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?

[woknblues]

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.

It seems like semantics at this point, considering I agree with your statements and assessment of the situation. I used ABC on my patient, considering he was unconscious, and not capable of experiencing anything beyond physiologic needs. I hope I conveyed my feelings and personal assessment of the situation as not favorable or ideal, and performed as best as my current educational level and training could provide for my client.

[Logan]

Hi,

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'll be blunt (and I'm not doing this to put you down or call you an ill informed idiot or what have you. I sincierly meant that) but,

Most of us nurses can't begin to judge the scenario the OP presented with. The simplest explanation is that "we were not there".

The OP mentioned that s/he: "loosened them everytime I went there, at least four times.'

Now I don't know how many ICUs/ERs you been to - but this is a strict NO-NO. You do not, I repeat, DO NOT; loosen or in any way alter a restraint on a patient.

I don't care if you're a family member, the family doctor, a student nurse with the best intentions or a nurse with 47 years experience - unless you are the nurse or the physician responsible for the patient, you do not mess with the restraints.

Period.

After several posters expressed their shock and doubts regarding the scenario, the OP took his/her time to state that "The nurse was in the room. I told her I was loosening the straps and that they were too tight. I told her I was a nursing student and she observed me loosen it."

This raises several more questions: Was the OP a "Nursing student on rotation in the unit?" If s/he was a nursing student on rotation in the unit, wouldn't the nurse assigned to the pt. already know? Even so, doesn't it seem a bit strange that a nursing student would be assigned to their own parent during clinical rotation? Never mind the fact that s/he was still in their "first year"? When was the last time you saw a 'first year nursing student' assigned to clinicals... much less the ICU?

To me, the big picture says: A first year nursing student found irregularities with the restraints on his/her father when s/he visited him in the ICU. S/he decided to take matters into his/her hands without consulting the nurse on duty (I'm sorry, but I don't buy the whole "The nurse was in the room. I told her I was loosening the straps and that they were too tight. I told her I was a nursing student and she observed me loosen it." story one darned bit).

The pt. might have had complications post ICU stay with his hands - and I won't rule out the fact that grossly incompetent ICU nurses might have overlooked his restraints ... but I find this very unlikely (think about it - was the pt. in restraints for just one shift? Was it the fault of just one nurse?).

But rather than consult their PMD about causation or remidiation, I see a thread here about "restraints too tight".

Uh-huh...

thanks,

Matthew

PS: Using "Wikipedia" for a source is usually not a good idea since it is unsourced information. Just an FYI.

[leslie :-D]

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.

i'm not sure about the cause of swelling.

your dad could have been fluid overloaded anyway.

and, how many times do i wear cotton socks and still can see the indentation betw sock and skin?

that dependent edema can and does occur, even w/o trauma.

but-

starting to cut his wrists?

yes, it sounds too tight and warranted assessment and intervention by the nurse.

i understand your concerns perfectly.

what will be more challenging is narrowing down the etiology of his hand pain.

carpal tunnel, highly unlikely.

but if you really wanted to push the issue, i'm quite sure that any nerve damage could be correlated to the impact of restraints or something else.

i'm glad your dad had an advocate.

leslie

[woknblues]

Hi,

I'll be blunt (and I'm not doing this to put you down or call you an ill informed idiot or what have you. I sincierly meant that) but,

Most of us nurses can't begin to judge the scenario the OP presented with. The simplest explanation is that "we were not there".

The OP mentioned that s/he: "loosened them everytime I went there, at least four times.'

Now I don't know how many ICUs/ERs you been to - but this is a strict NO-NO. You do not, I repeat, DO NOT; loosen or in any way alter a restraint on a patient.

I don't care if you're a family member, the family doctor, a student nurse with the best intentions or a nurse with 47 years experience - unless you are the nurse or the physician responsible for the patient, you do not mess with the restraints.

Period.

After several posters expressed their shock and doubts regarding the scenario, the OP took his/her time to state that "The nurse was in the room. I told her I was loosening the straps and that they were too tight. I told her I was a nursing student and she observed me loosen it."

This raises several more questions: Was the OP a "Nursing student on rotation in the unit?" If s/he was a nursing student on rotation in the unit, wouldn't the nurse assigned to the pt. already know? Even so, doesn't it seem a bit strange that a nursing student would be assigned to their own parent during clinical rotation? Never mind the fact that s/he was still in their "first year"? When was the last time you saw a 'first year nursing student' assigned to clinicals... much less the ICU?

