Skill Checklists for Taylor's Clinical Nursing Skills: A Nursing Process Approach

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Copyright © 2011 by Wolters Kluwer Health | Lippincott Williams & Wilkins. Skill Checklists for Taylor's Clinical Nursing Skills:

SKILL 3-3

Applying an Extremity Restraint (Continued)

Comments

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 sen-
    sory deprivation, such as increased sleeping, daydreaming,
    anxiety, panic, and hallucinations.
    12.Remove restraint at least every 2 hours, or according to
    agency policy and patient need.Perform range-of-motion
    exercises.


12. Evaluate patient for continued need of restraint. Reapply
    restraint only if continued need is evident and order is
    still valid.


13. 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.

ExcellentSatisfactoryNeeds Practice