Restraints

Clovery · Feb 5, 2014

It depends on the situation. Chemical restraints are useful if you need to perform a procedure without the patient fighting you, like an ABG draw. They are useful in emergency situations with a very violent or aggressive patient. The problem with chemical restraints is you really can't be sure when they will wear off. So for the average patient who is pulling at lines/tubes/drains, physical restraints are more useful and safe (in my opinion). Of course you want to use the least restrictive restraints possible, like padded mittens vs. wrist restraints. Ideally a one to one patient sitter should be used instead of physical restraints, but some facilities can't afford this from their staffing budget or it pulls a nursing assistant off the floor who would otherwise be performing patient care. However I have had a patient with a sitter, wrist restraints, and chemical restraints still manage to pull out a line. Another problem with chemical restraints is possible interactions with other medications, CNS depression, and interference with physical therapy and family visits. Last week I had a patient who had a benzo PRN for agitation. His daughter was visiting him and I checked in and asked her if he seemed restless or agitated to her and she said no. He appeared calm to me too, and had been fine all day, so I decided not to give him the Ativan I was saving for change of shift because I wanted him to be able to visit with his daughter without being knocked out. 20 minutes later the nursing assistant went to empty his foley and she found him with his midline in his hand. The daughter was still sitting at the bedside. So I had to get an order for mittens so he wouldn't decannulate himself or pull out his PEG tube.

MrChicagoRN, RN · Feb 5, 2014

I hate the term chemical restraints, and made sure it was stated in our policy that we don't do chemical restraints.

Chemical restraints indicates sedating someone to prevent undesirable behavior, and is often used in place of intervening to decrease the inappropriate behavior. It's often been misused in nursing homes.

Medications can be used to decrease anxiety or agitation, or to allow the person to be more in control of their behavior. If their is a legitimate reason to sedate someone for a short period of time, do so. But, it should is not used to "restrain" anyone.

nurseprnRN, BSN, RN · Feb 5, 2014

Medications can be used to decrease anxiety or agitation, or to allow the person to be more in control of their behavior. If their is a legitimate reason to sedate someone for a short period of time, do so. But, it should is not used to "restrain" anyone.

Short-term sedation or meds to help someone "be more in control" for a specific reason-- if it isn't something that is part of pre-medication for a procedure for which the patient has given consent, that IS restraint. Just so we're clear.

And I think you meant "there is a legitimate reason..."

Esme12, ASN, BSN, RN · Feb 6, 2014

Both....use both. There are times a physical restraint is necessary for the patients, and staffs, immediate safety. But never use physical restraint without chemical restraint.

Meds used to behaviorally treat someone is a chemical restraint.

A chemical restraint is a form of medical restraint in which a drug is used to restrict the freedom or movement of a patient or in some cases to sedate a patient.

MrChicagoRN, RN · Feb 6, 2014

Short-term sedation or meds to help someone "be more in control" for a specific reason-- if it isn't something that is part of pre-medication for a procedure for which the patient has given consent, that IS restraint. Just so we're clear.

No, we are not clear.

CMS DEFINITIONS: Physical restraints are any manual method or physical or mechanical device, material, or equipment attached to or adjacent to the resident?s body that the individual cannot remove easily which restricts freedom of movement or normal access to ones body. Chemical restraints are any drug used for discipline or convenience and not required to treat medical symptoms.

also:

"The JCAHO defines chemical restraint as the inappropriate use of a sedating psychotropic drug to manage or control behavior." See more at: http://www.psychiatrictimes.com/articles/use-restraint-and-seclusion-emergency-department#sthash.4tAknS8H.dpuf

http://www.cdph.ca.gov/programs/LnC/Documents/CAHPS-HSAG-White-Paper-Chemical-Restraint-Use-Final.pdf Page 3 describes the expert consensus of describing the use of medications to control psychiatric symptoms should be described as therapeutic treatment not restraints.

And that is why I object to chemical restraints.

Clovery · Feb 6, 2014

Both....use both. There are times a physical restraint is necessary for the patients, and staffs, immediate safety. But never use physical restraint without chemical restraint.

