University:
Chamberlain University
Course:
NR224 | Fundamentals I
Academic year:

2021
Views:

90

Pages:

1
Author:

Kristopher Elliott

ACTIVE LEARNING TEMPLATE: Nursing Skill Application of Physical Restraints SKILL NAME ____________________________________________________________________________ 26 REVIEW MODULE CHAPTER ___________ Description of Skill A physical restraint is any manual method, physical or mechanical device, material, or equipment that immobilizes or reduces the ability of a patient to move arms, legs, body, or head freely. Indications Altered mental status Physical combative Immediate danger to self & others Post surgical When all other options set in place does not work Outcomes/Evaluation Patient safety Staff safety Patient is free from inflicting injury to self & others Patient is able to calm down & display coorperative behavior towards staff, visitors, & others Potential Complications Skin breakdown Patient injury Suffocation No circulation CONSIDERATIONS Nursing Interventions (pre, intra, post) Pre: the nurse is to document the patient behavior and the event prior to obtaining and applying restraints Intra: Assess the integrity of patient's skin and provide skin care if needed according to facility protocol; usually assess patient every 2 hour. Offer fluids if patient can tolerate it Post: Continue to assess patient every 2 hours and decument and document the patient response to removal of restaint Client Education Educate patient and family member by emphazing the use of restraint is to keep the patient safe and it is only temporary Nursing Interventions Assess patient every 2 hour to determine the need for continue use of restraints Assess patient circulation Frequent ROM 1:1 supervision