A client with acute confusion (delirium) is trying to get out of bed and has multiple IV lines and a Foley catheter. After attempting re-orientation and distraction, the nurse is considering restraints. What is the correct process?

RESTRAINT USE — REGULATORY REQUIREMENTS: LAST RESORT: Restraints must be used only after less-restrictive alternatives fail (redirection, re-orientation, family presence, positioning, medication review, activity); PHYSICIAN ORDER REQUIRED: No nurse may initiate restraints without an order (except in emergency to protect from immediate harm — then get retroactive order within 1 hour); ORDER EXPIRATION: Most states require new orders every 24 hours; TJC requires specific restraint re-evaluation every 24 hours; MONITORING: Every 2 hours — circulation checks (pulses, sensation, warmth distal to restraint); skin integrity; position changes; offer fluids; provide ROM; DOCUMENTATION: Rationale; alternatives tried; type of restraint; client/family education; reassessment; PROHIBITED: Restraints as convenience (staffing shortages); punishment; restraints that restrict breathing; LEGAL/REGULATORY: CMS Conditions of Participation regulate restraint use in Medicare/Medicaid facilities; violations carry serious penalties; PN SCOPE: Apply and monitor ordered restraints; exhaust alternatives; document; notify RN of any adverse findings.