This isn't always true in my (limited) experience. Sometimes patients can't tolerate chemical restraints but need physical restraint. One example I can think of is a patient we've had at our facility long-term. She's generally calm, but in her 90s, confused, vented, and a full code. She constantly plucks off her tele leads and sticks them to her gown. Someone eventually goes in and puts them back on, it's a game we play all day long. Last week she was bradying down and hanging out in the 40s when her HR was normally around 70, with a. fib. I had to get an order for mittens because with a heart rate that low, we couldn't risk having her off the monitor, even for a few minutes. I certainly wasn't going to give her a sedative when her HR was 40.

When you have very confused or demented patients, sometimes they are perfectly calm, even with restraints on. And they will calmly pull their IV/trach/PEG/etc. if they didn't have restraints.

Esme12, ASN, BSN, RN · Feb 6, 2014

This isn't always true in my (limited) experience. Sometimes patients can't tolerate chemical restraints but need physical restraint. One example I can think of is a patient we've had at our facility long-term. She's generally calm, but in her 90s, confused, vented, and a full code. She constantly plucks off her tele leads and sticks them to her gown. Someone eventually goes in and puts them back on, it's a game we play all day long. Last week she was bradying down and hanging out in the 40s when her HR was normally around 70, with a. fib. I had to get an order for mittens because with a heart rate that low, we couldn't risk having her off the monitor, even for a few minutes. I certainly wasn't going to give her a sedative when her HR was 40.
When you have very confused or demented patients, sometimes they are perfectly calm, even with restraints on. And they will calmly pull their IV/trach/PEG/etc. if they didn't have restraints.

I have been a critical care nurse and emergency room nurse for 35 years. I am completely familiar with confused and agitated patients and the use of restraints both chemical and physical.

I'm confused by your statement. How can a patient that is vented not tolerate chemical restraint? Are you fearful of depressing respiration's with the chemical sedation? As far as her heart rate is concerned there are meds that can be given that have little effect on the heart rate. Did anyone consider that there was a possible vagal response to her straining against the restraints?

There has been documented evidence that the physical exhaustion that occurs with fighting the restraint has detrimental effects found that 9 out of 10 patient experience prolonged recovery and effect of their heart rates, 02 sats and other vital signs ...this was observed in "healthy individuals let alone a 90 year old patient. I am also confused why a 90 year old patient is a full code....I feel bad for her.

That being said...there is a difference between behavioral and medically necessary restraints....but they both should be used with something to calm the patient in the presence of agitation to ensure the patients safety. However... Can you imagine being confused with a garden hose shoved in your throat (whether a trach or ETT) machines all around you, tubes shoved in every orifice and then a few man made ones and you are tied down like an animal? That is cruel and inhumane treatment.

She constantly plucks off her tele leads and sticks them to her gown. Someone eventually goes in and puts them back on, it's a game we play all day long.

Really? A game. It is not a game to her...she is confused, frightened, tied up, poked and prodded with THINGS all over her. Maybe the lead burn her skin? maybe they itch? Maybe they pinch her skin and pull when she moves and it removing something that is bothering her. While I understand the necessity to monitor her...you need to try to place yourself in her position...what would od? How would you feel?

I once had a patient extubate himself with his feet with his ETT and tubing secured out of his each with a turban we manufactured to his head in 4 point soft restraints WITH hand mits!!! He still deserved to have sedation to assist with us trying to keep him medically safe without sacrificing his sanity at being tired down, helpless, and frightened.

When I call the police department to help me place and aggressive uncooperative patient in the ED in 4 point leathers....it is once again cruel and inhumane to NOT chemically sedate them until they are able to control themselves.

