Do all of your vented pt's get restrained?

Specialties MICU

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Hello all - I was just sitting in a meeting and the question came up about restraints and pt's on vents. One person said that all pt's in the ICU setting on a vent were to be placed into restraints, while another one said it depends on the pt's themselves (i.e. brain function, etc). How about your place? What do you folks do? Also, does anyone know if a protocol has made made addressing this issue (I know that is a very touchy subject with JCHO). Thanks very any help and God Bless you all - Gary

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These same people who JCAHO claims have the 'right' not to be restrained may well extubate themselves and harm themselves in a moment of panic. What is the nurses' liability then? Picture the BON or civil court's take on this: Did the nurse fail to safeguard her patient? Maybe the patient was not reintubated quickly enough (due to time constraint, unavailability of intubator, swollen airway, etc etc) The patient suffered hypoxic brain injury as a result. Guess what...the nurse may be liable for this.

So yes, IMO restraints on an intubated patient ARE a necessity for me. Last week I had a IM doctor claim his intubated patient did not need to be restrained and I badgered him til he wrote the order...out of my concern for my patient and my refusal to accept responsibility for what she might do. Next shift the nurse let her go unrestrained...and guess what?? She extubated herself , had to be reintubated...luckily no apparent harm to her BUT sure could have been.

Most pulmonologists I know have a written protocol that ALL their vented pts must be restrained and I'm glad. Even when sedated some of these patients will awaken suddenly and instinctively grab the tube. The calmest patient may feel panicstricken and start yanking. I would too. Years of experience have taught me this lesson.

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Specializes in CCU (Coronary Care); Clinical Research.

All of our vented patient's are restrained in soft restraints. Most of our vented patient's are on propofol and fentanyl as well as post-anestehsia too as I work in an open heart unit. When we do have longer term vents...I would say that they are also frequently on propofol...It seems that when I float to the ICU the trached patients that are ventilated (not on a t-piece or trach hood) are also restrained. All that being said, if the patient is "with it" I have seen restraints not be used despite mechanical ventilation. I will never forget the man we had with post op...was extubated and then had to be reintubated for respiratory failure...long lung hx to begin with. We eventually weaned off all sedation...(prn stuff of course was ordered...) he would sit up in bed, read the paper, etc all with an et tube...totally with it...it made me nervous to leave him unrestrained but for him it worked...I don't think he wanted to go through another extubation/reintubation...I feel too uncomfortable to leave off the restraints on 99.9% of my patients...I am not into the whole self extubation thing, especially before they are ready...it is my job to keep the patient safe--not to allow them the "right" to self-extubate...I will take off restraints and let the patient stretch their arms or help was up if they can tolerate it and I am right there in the room bathing or something...

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JHUBRAIN said:
Hello all - I was just sitting in a meeting and the question came up about restraints and pt's on vents. One person said that all pt's in the ICU setting on a vent were to be placed into restraints, while another one said it depends on the pt's themselves (i.e. brain function, etc). How about your place? What do you folks do? Also, does anyone know if a protocol has made made addressing this issue (I know that is a very touchy subject with JCHO). Thanks very any help and God Bless you all - Gary

The majority of my patients are on restraints but not all. I have had some patients that can go without.

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We don't physically restrain all vented pts. We use a lot of Propofol or Versed but restraints only get pulled out for the sedation weaning process and then only if they give an indication that they are reaching for the tube. When they are awake and "with it", we'll usually use restraints unless we have both a pt who understands that they cannot pull at the tube and we know that the pt is likely close to extubation anyway. Yes, there are some pts who chew up sedation and still pull at the tube with their toes -- but it is unusual for us to restrain both chemically and physically. Besides...restraint charting is a pain in the behind!

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Specializes in Neuro/Med-Surg/Oncology.

Just a personal anecdote . . .

My MIL has very bad COPD and as her heart weakens from compensating, she winds up with pulmonary edema about once every year to eighteen months. She knows the drill. She calls the ambulance when she gets the rush of heat from her toes up (that's her CO2 skyrocketing)and we meet her at the hosp. She also knows the drill with the vent. While she is unconscious/drugged, she is restrained. When she becomes more alert, they remove them. But . . . . . (unfortunately) this is old hat for her so she knows not to take it out. Her NG tube, on the other hand, was another story. :rolleyes: :chuckle She was fiddling one day with it trying to see where it went and she pulled and pulled and pulled. She wouldn't let them reinsert it. She insisted on solid food. But she knew she was ready. They have her under pretty good control now and she is learning how to pace herself better, so maybe she won't have a repeat for a long time.

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The majority of our vented pt's are restrained, though not all. Lately there has been a push on our unit to not restrain our vented pts if we can help it, which frankly, I get rather uncomfortable with. This all started when we had one of our friendly little "reminders" of JCAHO requirements for full restraint charting (an hour-long class) where we were told that we can't get an order for restraints right when a person gets intubated, because at that point they are sedated with whatever the CRNA/anesthesiologist used to intubate them. So we have to wait for our pts to wake up enough to reach for the tube before we can restrain them... generally depending on what MDs we are dealing with, we also don't have appropriate sedation ordered (that part is getting better). But essentially, trying to get really nit-picky, there are some who practically want to let people extubate themselves before the restraints go on. In my short 2 years of ICU experience, I have seen too many people extubate themselves - some even while restrained - to be comfortable with most of my vented pts unrestrained unless I trust the sedation they're on, especially when I'm off in another pt's room, either my own other pt or just trying to help out the unit.

