The nurse applies a physical restraint to the patient. Which entry should the nurse make after applying physical restraints?

Question

a. Performed restraint application reluctantly
b. Applied bilateral soft lamb's wool wrist restraints; skin pink, moist, and intact
c. Will perform a neurovascular assessment every 4 hours
d. Checked provider's prescription for prn restraints

Answer 1

B
The nurse documents the type of restraint applied and the condition of the skin where the re-straint was placed in the progress notes to communicate the information to the healthcare team. The nurse does not document subjective statements about the nurse. Neurovascular assessments of a patient's extremity must take place at least every 2 hours because skin breakdown can occur very quickly. The nurse does not accept prn prescriptions for restraints according to nursing standards and federal regulations.