What assessments are essential for a nurse when considering the use of bilateral wrist restraints?

When considering the use of bilateral wrist restraints, assessing skin integrity is crucial. The application of restraints can potentially lead to skin breakdown, bruising, or pressure ulcers if the restraints are too tight or if they are used for extended periods. Nurses need to evaluate the condition of the skin before restraint application to ensure that any risk factors for skin injury are identified and addressed. This assessment helps prevent complications and ensures the safety and well-being of the patient while restraints are in use.

While the other assessments like previous restraint use and behavioral status are also important in making decisions about restraint application, they do not directly address the immediate physical risks associated with the use of restraints. Urinary continence is less relevant in this context, as it doesn’t directly impact the decision to use wrist restraints or the need for ongoing monitoring of skin integrity. Therefore, skin integrity stands out as the most immediate and critical assessment in this situation.