[mnono009]

I work in the US, and didn't realize how out of date our views on restraints are. I've been reading a huge amount on reducing usage, and am interested in "real life" information, not just research articles.
I work in a community hospital (no trauma) in the 16 bed ICU. Out main restraint use occurs with intubated patients. We have a good amount of COPD'ers, and they end up with us due to resp failure, pneumonia, and post op slow weans.
We use wrist restraints on people usually when initially trying to reach adequate sedation levels, when waking them up for daily assessments, and when working on extubation. Our MD's can be a little conservative with weaning, and the whole process can end up taking several days. In the meantime, the patient's can get aggravated by the tube....
What do you do to keep the patient's airway safe?
I'm looking forward to answers that I can relay to my co-workers! Thanks in advance, Michele

[Silverdragon102]

I have never seen physical restraints used on anyone during my 20+ years experience in the UK and only a handful of times I can think of physically holding a patient so an injection to calm them be administered. I have even at times refused to put cotsides up on confused patients as they seemed worse with them up and felt the patient would cause more harm to themselves by climbing over them. Have on occasions nursed patients on the floor as team wise it was felt safer

[sharrie]

In ICu in the UK we tend to nurse our patients on a 1:1 ratio so there is no need for restraints.

I haven't seen restraints used anywhere else either

[sofaraway04]

I have never working in ICU but I had a 5 weeks placement as a student in neuro ICU, I didn't see any restraints used at all, the pateints were all sedated to the extent that no restraints were needed. I had a converstaion with a US nurse who worked on the unit, and she said that in the Uk sedation was used more heavily than it was in the states.

[RGN1]

In 12 years of nursing I've never seen, or used retraints. To be honest there have been times when I wished I had them though - when a 95 year old, confused little old lady with paper skin & rotten veins pulled out her venflon for the umpteenth time I remember thinking that I wished I could put some kind of soft mittens on her!!

There are differing rules on restraint in psychiatric nursing though. It's a last resort but you can use various things if the safety of anyone is compromised.

[mnono009]

Thanks for the input, but, what do you do? When sedation is lightened, and the patient's not liking the tube? Or has already pulled a central line and several peripheral IV's, and you need to keep the current central line? If it looks like someone is going to end up on the vent longer rather than shorter, and keeps grabbing for the ETT (and has dementia, of course!). We use mostly propofol, sometimes midazolam drips for sedation, and it seems as if they reach a tolerance every few days, and a nicely sedated person can wake up with a bang. JCAHO (accrediting body for health care facilities) doesn't want people deemed to be alert and oriented restrained (soft wrist restraints made with cloth and velcro with long straps that tie to the bedframe so that the person can't reach medical devices--it really does sound awful), but orientation can change quickly, maybe they weren't so oriented, or they suddenly decide they don't like that tube anymore....
For the roamers, especially on general units, what is done to prevent falls or the pulling out of equipment? The people that decide to walk to the bathroom and forget that they haven't actually walked for a few years? Or the one that keeps pulling a nasogastric tube out?
The research I've read has found that restraints do not prevent falls, and many unplanned extubations occur while the patient's are restrained. Because it has always been the norm for me, I'm working at getting my mind wrapped around a new standard. And, I'm the one that's going to be trying to influence the rest of the staff to believe that restraint minimization is possible and preferred!
I'm amazed at your answers, and will be sharing the with my coworkers. Please tell me more, Michele

[sharrie]

Originally Posted by mnono009

Thanks for the input, but, what do you do? When sedation is lightened, and the patient's not liking the tube? Or has already pulled a central line and several peripheral IV's, and you need to keep the current central line? If it looks like someone is going to end up on the vent longer rather than shorter, and keeps grabbing for the ETT (and has dementia, of course!). We use mostly propofol, sometimes midazolam drips for sedation, and it seems as if they reach a tolerance every few days, and a nicely sedated person can wake up with a bang. JCAHO (accrediting body for health care facilities) doesn't want people deemed to be alert and oriented restrained (soft wrist restraints made with cloth and velcro with long straps that tie to the bedframe so that the person can't reach medical devices--it really does sound awful), but orientation can change quickly, maybe they weren't so oriented, or they suddenly decide they don't like that tube anymore....
For the roamers, especially on general units, what is done to prevent falls or the pulling out of equipment? The people that decide to walk to the bathroom and forget that they haven't actually walked for a few years? Or the one that keeps pulling a nasogastric tube out?
The research I've read has found that restraints do not prevent falls, and many unplanned extubations occur while the patient's are restrained. Because it has always been the norm for me, I'm working at getting my mind wrapped around a new standard. And, I'm the one that's going to be trying to influence the rest of the staff to believe that restraint minimization is possible and preferred!
I'm amazed at your answers, and will be sharing the with my coworkers. Please tell me more, Michele

In ICU we nurse 1:1 so there will be a nurse present at the bedside all of the time to manage patients who may pull. On the wards that I cover if we have a patient who is assessed as high risk of fall and have already fallen or is confused then we special them on a 1:1 with an unqualified member of staff as well.

It's not perfect as it is sometime difficult to predict which patients will need increased care but it's one way of managing

[sofaraway04]

Originally Posted by mnono009

For the roamers, especially on general units, what is done to prevent falls or the pulling out of equipment? The people that decide to walk to the bathroom and forget that they haven't actually walked for a few years? Or the one that keeps pulling a nasogastric tube out?

We put another in, and again and again. We have a guy who 99% of the time is fine and just lays there, but every other day decides he doesn't like his NG or venflon and pulls them out.
once had someone pull his NG out when on one to one, the HCA tried to stop him but this guy was too strong.

where i used to work we had a line of chairs opposite the nurses station where we sat the fallers so they could be kept an eye on, it did work i don't recall any pateint ever falling there. where i work now that wouldn't be practical there is no space. sometimes we get a one to one, but we have to have permission because of cost and sometimes the shifts don't get filled.

Where i used to work (elderly rehab), we had to get permission from the patient and the family to use the seat belt on wheelchairs. I've seen handling belts used before to strap patients in (harder to undo than a seatbelt) but it's not good practice and would be considered restraint.

[sharrie]

Originally Posted by sofaraway04

We put another in, and again and again. We have a guy who 99% of the time is fine and just lays there, but every other day decides he doesn't like his NG or venflon and pulls them out.
once had someone pull his NG out when on one to one, the HCA tried to stop him but this guy was too strong.

where i used to work we had a line of chairs opposite the nurses station where we sat the fallers so they could be kept an eye on, it did work i don't recall any pateint ever falling there. where i work now that wouldn't be practical there is no space. sometimes we get a one to one, but we have to have permission because of cost and sometimes the shifts don't get filled.
.

As a senior nurse I always authorise extra staff for patients such as this, if they aren't filled then we go out to security to act as a sitter, they security officers always jump at the chance to work overtime and are excellent with the elderly confused patients.

I love our security officers

[ayla2004]

i have seen restraint used on a stepdown nhdu to a neurosugerical ward. however these were gloves made out of a surgical pad and a bandage she had been persitently removing the ng, venflons and tring for the trachy we abandoned this restaint after two days it was too disgtressing she was up and mobile