Restraints too Tight?

[laxxrickLPN]

I am a first year nursing student and I have a question relating to restraints.

My father had respiratory failure and was on a ventilator in the ICU. When he was there, I noticed everytime I went in his wrist restraints were extremely tight and his hands swelled up horribly and the restraints began to cut his wrists. I loosened them everytime I went there, at least four times.

He was in the hospital more than a month ago, but he still has excruciating hand pain in the wrist that had the restraints on too tight. When he went back to the hospital, they are saying he has carpal tunnel syndrome.

I suggested getting a second opinion, because as tight as those restraints were, and the fact he'd never had a hand problem before he was in ICU last time, I feel that they may be saying CTS because they knew the restraints were too tight for very long periods of time.

My question is, isn't that the responsibility of the nurse to write in the care plan that the restraints need to be loosened so they are not cutting off circulation every so often?

[kmoonshine, RN]

Never touch restraints unless you are directly caring for the patient yourself. Think about it: if the nurse charted that you were observed to be adjusting the restraints, you could have a problem should you decide to claim legal action (it could be perceived that you had altered the restraints and therefore caused nerve damage for monetary gain). I do not doubt that your intentions were only the best, but I'm just playing devil's advocate.

There are many things that can cause wrist-nerve pain. Whether it be the restraints, or even radial ABG draws.

To directly answer your question "Isn't that the responsibility of the nurse to write in the care plan that the restraints need to be loosened so they are not cutting off circulation every so often?", no. Its the responsibility of the nurse to follow the policy and procedure of the facility, in accordance with law, regarding restraint use.

Restraints shouldn't be "loosened", otherwise they would defeat their purpose. Also, when restraints are used properly they don't cut off circulation. Soft-wrist restraints should be snug but the nurse should be able to comfortably fit 1-2 fingers between the restraint and the patients skin. Color, motion, temperature, and sensation must be assessed frequently distal to the site of restraint application. Pulses should be palpable, and capillary refill should be brisk in the fingers. Restraints should also be removed at regular intervals and range-of-motion should be performed on the extremities that are restrained.

[RN1989]

Most family members are not present when pts are struggling against their restraints to try to extubate themselves, pull out a swan/fole/art line. So the family members do not understand how quickly someone's hand and wrist can become swollen with all the struggling.

There is a fine line between restraints tight enough to prevent undesirable behaviors and being too tight.

I have seen pts wake up and go nuts when we all thought that they were under heavy sedation. That kind of situation is a real test of whether the restraints are tight enough to prevent them from hurting themselves.

Your postings ring of someone that is very confident. If you showed such confidence to the nurse while you were readjusting the restraints, it is likely that she merely shined you on instead of dealing with the issue to not cause an argument.

Next time, act a little dumb, ask nice but probing questions, and get more info - you will usually get a better response from the nurse that way. You will also be able to make an informed judgement of what is going on by getting information instead of simply "telling" the nurse something.

[nrsang97, BSN, RN]

restaints. when used, must be loosed enough to allow nurses fingers to easily slide between wrist and restraint

also restraints should be removed every 2/3 hours and patient reacccessed

We aren't allowed to do trial release any more. If you take them off then put them back on you need a new order.

[RN1982]

We don't do trial releases where we work at and I wouldn't do one either way. If the patient has an ET tube or is pulling at lines and devices that are medically needed, the restraints stay on. This whole thread leaves me with a burning question in my mind..Isn't it better to be alive with some wrist/hand pain than the other alternative?

[SFRN]

BIG mistake on your part! Don't ever loosen the restraints on a pt. YOU are not caring for.....let the nurse responsible for the pt. know your concern and that you would like the restraints loosened--he or she may decide to loosen the restraint. How would you feel if someone were loosening restraints on YOUR pt???? I assure you, nursing student or not, you would have been asked to leave the ICU where I work.

I was just mad at the extreme tightness. With a 1-to-1 nurse ratio in the ICU, there was no reason it was ever that tight while I was there. I loosened it myself because while I still only am a nursing student, I have learned how to properly use restraints.

I definitely wanted the restraints on, no doubt about it! He would have extubated (knowing him)!!

[RN1982]

Lax already posted that she/he had the permission from the RN in charge of her father's care and was also observed by the RN. It would be completely different had she done it without the nurse's knowledge or permission.

[woknblues]

Student nurse here.

I was recently in the PICU on a rotation, and received a kid recently intubated/vented. He was not conscious, and really thrashing around q 10 seconds. Here was the problem, and I never figured out what the real story was, the doctors order for restraints didn't come in until 90 minutes later. 90 minutes after I basically had to hold the kid down, though he calmed down more as the time wore on, S-L-O-W-L-Y... Anyways, we got the restraints for his hands, kept them "two finger loose" the whole time, and had no further issues. Quite an eye opening experience.

