36
Copyright © 2011 by Wolters Kluwer Health | Lippincott Williams & Wilkins. Skill Checklists for Taylor's Clinical Nursing Skills:
Skill Checklists for Taylor's Clinical Nursing Skills:
A Nursing Process Approach, 3rd edition
Name Date
Unit Position
Instructor/Evaluator: Position
SKILL 3-3
Applying an Extremity Restraint
Goal: The patient is constrained by the restraint, remains
free from injury, and the restraint does not interfere with
therapeutic devices. Comments
- Determine need for restraints. Assess patient’s physical con-
dition, behavior, and mental status. (Refer to Fundamentals
Review 3-1, 3-2, 3-3, and 3-4 at the beginning of the
chapter.) - 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. - Perform hand hygiene and put on PPE, if indicated.
- Identify the patient.
- Explain reason for restraint use to patient and family.
Clarify how care will be given and how needs will be
met. Explain that restraint is a temporary measure. - Include the patient’s family and/or significant others in the
plan of care. - 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 a hand mitt is being
used, pull over the 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. - 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
a chair frame.The site should not be readily accessible
to patient. - Remove PPE, if used. Perform hand hygiene.
ExcellentSatisfactoryNeeds Practice