MATRIX HOSPITAL
Checklist for patients with Restraint
Date
Time
Device
application
Position
Circulation
Skin integrity
Range of motion
Fluid needs
Nutrition needs
Toileting needs
Signature
Date
Time
Device
application
Position
Circulation
Skin integrity
Range of motion
Fluid needs
Nutrition needs
Toileting needs
Signature
Enter a tick mark when the following criteria is met or an asterisk (*) if not. Documentation of monitoring / care is required
no less than every 2 hours. Reassessment every 12 hours for continuation of restraint(s).
Device Application: Device secured but not tight; straps secured to bed or chair frame (not to side rails or other movable parts); quick
release possible.
Position: Proper alignment of the rest of the restrained limb(s) maintained.
Circulation : Affected limb(s) checked and application is determined not to impair circulation to the extremity (a) nail bed blanches
in less than 3 seconds (b) pulse present above and below restraint.
Skin integrity: Skin integrity around / under the device and all bony prominences indicate no pressure or reddened areas developed.
Range of motion : Active or passive range of motion in the affected limb (s) completed either by the patient or the care giver.
Fluids Needs: Fluid administered as per physician order (Oral or parenteral). If patient is not on restriction, fluids offered every hour.
If the patient is on NPO, oral care provided hourly.
Nutrition Needs: Nutritional needs met as per physician order. If oral intake allowed, patient offered and assisted with meals.
Toileting Needs: Elimination needs attended to either by Foleys catheter (only if ordered for other necessity) or by offering bed pan
or assistance to bedside commode.
