staff convenience 2, 3
• Compensation for inadequate staffing patterns 2

A PRN order creates risk that restraints might be applied for these inappropriate reasons without proper clinical evaluation and oversight. 2

What Should Happen Instead

Proper Ordering Process

When a patient requires restraint, the following sequence must occur:

1. Less restrictive interventions attempted or documented as impractical 2, 3
2. Licensed independent practitioner contacted for specific order 1, 3
3. In-person evaluation by practitioner within 1 hour of application 1, 3
4. Continuous monitoring with assessments every 15 minutes for vital signs, circulation, signs of injury, and readiness to discontinue 1, 3

Critical Safety Monitoring

Every 15 minutes, staff must assess:

• Extremity circulation and range of motion 3
• Vital signs 1, 3
• Signs of injury due to restraint 1, 3
• Nutrition and hydration status 1, 3
• Physical and psychological status/comfort 1, 3

Airway protection is paramount—supine restraints require the patient's head to rotate freely with head of bed elevated, and prone restraints require unobstructed airway at all times with no excessive pressure on the back. 2 Prone positioning has been associated with deaths and should be avoided. 1, 2, 3

Common Pitfall to Avoid

The most dangerous pitfall is accepting PRN restraint orders as routine practice. This represents a fundamental misunderstanding of both the clinical indications and regulatory requirements for restraint use. 1, 2, 3 Each restraint episode requires individualized assessment, physician involvement, and specific time-limited ordering that cannot be satisfied through standing PRN orders. 1, 3