Restraints

Magsulfate, BSN, RN · Feb 24, 2009

There are several different reasons to use soft wrist restraints. One that I can think of and that is used most often is in ICU where you have a vent patient who has altered mental status... or a patient who has several central lines and other lines and tubes that if he pulled them out he might die.

With a VENTILATOR patient, you MUST secure the tube at all times. If the patient is sedated but still wakes up and tries to pull out his tube, it is up to the nurse to determine if soft wrist restraints are the answer. If you can't get a family member to sit at the patient's side and seriously watch their hands, or if you feel like they might try to pull on the tube at any moment, then you must use soft wrist restraints for the safety of the patient, and to keep him from extubating himself.

There is nothing wrong with this and is actually standard practice in most ICU's. Most of the time the patient is on Diprivan and doesn't remember being "tied up" anyway. I have seen too many patients pull out their ET tubes. It is not fun at all. The patient could die. Sometimes when the tube comes out, it is even harder to re intubate the patient due to trauma during the first intubation.

Some hospitals have a restraint free policy on their med/surg floors and I agree with this. As long as the patients can have a one on one sitter, then they should never be tied down just for trying to get oob. Other options besides physical restraints are chemical restraints. Again, most of those are used in the ICU with vent patients. A nurse could also use her nursing judgment and apply a bed alarm to a patient's bed if he is trying to get out of bed just so he can fall on his face. Heck, he doesn't know he's going to fall, he just wants to get up and go feed the chickens! lol

widi96 · Feb 24, 2009

Restraints are used for a variety of reasons, some of which are listed above. The last pt I had to obtain a restraint order for was an elderly individual with sundowners. She was very confused and swinging at staff. It is a huge catch 22 on the fall thing. No we don't want to restrain a pt on the chance they might fall, but at the same point in time - hospitals no longer get reimbursed for any treatment for a pt's injuries if they have fallen, nor does it look good on the hospital. In most cases (not just ICU) I have seen restraints to keep them from pulling out PICC lines, NG tubes, etc.

feralnostalgia · Feb 24, 2009

Heck, he doesn't know he's going to fall, he just wants to get up and go feed the chickens! lol

heh, I see how that could be necessary and I wouldn't have a problem with that.

my grandfather died recently of COPD, and the whole time he HATED being in the hospital. he still died fairly quickly, but spent his last few weeks throwing pillows at nurses and demanding that somebody take him outside so he could see the sun. for a man who was always outdoors in the country, who knew his time had come, being kept in the hospital against his will seemed kind of cruel. my whole family was kind of conflicted about it. I just hope when I get people going through really hard times like that I'll remember my grandfather was probably really nasty to some nurses too, and try to treat them with respect. I'm glad the restraints thing is more about altered mental states...I've heard a lot of stories about tough old country folks who just wanted to be let alone but ended up forced through painful surgeries only to live a month or two in a nursing home, miserable, and then die. I'll probably be refusing medical treatment when I'm that old too...nobody deserves to be cooped up when it won't do them any good.

thanks for the input, I feel better about this now.

taz628, BSN, RN · Feb 24, 2009

Restraints come in various descriptions. Restraining a patient can be as simple as putting all 4 side rails up on a bed. I will typically ask for this order if I have a confused patient at risk for falling out of bed. Whether it be a head trauma or elderly dementia, 4 side rails are my friend in these cases. Much easier to ask for the restraint order than have the pt climb out of bed and crack their head open on the floor!

Beyond 4 side rails, you can place wrist restraints, ankle restraints, and lap belts on a person. All these DO keep a person "tied" in bed, and you could say it's always against the will of the pt, but it IS for their own safety. 99% of the time I'd say the pt is not mentally competant at the time restraints are needed to make an informed decision regarding their care.

Take into consideration a guy named "Fred." Fred was admitted to your unit with a dual diagnosis of Etoh withdrawal and schizophrenia and is, to put it simply, CRAZY. He's fighting with the nurses, constantly forgetting his own abilities, and consequently has managed to climb out of bed and fall multiple times despite the watchful eyes of nursing staff. One night inparticular he's written to have 4 side rails up as an attempt to get into bed. The nurse finishes her assessment, is POSITIVE at that time that he's ok, and leaves the room to see her other patient. As soon as she leaves there is a loud BANG heard from the room. The patient has crawled OVER the foot of the bed and fell flat on his face. Ok, that didn't work, time to restrain his wrists to keep him IN the bed. Great. Except now he's doing a wonderful impression of the exorcist as he's constantly sitting straight up then flopping back in bed. The nurse attempts to calm him, just to have him kick her straight in the sternum. Ok, 4 point restraints now! But he's still flopping around in bed, threatening to harm himself (despite doses of ativan, haldol, and risperdol) so a lap belt was added and IM haldol given.

NOW the patient, AND nursing staff are finally safe. When you get patients like this on an impatient floor (ICU step-down), restraints can be your friend!

nursej22, MSN, RN · Feb 24, 2009

Acute CVA pts with neglect do not realize that they have no motor function on one side of their body. Subsequently, they attempt to stand or walk and boom, down they go. Unfortunately, they often hit their heads on something. Add to this that they may be on anticoagulation for DVT prophylaxis or atrial fib and you are just asking for a head bleed. Or their 80 yo femurs just snap. The sight of an internally rotated, shorted leg is a sickening sight I've never gotten used to. I have also had a patient who fell and fractured a rib, punctured a lung and exsaguinated over the course of several days.

Bed alarms just tell you when they have fallen, just in case you don't hear the crash.

