The use of protective devices may be considered false imprisonment. In order to assure the rights of the client are not violated, which practices must be implemented when using a device? (Select all that apply.)
a. A written medical order must be on the medical record.
b. Client must be confined to bed.
c. Restraints must be removed and limb exercised every 2 hours.
d. Implement use of restraints in the event of short staffing as a preventive measure.
e. Client must be assessed and monitored every 15 minutes.
A, C, E
Restraints must be used only to protect the client, not for staff convenience. All less restrictive measures should first be attempted and documented. A written medical order for restraints must be on file in the client's chart. Once restraints have been applied, the caregivers have an increased obligation to observe, assess, and monitor the client every 15 minutes. The restraints must be removed, one limb at a time, and the limb exercised every 2 hours. All observations and actions must be documented. Restraints are removed as soon as the client's behavior is under control.
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