To address OPs concern, I was 1:1 with him, and I cannot understand how with a ratio like that, that someone could possibly allow a circulation issue to arise. Actually, I don't see how it could at all, unless the pt has a continuous exertion on the restraint (how long can they fight the restraint? I found out. About 90 minutes for an emaciated 10 y.o.)

Besides intact/patent airway, the ONLY thing I would be concerned about next would be breathing rate/quality (vented) and circulation (the restraints). Shame on anyone who cannot follow the ABCs, and is actually working as an ICU nurse.

[RN1982]

In ABCs, the circulation aspect is in regards to whether or not blood is perfusing to vital organs. It has nothing to do with restraints.

[PICNICRN, BSN, RN]

"i was recently in the picu on a rotation, and received a kid recently intubated/vented. he was not conscious, and really thrashing around q 10 seconds. here was the problem, and i never figured out what the real story was, the doctors order for restraints didn't come in until 90 minutes later. 90 minutes after i basically had to hold the kid down,"

wow.... really?? did they not believe in sedation at this picu? an intubated kid needs sedation(drips or bolus) to keep them safe- you would never see any kid in my unit "thrashing" for 90 mins. also, the policy for medical restraints is to keep the pt from harming themselves- you put the restraints on and get the order when the doc comes by in the real world---- remember, we are not talking about "no nos" not 4 point leathers here. every intubated pt who is not paralyzed should have restraints and more inportantly, proper sedation never should you have to "hold a kid down"-- that is just outrageous!!!

[woknblues]

in abcs, the circulation aspect is in regards to whether or not blood is perfusing to vital organs. it has nothing to do with restraints.

http://en.wikipedia.org/wiki/abc_(medical)

well, can i say that circulation has a part in assessment when restraints are too tight? capillary refill, pulse, etc. i think that does have something to do with circulation. http://en.wikipedia.org/wiki/circulatory_system

anywho, not to argue. my point was simply that after the airway and breathing, i can't see how restraints are not maintained safely.

"i was recently in the picu on a rotation, and received a kid recently intubated/vented. he was not conscious, and really thrashing around q 10 seconds. here was the problem, and i never figured out what the real story was, the doctors order for restraints didn't come in until 90 minutes later. 90 minutes after i basically had to hold the kid down,"

wow.... really?? did they not believe in sedation at this picu? an intubated kid needs sedation(drips or bolus) to keep them safe- you would never see any kid in my unit "thrashing" for 90 mins. also, the policy for medical restraints is to keep the pt from harming themselves- you put the restraints on and get the order when the doc comes by in the real world---- remember, we are not talking about "no nos" not 4 point leathers here. every intubated pt who is not paralyzed should have restraints and more inportantly, proper sedation never should you have to "hold a kid down"-- that is just outrageous!!!

like i said, the situation was ugly. just a sn, so i just referred, and did the best i could, which was to ensure the airway and safety. i even "suggested" an anti-anxiety (as i had read is often used to ease pt's bucking the vents), but there was not a lot of movement towards getting much done. thankfully, everything seemed to work out for the kid, he was off the vent and eating by the time the week ended, and i learned some lessons. also, the situation was traumatic, so i might be extending the duration a bit. but it seemed to go forever.

[lpnflorida]

Yes, the nurse should/would be observing circulation and skin condition under the restraint every 2 hours.

Sometimes patients restlessness affects the tightness, swelling of extremities caused by patient's pulling on the restraint. I have seen this multiple times. In which case restraint is reapplied due to the swelling so that one finger can be passed underneath the restraint.

However I can recall a patient that no matter how much we readjusted the restraint, due to his continued causing trauma to tissue by his continued pulling it seemed to be a never ending task. In that case, thankfully they did not have tubes, or lines their were being restrained for. The decison was to just take them off.

Utilizing family members to be with patient's to help them remain calm often times can help.

I am sorry your father has continued pain to his wrists.

[RN1982]

http://en.wikipedia.org/wiki/ABC_(medical)

Well, can I say that circulation has a part in assessment when restraints are too tight? Capillary refill, pulse, etc. I think that does have something to do with circulation. http://en.wikipedia.org/wiki/Circulatory_system

Anywho, not to argue. My point was simply that after the airway and breathing, I can't see how restraints are not maintained safely.

When patients are restrained you are supposed to be assessing capillary refill, pulse etc every two hours. ABC is meant for basic life support. A-airway B-breathing C-circulation (does the patient that you just found in bed unresponsive have a pulse). In the situation you wrote about, of a PICU patient being restless for 90 minutes, that would NEVER happen on my unit. I think it is very cruel to not properly sedate anyone who is intubated.