Esme12, ASN, BSN, RN · Feb 6, 2014

No, we are not clear.
CMS DEFINITIONS: Physical restraints are any manual method or physical or mechanical device, material, or equipment attached to or adjacent to the resident?s body that the individual cannot remove easily which restricts freedom of movement or normal access to ones body. Chemical restraints are any drug used for discipline or convenience and not required to treat medical symptoms.

also:

"The JCAHO defines chemical restraint as the inappropriate use of a sedating psychotropic drug to manage or control behavior." See more at: Use of Restraint and Seclusion in the Emergency Department | Psychiatric Times
http://www.cdph.ca.gov/programs/LnC/Documents/CAHPS-HSAG-White-Paper-Chemical-Restraint-Use-Final.pdf Page 3 describes the expert consensus of describing the use of medications to control psychiatric symptoms should be described as therapeutic treatment not restraints.
And that is why I object to chemical restraints.

Iam confused...again. Maybe it's my age.

If a patient is having an acute psychotic episode you object to administering antipsychotic and sedative meds to help with the current psychosis? I don't view this as discipline nor convenience of the staff....the patient needs the meds to being the situation under control until they can control themselves.

Clovery · Feb 6, 2014

Yes, we all feel terrible that she is a full code. She's been at our facility for 2 years, trach'd and on a vent. The restraints I'm referring to are just padded mitts, so she's not straining against them. We have advocated several times to get an order for her to be without tele monitoring, but her being in a fib and a full code, the docs just won't write that order. Her family member and POA has very unrealistic expectations and thinks mom is a fighter who is going to get up and walk out of there one day. She also does not want her mom sedated at all, and based on her behavior, there's nothing that indicates she needs sedation.

The patient is always very calm, she takes off the leads, sticks them to her gown. We go in and say "That's your heart monitor, you need to keep those on." She smiles and nods and mouths "Oh, okay." We replace the leads and 10 minutes later she's taking them off. They are probably a mild annoyance but her skin is fine... She fiddles with all her wires and tubes. She's probably very bored. I usually go in and put something in her hands. The docs played with her heart meds and got her back up to the 60s so now she is out of the mitts and back to taking the leads off every 20 minutes and pulling the occasional IV.

Esme12, ASN, BSN, RN · Feb 6, 2014

Yes, we all feel terrible that she is a full code. She's been at our facility for 2 years, trach'd and on a vent. The restraints I'm referring to are just padded mitts, so she's not straining against them. We have advocated several times to get an order for her to be without tele monitoring, but her being in a fib and a full code, the docs just won't write that order. Her family member and POA has very unrealistic expectations and thinks mom is a fighter who is going to get up and walk out of there one day. She also does not want her mom sedated at all, and based on her behavior, there's nothing that indicates she needs sedation.
The patient is always very calm, she takes off the leads, sticks them to her gown. We go in and say "That's your heart monitor, you need to keep those on." She smiles and nods and mouths "Oh, okay." We replace the leads and 10 minutes later she's taking them off. They are probably a mild annoyance but her skin is fine... She fiddles with all her wires and tubes. She's probably very bored. I usually go in and put something in her hands. The docs played with her heart meds and got her back up to the 60s so now she is out of the mitts and back to taking the leads off every 20 minutes and pulling the occasional IV.

Poor sweetheart...that actually makes me smile. That daughter really loves her Mom or is paying her back for something...I once again just shake my head. You're right she is probably bored and wants company...frustrating but cute.

MrChicagoRN, RN · Feb 6, 2014

Iam confused...again. Maybe it's my age. If a patient is having an acute psychotic episode you object to administering antipsychotic and sedative meds to help with the current psychosis? I don't view this as discipline nor convenience of the staff....the patient needs the meds to being the situation under control until they can control themselves.

It's only the language that's confusing. Medications need to be given when appropriate, and necessary to treat symptoms.

Old Joe sitting in front of the nurses station, keeps asking for more pudding. He's agitated, yelling, swearing; he may benefit from a low dose anxiolytic. If he's merely being repetitive and the staff snows him "to shut him up", that's not therapeutic, but it is a chemical restraint.

Calm but needy patient? "Mary, if you come up to the desk one more time, You're getting a shot!". Or, she keeps turning the Tv too loud, so you give a shot "because she won't follow the rules." Both cases are non therapeutic chemical restraints.

If someone is acutely psychotic, you treat the psychosis. That's not a case of convenience or discipline. It's intended to induce a therapeutic response. In this case, it's a therapeutic measure, not a restraint.