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 Checklists for Taylor's Clinical Nursing Skills:
A Nursing Process Approach, 3rd edition

Name Date

Unit Position

Instructor/Evaluator: Position

SKILL 3-4

Applying a Waist Restraint

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 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.)


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 correct size of the least restrictive type
   of device that allows the greatest possible degree of
   mobility.
   b. Pad bony prominences that may be affected by the waist
   restraint.
   c. Assist patient to a sitting position, if not contraindicated.
   d.Place waist restraint on patient over gown. Bring ties
   through slots in restraint. Position slots at patient’s
   back.
   e. Pull the ties secure. Ensure that the restraint is not too
   tight and there are no wrinkles in it.
   f.Insert fist between restraint and patient to ensure that
   breathing is not constricted. Assess respirations after
   restraint is applied.
   8.Use a quick-release knot to tie the restraint to the bed
   frame, not side rail.If patient is in a wheelchair, lock the
   wheels and place the ties under the arm rests and tie
   behind the chair. Site should not be readily accessible to
   the patient.

ExcellentSatisfactoryNeeds Practice