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 3-3

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

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 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.


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 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.


8. 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.


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

ExcellentSatisfactoryNeeds Practice