Families stay when they can, but elderly spouses can't be up 24/7, and adult children usually have jobs and/or children to care for. Tough enough to get enough staff for the floor let alone a sitter. So, sometimes a vest restraint is needed to prevent a broken hip or subdural hematoma. I've heard of lower beds and floor cushions, but haven't seen them used.

So which is worse: restraining someone up against their will, at least during the acute phase of their illness, or letting them fall and die?

by_stander22, LPN · Feb 24, 2009

heh, I see how that could be necessary and I wouldn't have a problem with that.
my grandfather died recently of COPD, and the whole time he HATED being in the hospital. he still died fairly quickly, but spent his last few weeks throwing pillows at nurses and demanding that somebody take him outside so he could see the sun. for a man who was always outdoors in the country, who knew his time had come, being kept in the hospital against his will seemed kind of cruel. my whole family was kind of conflicted about it. I just hope when I get people going through really hard times like that I'll remember my grandfather was probably really nasty to some nurses too, and try to treat them with respect. I'm glad the restraints thing is more about altered mental states...I've heard a lot of stories about tough old country folks who just wanted to be let alone but ended up forced through painful surgeries only to live a month or two in a nursing home, miserable, and then die. I'll probably be refusing medical treatment when I'm that old too...nobody deserves to be cooped up when it won't do them any good.
thanks for the input, I feel better about this now.

I want to extend my heartfelt condolences to you and your family. Your family could have requested for a room transfer wherein there are windows and where the sun rises. Was your grandfather on a mechanical ventilator at the time he requested to go outside and see the sun? Taking into account if he's not on a mech vent and he's not contented with the room transfer and he really wants to go out of his room, well, someone in your family could borrow a wheelchair from the nurses station and ask the nurse (if he's/she's not busy) to accompany them to the end 0f the hallway windows where he can see the sun with a portable Oxygen tank attached to him (if needed). As nurses, our responsibility to a dying patient is to respect their dignity for them to have a peaceful death. Granting a simple request of a dying patient leads to a happy death.

DorothyAnn0403 · Feb 24, 2009

I work in LTC and we have 2 "restraints" in use, as considered by our state, out of our 150 beds. Our two lovely ladies have little seat belts on their wheel chairs, because they have a tendency to either slump over in their chairs asleep or try to pick things up off the floor that really arent there! If it weren't for those seat belts, there would be a whole heck of a lot more falls. Our facility also uses low beds with mats for those that have a tendency to just hop out of bed, thinking they have full motor function.

Flare, ASN, BSN · Feb 24, 2009

Restraints is really an umbrella term. While the classic idea of wrist restraints certainly is useful when you simply can't get the one on one sitter and you have the confused patient trying to get out of bed, pulling out his catheter, pulling out iv's, swinging at staff you can also use the simple posey vest simply to keep someone in bed so they won't get up and wander. There are even zip in enclosues that will keep a person in bed by zipping all around the bed. All restraints need an order. Yes, you can apply first and get the order later (ASAP once the issue at hand calms to a managable piont) but they also come with rules like frequent checks, releasing limbs and so on. It's hardly tying someone to a bed and walking away.

Daytonite, BSN, RN · Feb 24, 2009

are we talking about literally strapping someone into bed?

yes.

under what circumstances does this happen?

when they are a danger to themselves or others.

is this talking about making sure someone doesn't fall out of bed accidentally, or keeping someone in bed against their will?

it would be to make sure they don't fall out of bed accidentally or pull equipment out of them that could potentially cause serious injury to them. however, the restraint would only be a last resort. federal laws now required that other interventions be attempted before actually restraining someone.

we used locked leather restraints on violent drunks in the er to prevent them from injuring people. these restraints were removed as soon as these patients calmed down.

i really hope it's the former. are there any circumstances (aside from psych nursing, i assume) where nurses are expected to restrain the unwilling?

no. restraint is used in psychiatric facilities under specific instances where there are rules agreed to by the patient and doctor.

feralnostalgia · Feb 26, 2009

I want to extend my heartfelt condolences to you and your family. Your family could have requested for a room transfer wherein there are windows and where the sun rises. Was your grandfather on a mechanical ventilator at the time he requested to go outside and see the sun? Taking into account if he's not on a mech vent and he's not contented with the room transfer and he really wants to go out of his room, well, someone in your family could borrow a wheelchair from the nurses station and ask the nurse (if he's/she's not busy) to accompany them to the end 0f the hallway windows where he can see the sun with a portable Oxygen tank attached to him (if needed). As nurses, our responsibility to a dying patient is to respect their dignity for them to have a peaceful death. Granting a simple request of a dying patient leads to a happy death.

thanks =)

I'm not sure what kind of ventilator he was on - when we heard he was in the hospital we drove from arkansas to indiana (he has 2 kids and 10 or so grandkids who live in state, and two kids out of state, my mom being one of them) and only got there after they had taken him off the ventilator. by the time we got there to see him he was sleeping peacefully, then we went home for the night while my mom stayed with him, and he died with her there in the room.

before we got there, actually, there was a really nice male nurse who rolled his bed and IV and all that out to a hallway with floor to ceiling glass windows so he could see the sun and the trees for a while, he sat with him there for 10 minutes or so. he was the only one my grandpa didn't throw pillows at, haha.

hearing about how much of a difference he made is also the reason I applied to nursing school.

diane227, LPN, RN · Feb 28, 2009

The use of restraints is regulated by your state department of health and JCAHO. Your hospital will have a policy regarding the use of restraints and you will do yourself a big favor by knowing what this policy requires. There are times when you must use restraints in an emergency and there will be a section on this in your policy. You should never use a restraint device unless absolutely necessary.