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 3-5

Applying an Elbow 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
   condition, behavior, and mental status. Refer to review
   material in the chapter introduction.


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. 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
   restraint.
   c. Spread elbow restraint out flat. Place middle of elbow
   restraint behind patient’s elbow. The restraint should not
   extend below the wrist or place pressure on the axilla.
   d.Wrap restraint snugly around patient’s arm, but make
   sure that two fingers can easily fit under restraint.
   e. Secure Velcro straps around restraint.
   f. Apply restraint to opposite arm if patient can move arm.
   g. Thread Velcro strap from one elbow restraint across the
   back and into the loop on the opposite elbow restraint.
   7.Assess circulation to fingers and hand.


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


8. Assess the patient at least every hour or according to facil-
   ity policy. An assessment should include the placement of
   the restraint, neurovascular assessment, and skin integrity.
   Assess for signs of sensory deprivation, such as increased
   sleeping, daydreaming, anxiety, inconsolable crying, and
   panic.

ExcellentSatisfactoryNeeds Practice