How/When To
General
Elbow
Extremity
Alternatives
100
Should be used when less-restrictive methods have failed
What is restraints
100
Short term for infant or child to control movement during procedure or to provide care for head/neck using sheet or blanket.
What is Appropriate use of mummy restraint
100
patient CAN move arm
What is apply restraint to opposite arm
100
Can be applied to hands, wrists, and ankles
What is extremity restraints
100
When would you use bed/chair alarms?
What is when a patient is at risk for falls and continually attempt to get out of bed/chair
200
Acute Confusion, Risk for Injury, Risk for self-mutilation, Risk for suicide, Risk for other-directed violence, Anxiety, Self-mutilation, Distrurbed sensory perception, Risk for Self-Directed Violence
What is possible Nursing Diagnosis for restraint patient
200
Used to tie restraint to bed frame or chair frame
What is quick-release knot
200
When applying elbow restraint you should not
What is extend the restraint below the wrist or place pressure on the axilla.
200
Can be inserted between patients wrists and ankles
What is Two fingers
200
Alternative for patient at risk of falls or wandering
What is relocate close to nurses station
300
Placed on patient over gown, clothes, or pj's
What is waiste restraint
300
With this patient can move extremities but cannot get out of bed/chair
What is waist restraint
300
What is the best way to determine the appropriate size elbow restraint?
What is Measure distance from shoulder to wrist
300
Pull over hand with cushion to the palmar aspect of hand
What is hand mitt
300
keep within reach
What is call bell
400
Assess ____ _____and _____ ______ in the arm to which restraint will be applied
What is capillary refill and proximal pulse
400
If appied incorrectly, the waist restraint can restrict
What is ability to breath
400
Your patient cries everytime her elbow restraints are removed. What would be the best response in this situation?
What is Increase passive ROM
400
What position should restrained extremity be in?
What is normal anatomic position
400
A patient continually pulls at IV site/tubing what is one alternative to use
What is Increase frequency of patient observation
500
Secure an order from primary care provider or validate that the order was obtained
What is within 24 hours
500
Use has been decreased due to potential risk for asphyxiation with device
What is vest or jacket restraint
500
Upon assessing skin integrity of a patient with a elbow restraint you a note a pressure ulcer at the elbow. What intervention would prevent this?
What is pad the elbow
500
Assessment of extremity restraint should include
What is placement of restraint, neurovascular assessment, and skin intergrity
500
Alternative for patient that is trying to pull out tubing and other treament sites
What is camouflage the tube or other treatment site with clothing, elastic sleeve, or bandaging
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