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 3-4

Applying a Waist Restraint (Continued)

Comments

9. Remove PPE, if used. Perform hand hygiene.


10. Assess the patient at least every hour or according to facil-
    ity policy. An assessment should include the placement of
    the restraint, respiratory assessment, and skin integrity.
    Assess for signs of sensory deprivation, such as increased
    sleeping, daydreaming, anxiety, panic, and hallucinations.
    11.Remove restraint at least every 2 hours or according to
    agency policy and patient need.Perform ROM exercises.


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


12. 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.


13. Perform hand hygiene.

ExcellentSatisfactoryNeeds Practice