The government standards regarding mechanical and physical restraints identify that:
A. Alternative measures are to be implemented first
B. The nurse's judgment is all that is required for their implementation
C. Restraints should be used immediately for all clients who may need them
D. Restraints cannot be used except to prevent others from being harmed
A
A and C. The use of mechanical or physical restraints must be part of the prescribed medical treatment, all less restrictive interventions must be tried first, other disciplines must be used, and supporting documentation must be provided.
B. If the alternatives fail, the nurse may consider use of a restraint to prevent injury. Determine client's need for restraint if other less restrictive measures fail to prevent interruption of therapy or injury to self or others. Confer with physician or primary health care provider.
D. Restraints may be needed in the confused or combative client to prevent interruption of therapy or injury to self or others. Confer with physician or primary health care provider.
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