To me, the big picture says: A first year nursing student found irregularities with the restraints on his/her father when s/he visited him in the ICU. S/he decided to take matters into his/her hands without consulting the nurse on duty (I'm sorry, but I don't buy the whole "The nurse was in the room. I told her I was loosening the straps and that they were too tight. I told her I was a nursing student and she observed me loosen it." story one darned bit).

The pt. might have had complications post ICU stay with his hands - and I won't rule out the fact that grossly incompetent ICU nurses might have overlooked his restraints ... but I find this very unlikely (think about it - was the pt. in restraints for just one shift? Was it the fault of just one nurse?).

But rather than consult their PMD about causation or remidiation, I see a thread here about "restraints too tight".

Uh-huh...

thanks,

Matthew

PS: Using "Wikipedia" for a source is usually not a good idea since it is unsourced information. Just an FYI.

Well, just to clear this up for you. I am not the OP. Nor was I making any assertions that she "should have done this or that." As to whether or not I am qualified to judge, well, this is the "internets" my friend, and we are all experts with PhDs here. Actually, all I was doing was relaying a restraint related story that I faced in my own experience as a SN. I mentioned that I would use an ABC assessment if confronted with a patient on a vent, and another member took exception to either the terminology that I used, or the very definition of ABC that I was using. Thanks for the suggestion on sourcing information over the internet. I missed the part in the terms of agreement that state acceptable sources. Also, as you put it, since we are not qualified to judge in any way this scenario, so may I on behalf of anyone who posted in error, thank you whole heartedly for doing it for us, as you obviously possess such qualifications. Good day.

[laxxrickLPN]

UPDATE:

My father has permanent nerve damage in his wrists because of neglect on the nurses part to loosen the restraints to an acceptable level. It has been reported to the Board of Nursing and they are currently conducting an investigation.

The hospital stay has been written off.

[RN1982]

UPDATE:

My father has permanent nerve damage in his wrists because of neglect on the nurses part to loosen the restraints to an acceptable level. It has been reported to the Board of Nursing and they are currently conducting an investigation.

The hospital stay has been written off.

When the investigation is over, please give us an update. Who reported the nurse, you or the hospital?

[RN1989]

Writing off a hospital bill or settling in the face of a lawsuit does not imply any negligence or guilt on the part of the facility. It simply means that the amount of money to write off the bill is cheaper than trying to fight a convoluted case that would take months/years to finally determine an outcome.

It is unfortunate that your father has had longstanding issues after hospitalization. Many bad things happen in healthcare and this may be the case with your father. However since I am not privy to every fact of your father's case, but I do know that you do not have any experience as a licensed nurse - I believe that there is much more that should be examined as your actions as you have stated them were not appropriate and could have exacerbated the problems.

[Altra, BSN, RN]

UPDATE:

My father has permanent nerve damage in his wrists because of neglect on the nurses part to loosen the restraints to an acceptable level. It has been reported to the Board of Nursing and they are currently conducting an investigation.

The hospital stay has been written off.

Seems an unusually quick diagnosis of a "permanent" condition has been made by the patient's physician, as well as an unusually quick determination of definitive cause & effect on the part of one provider, though I am uncertain who has made these determinations.

Enough said.

[ZippyGBR, BSN, RN]

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.

it might in respect of CPR but in the globabl assessment C for circualtion can include the neuro vascular status of an injured ( or forthe left pondians who insist of tying people to beds ) restraints.

oddly enough here in the civilised world tying people to beds is frowned upon in the extreme ...

[icunurse42066]

it might in respect of CPR but in the globabl assessment C for circualtion can include the neuro vascular status of an injured ( or forthe left pondians who insist of tying people to beds ) restraints.

oddly enough here in the civilised world tying people to beds is frowned upon in the extreme ...

I totally agree with the fact of restraints not being used. I personally think that they tend to increase a pt's agitation. However, when it comes to pt safety, I would much rather restrain them than have a fresh post CABG pt extubate themselves or pull out their Swan, etc.... Yes circulation does include neuro/vascular status, however, when you say "the ABC's" to a critical care nurse (ICU, ER, CCU,etc...) then we think "Do they have a pulse?" In a code situation, you don't think "Is the Airway open, are they Breathing, and What is their Cap refill?", but I guess they do in a "civilized" world.

[november17, ASN, RN]

it might in respect of CPR but in the globabl assessment C for circualtion can include the neuro vascular status of an injured ( or forthe left pondians who insist of tying people to beds ) restraints.

oddly enough here in the civilised world tying people to beds is frowned upon in the extreme ...

I suppose you british people are a lot more unflappable and a few kicks to the boat or pillicock by some punter probably wouldn't make you go orifice-about-face.

[leslie :-D]

i would hope that csm would have been part of the nurse's assessment of nv status.

leslie