A nurse is assessing a client and considering the use of physical restraints to keep the client safe. In making this decision, which factors should the nurse consider? (Select all that apply.)
a. A goal is to use the least restrictive device for the shortest possible time.
b. Alternatives to restraint should be tried first as death and injury can occur.
c. How to communicate with the physician so an order is signed every 48 hours.
d. The frequency with which the client must be re-assessed.
e. The types and sizes of restraints the facility has available.
A, B, D, E
Using restraints is considered a high-risk intervention. The major goal is to use the least restrictive device for the shortest possible time. Alternatives to restraining a client must be attempted and documented. Each institution has its own policies for the frequency of re-assessment, and the nurse must be available to provide for nutrition, comfort, and elimination needs of the client, or can delegate these. Restraints must fit properly. A signed order is needed from the physician every 24 hours.
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