Here's my personal anecdote - my mom stayed vented about 24 hours after a major surgery a couple years ago. She said after the fact that although she was pretty awake, and knew not to pull the tube, she probably would have extubated herself if restraints had not been on. It seems she must have accidentally gotten lavaged or something, and felt like she was drowning, and naturally panicked and tried to get at what was giving her that feeling.

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I tend to keep my patients restrained until they fully wake up from their anesthesia and can get a feel for their mentality on the ETT.

Some patients don't need to be restrained, and fully understand the consequences of self-extubation.

We have a few CV surgeons that have orders for NO restraints because they feel it compromises the sternum. BUT... according to risk management, no matter what the physician has ordered, we can still restrain patients that are still under anesthesia.

All of the nurses I work with are very good at judging which patients are candiates to leave unrestrained. I personally have never had a patient I left unrestrained, self-extubate. And, I've only have one self-extubation to my name, and that man was restrained.... just super bendable! :)

At any rate.... it's a judgement call where I'm at....

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JHUBRAIN said:
Hello all - I was just sitting in a meeting and the question came up about restraints and pt's on vents. One person said that all pt's in the ICU setting on a vent were to be placed into restraints, while another one said it depends on the pt's themselves (i.e. brain function, etc). How about your place? What do you folks do? Also, does anyone know if a protocol has made made addressing this issue (I know that is a very touchy subject with JCHO). Thanks very any help and God Bless you all - Gary

You have GOT to be kidding!!! Yes, many of our pts. are on Propofol. But I cannot see the sense in tying them down unless they are wild. Then this questions would be appropriate: Doc, if you are not going to extubate them, sedate them. simple. Otherwise, let them wake up, determine their orientation, and see if you can let them be. unless it is a pt with airway precautions, intubation is no biggie. In my mind a dobhoff replacement is MUCH more painful....(of course I'm not the one intubating either!)

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mattsmom81 said:
These same people who JCAHO claims have the 'right' not to be restrained may well extubate themselves and harm themselves in a moment of panic. What is the nurses' liability then? Picture the BON or civil court's take on this: Did the nurse fail to safeguard her patient? Maybe the patient was not reintubated quickly enough (due to time constraint, unavailability of intubator, swollen airway, etc etc) The patient suffered hypoxic brain injury as a result. Guess what...the nurse may be liable for this.

So yes, IMO restraints on an intubated patient ARE a necessity for me. Last week I had a IM doctor claim his intubated patient did not need to be restrained and I badgered him til he wrote the order...out of my concern for my patient and my refusal to accept responsibility for what she might do. Next shift the nurse let her go unrestrained...and guess what?? She extubated herself , had to be reintubated...luckily no apparent harm to her BUT sure could have been.

Most pulmonologists I know have a written protocol that ALL their vented pts must be restrained and I'm glad. Even when sedated some of these patients will awaken suddenly and instinctively grab the tube. The calmest patient may feel panicstricken and start yanking. I would too. Years of experience have taught me this lesson.

I agree with your post 100%.

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It depends on the patient. I have had some patients who are intubated, completely calm, can even sit up in a chair while on the vent. Then again I have had others that are in four points, on propofol, fent, and versed, and still try to reach for the tube. I always try to make a deal with the patient in the beginning of my shift....if they promise not to touch their lines, I won't tie them down. Then I watch really close....most of the time, it actually works. I have had some patients who request to be restrained because they don't think they can remember not to reach for the tube. (Good for them for knowing their limits:-)

If I have a light assignment, I will try my best to leave them unrestrained and watch them closely. I hate to restrain people when I can help remind them not to touch the ETT.

Although when I get a fresh heart from the OR and I get in report that it was a difficult and/or fiberoptic intubation, you bet I restrain them, usually until they are extubated. Just a few weeks ago we had an emergent bedside trach for a person who self-extubated after requiring a fiberoptic intubation to get the tube in in the first place. (The nurse went to lunch and didn't restrain her patient...he woke up in a panic from the anesthetic and immediately reached for what was choking him...the good old ETT). Thankfully, the patient was ok in the long run...just had some extra healing to do.

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Specializes in critical care.

I agree with mattsmom.

It is rare we have a pt who can sit up,read the paper and not self extubate. We do get them . Most of our pts are OD's.They are sedated,restrained,and out of control and some have a sitter. I think the etoh's are the hardest in the group to get down!

Anyhoot, even if you are lucky enough to be 1:1, In the few the moments it takes to help a coworker with a "boost" or whatever other reason you are called away from the pt (break,lunch,code) A patient can do more harm to themselves in those few moments, and the RN is the one in court for failing her duty! The ICU should be a separate entity from the rest of the hospital. We even need an order for 4 side rails now. give me a break! It is getting harder and harder to care for your patients with all the documentation and order chasing we have to do. We are not talking about the little granny that is confused in the TCU and could fall out of bed or wander into some one elses room. We have PA lines,Alines.CVPS,endo tubes,chestubes,cath sheaths. We are talking life support here.In an ideal world when for every second that pt is under observation I could understand no restraints. but that never happens,atleast where I work.

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