Do all of your vented pt's get restrained?

[JHUBRAIN]

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

[KR]

Out of all the hospitals I have worked at, 5, none of them have had a protocol for restraining vented patients. I, myself do not automatically restrain a vented patient. If the patient is lucid, awake, and calm I leave them unrestrained. So far this has worked for me. 5 years of ICU and no unplanned extubations. Hope this helps.

Kimberly

[shopgal, RN]

I work on a Long-Term Vent unit and so because we are "long-term" we are considered under nsg home guidelines and so we not only can't use restraints, we can't even have siderails! Most of my pts are paralyzed in some way and it's just safer to at least have SRs. Anyway, I think that sometimes the restraints are necessary, we have pts that are wild and until you get ahold of the doc to sedate and get the meds from pharmacy, blah, blah, sometimes they need restrained. I had a pt pull his trach in that time and he coded and we lost him. I know that at the hosp. which is through the double doors, they have policy that they can only be on for 20 min at a time, but I think that part of those laws may vary state to state.

[*PICURN*]

Interesting......ours are not restrained, but definately sedated w/Versed and/or paralyzed with Vec

[RoxanRN]

I work in a Neuro Critical Care Unit. We have restraint protocols available to us as needed. It is intended for "protective immobilization" or "fall risk" or both. All our vented patients start out restrained until we determine their motor capability. We only remove the restraint(s) if there is absolutely ZERO movement to an extremity - even with painful stim (usually from a CVA with great involvement of the motor strip or high c-spine injury). Being in an ICU or ER makes it much easier to restrain (including all side rails all the time without orders needed) when it comes to JACHO requirements due to the amount of equipment potentially attached to the patient and the potential of the patient doing greater harm to themselves if they were not in place.

Someone commented about using posies, wrist restaints and mittens, but not all at the same time.....while not common, we do occasionally have patients (usually non-vented) who end up in 5-point restraint (posey + 4 limbs) - and some even with wrist AND mittens - they have a history of getting out of the mittens and going for their lines (just some added security). However, most of the time, when it gets to this point, we can talk the doctor into some sort of sedation (unless it's the Trauma residents - then we are just SOL)

Just

Roxan

[danamobile]

In my unit, we have restraints ordered prn with admission. Restraints are used to patient safety. period. Its a nurse judgement call

[ZASHAGALKA, RN]

danamobile said:

in my unit, we have restraints ordered prn with admission. restraints are used to patient safety. period. its a nurse judgement call

"PRN" restraint orders is a JCAHO violation. Either you need them, or you don't. They can only be ordered if justified, not, "as needed". JCAHO has a big problem with the concept of PRN restraints.

That being said, we restrain 95% of our vent patients with soft wrists. The only patients we don't restrain have such profound neurological injuries (e.g. anoxic) that they couldn't reach up to pull on their tubes in any case.

~faith,

Timothy.

[meandragonbrett]

Yes we restrain our vented patients unless they are heads and aren't moving.

[Creamsoda, ASN, RN]

When I first started in ICU, I worked in a smaller community hospital, and they were pretty strict regarding restraints. We needed to have an order written daily, and if there was no order, the charge nurse was usually pretty nervous about letting us put them on because "we dont have an order". Because of this rediculous policy, I had a patient who self extubated himself. Yes nursing is 1:1, but it takes them 2 seconds to yank it where it takes me 6 seconds to get there, and by that time it is already too late. They also didnt like using sedation freqently either so that just made it worse.

Now I work in a large ICU and was so surprised when I started. 99% of people who are tubed are restrained, and they are much more liberal with continous sedation. Most of my patients are restrained, but there are the odd few who dont need to be. Recently we had an older lady, probably early 60's, and she had surgery amd was a pretty long wean. She was totally alert and with it, she would sit up in bed, cross her legs and read the paper. She didnt need to be restrained. I had another patient not too long ago, post op (about 6 hrs) for GI surgery, was very obtunded, would barely respond, could barely open his eyes, needed pretty vigorous stimulation. He had been restrained on the prev. shift-our patients are guilty untill proven innocent, and only then will we trust them. Anway, I was in the room with him, just finished his bath, literally turned my back for 2 seconds and he had extubated himself. He had managed to grab the inline suction which I left too close for him to reach. Unfortunately, this was about 2200 at night, so the intensevists were gone, and the resident was on the floor intubating someone to bring to us. Luckily it wasnt long before he was came back, cuz the guy needed to be reintubated. (our RT's could intubate if needed).

Long story short, i almost always restrain, and keep that inline out of reach!

[angelladyclaire]

Wow. I work in the SICU/trauma overflow of a level 1 trauma center. We have the luxury of having someone in house at all times to do intubations. We never restrain our vent patients unless they have given us reason to. Administration is really adamant about having an order within 1 hour of application and renewing orders daily. The paperwork in our unit is a major deterrant for using restraints unless absolutely necessary. I've never had a patient self extubate, although it does happen on our unit at times. I've never even heard of a blanket policy to restrain all vented patients...:penguin:

[XB9S, BSN, MSN, EdD, RN, APN]

I worked for 10 years in ICU in various UK hospitals and we never restrained patients. In all those years I never had a patient self extubate, although we do 1 to 1 our ITU patients so if a patient was aggitated then you sit at the side of the bed and hold thier hands and reassure them. When you need to do observations or draw up drugs then ask the float nurse for assistance.

[criticalcarenurse93]

We have a largecombination intensive care unit. We have neuro, cv surgery, pulmonary, medical, surgical, cardiac patients.....we do them all. It is common practice in our unit to restrain ALL vented patients. This is the preference of our pulmonalogists.

Recently, I had an incident with a doctor that wrote a DC order for the restraints of a particular vented patient. He was not the attending and not the pulmonalogist. I told him to forget it! I refused to follow his orders. This did not go over well with him......but my responsibility is to keep my patients safe! My manager was not very supportive of my decision......but I know I did the right thing for my patient. The attending pulmonalogist stood up for me.....and believe me, the other doctor does not write DC restraint orders any more!!

We document patient and family teaching, re: rationale for use of restraints while intubated and have preprinted restraints orders for use in critical care to protect ETT, etc.

The only time I take the restraints off is if I feel the patient will fly if she accidently self-extubates.....and this is rare since we extubate asap.

[RRT2RN2CRNA]

If they are tubed, they have soft restraints on. Period.

Even the calmest looking pt who indicates he understands not to pull tubes or lines can pull his tube and cause hurt himself. Sometimes they just suddenly panic, and reason goes out the window. Maybe they cough and feel the vent pressuring or something and they just get a fright.

And you know how hard it is to re-tube some of these people? The airway is sometimes very swollen from the trauma, and trying to get a tube down there after a bad self-extubation is difficult. Now you've got a sick patient, with no airway. And he's panicking- so now he's tachy, hypertensive and desatting.... not what you want to see in a pt.

If the pt has had open chest or abdominal surgery, we also watch that the pt isn't pulling against the restraints too frequently, because this causes increase in intra-thoracic and abdominal pressures and you can actually pull at internal surgical closures and damage the surgical site. In those cases, they are also sedated heavily enough so they don't pull.

And if you're comfortable enough that your pt will be ok even if he happens to self-extubate... you kinda have to think, why is he intubated at all then?

You have to make sure though that if the family is coming in to visit, you warn them about the restraints and make sure they understand that it's for the pt's own good and the kind of damage that can be done by self-extubation and pulling out invasive lines. This should also explained before the procedure so they know what to expect after surgery. Usually as long as the pt and family are educated, I've never had them give me a problem.

RRT2RN2CRNA