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    Skill Checklist Applying An Extremity Restraint

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    Asep Bageur

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    Skill Checklist Applying An Extremity Restraint

    Uploaded by

    Asep Bageur
    690 views2 pages

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    Skill Checklist Applying an Extremity Restraint

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    Copyright:

    © All Rights Reserved
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    690 views2 pages

    Skill Checklist Applying An Extremity Restraint

    Uploaded by

    Asep Bageur

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    of 2

    LWBK680-c26-p09-10.

    qxd 9/3/10 5:24 PM Page 9 Aptara Inc

    Skill Checklists for Fundamentals of Nursing:


    The Art and Science of Nursing Care, 7th edition
    Name Date

    Unit Position

    Instructor/Evaluator: Position

    Needs Practice SKILL 26-1


    Applying an Extremity Restraint
    Satisfactory
    Excellent

    Goal: The patient is constrained by the restraint, remains


    free from injury, and the restraint does not interfere with
    therapeutic devices. Comments

    1. Determine need for restraints. Assess patient’s physical


    condition, behavior, and mental status.
    2. Confirm agency policy for application of restraints. Secure
    an order from the primary care provider, or validate that
    the order has been obtained within the past 24 hours.
    3. Perform hand hygiene and put on PPE, if indicated.
    4. Identify the patient.
    5. Explain reason for use to patient and family. Clarify how
    care will be given and how needs will be met. Explain that
    restraint is a temporary measure.
    6. Include the patient’s family and/or significant others in the
    plan of care.
    7. Apply restraint according to manufacturer’s directions:
    a. Choose the least restrictive type of device that allows
    the greatest possible degree of mobility.
    b. Pad bony prominences.
    c. Wrap the restraint around the extremity with the soft
    part in contact with the skin. If hand mitt is being used,
    pull over hand with cushion to the palmar aspect of
    hand. Secure in place with the Velcro® straps.
    8. Ensure that two fingers can be inserted between the
    restraint and patient’s wrist or ankle.
    9. Maintain restrained extremity in normal anatomic
    position. Use a quick-release knot to tie the restraint to
    the bed frame, not side rail. The restraint may also be
    attached to chair frame. The site should not be readily
    accessible to patient.
    10. Remove PPE, if used. Perform hand hygiene.
    11. Assess the patient at least every hour or according to facil-
    ity policy. Assessment should include: the placement of the
    restraint, neurovascular assessment of the affected extrem-
    ity, and skin integrity. In addition, assess for signs of
    sensory deprivation such as increased sleeping, daydream-
    ing, anxiety, panic, and hallucinations.

    Copyright © 2011 by Wolters Kluwer Health | Lippincott Williams & Wilkins. Skill Checklists for Fundamentals of Nursing:
    The Art and Science of Nursing Care, 7th edition, by Carol Taylor, Carol Lillis, Priscilla LeMone, Pamela Lynn, and Marilee LeBon.
    LWBK680-c26-p09-10.qxd 9/3/10 5:24 PM Page 10 Aptara Inc

    10

    SKILL 26-1

    Needs Practice
    Applying an Extremity Restraint (Continued)
    Satisfactory
    Excellent

    Comments

    12. Remove restraint at least every 2 hours, or according to


    agency policy and patient need. Perform range-of-motion
    exercises.
    13. Evaluate patient for continued need of restraint. Reapply
    restraint only if continued need is evident and order is still
    valid.
    14. Reassure patient at regular intervals. Provide continued
    explanation of rationale for interventions, reorientation if
    necessary, and plan of care. Keep call bell within easy
    reach.

    Copyright © 2011 by Wolters Kluwer Health | Lippincott Williams & Wilkins. Skill Checklists for Fundamentals of Nursing:
    The Art and Science of Nursing Care, 7th edition, by Carol Taylor, Carol Lillis, Priscilla LeMone, Pamela Lynn, and Marilee LeBon.

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