LWBK680-c26-p09-10.

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Skill Checklists for Fundamentals of Nursing:

The Art and Science of Nursing Care, 7th edition
Name Date

Unit Position

Instructor/Evaluator: Position

Needs Practice SKILL 26-1

Applying an Extremity Restraint
Satisfactory
Excellent

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.
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 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 hand mitt is being used,
pull over 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.
9. 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 chair frame. The site should not be readily
accessible to patient.
10. Remove PPE, if used. Perform hand hygiene.
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
sensory deprivation such as increased sleeping, daydream-
ing, anxiety, panic, and hallucinations.

Copyright © 2011 by Wolters Kluwer Health | Lippincott Williams & Wilkins. Skill Checklists for Fundamentals of Nursing:
The Art and Science of Nursing Care, 7th edition, by Carol Taylor, Carol Lillis, Priscilla LeMone, Pamela Lynn, and Marilee LeBon.
LWBK680-c26-p09-10.qxd 9/3/10 5:24 PM Page 10 Aptara Inc

10

SKILL 26-1

Needs Practice
Applying an Extremity Restraint (Continued)
Satisfactory
Excellent

Comments

12. Remove restraint at least every 2 hours, or according to

agency policy and patient need. Perform range-of-motion
exercises.
13. Evaluate patient for continued need of restraint. Reapply
restraint only if continued need is evident and order is still
valid.
14. 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.

Copyright © 2011 by Wolters Kluwer Health | Lippincott Williams & Wilkins. Skill Checklists for Fundamentals of Nursing:
The Art and Science of Nursing Care, 7th edition, by Carol Taylor, Carol Lillis, Priscilla LeMone, Pamela Lynn, and Marilee LeBon.