Speaking of restraints.....

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Specializes in Anesthesia.

I was just perusing the thread re: RN extubation, and reading several posters comments about restraints for intubated patients. The hospital I work at has recently become soooooo uptight about restraints that we no longer can use the soft wrist restraints like we used to. For instance, I'm in a CTS ICU and our fresh hearts come up to us still sedated and completely out. One of the first things we used to do after hooking up all their lines and initial assessment was to apply bilateral soft wrist restraints, because you just know that when this patient suddenly comes around, and you have your back turned for a second, the first thing they want to reach for is that ETT and the second thing is the swan. Very, very dangerous. We always prefered to let them wake up first, know that they were not flipping out, see that they could follow requests, and then do a trial release. The docs even to this day sign a restraint order right off the bat when the patient arrives on the unit. Well, now this is a big no-no. Even though we were previously told that restraints were acceptable for post-anesthesia recovery, now everything has changed. There is this hospital wide push to avoid even soft wrist restraints at just about any cost.

I just hold this mantra dear: Never trust an intubated patient. In fact, I want to write the following directions in my living will: If for any reason I should ever require intubation or the placement of invasive lines such as a swan, please, for the love of God, tie my *** down. Please do not allow me to self-extubate or pull out some huge line risking all sorts of life threatening complications because you as my nurse or the hospital policy and procedure gurus have decided that it looks kind of cruel to restrain my arms to protect my airway and life.

Anyway, how are other hospitals handling the restraints issue in relation to inubated patients, and what are your feelings about it?

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I agree :) When the patient lacks the requisite mental capacity that would prevent him from self injury or harm to others, then the use of the least restrictive device is appropriate. Document, document.

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Specializes in Neurology, Neurosurgerical & Trauma ICU.

Gee RNLou, I thought it was bad when my hospital started making us get a daily restraint order sheet signed! Up until about 6 months ago, we used to be able to fill out only one and that was good for the length of stay in our ICU.

Our situation is just slightly different because our patients are neuro and REALLY have no clue what's going on sometimes, but still, an intubated patient is still an intubated patient!!! The first thing we're always taught is to protect the airway, at all costs!

Teehee...you should have seen a coworker and myself trying to hold down a 6'0", 200# (solid muscle) man who was intubated because he OD'd. I had only untied him momentarily for repositioning (isn't that always the case), when he suddenly woke up, for the first time! She was literally laying on the floor trying to hold his one hand down while I tried to hold his upper body so he couldn't bend down to his hand. All I have to say is thank god for propofol and the ability to bolus as needed! LOL

I think I'm gonna add that request to my living will too! LOL Along with the one that if you can get three attending docs to agree that I will never have a meaningful life again (completely independent), then pull the darn plug!!!

Take care!

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Well hopefully we are gonna have the right to die eventually. Right now with our health care system you are allowed to be tortured by your loved ones for at least 10 years. Against your pre-written beliefs and requests too.

Socialized medicine is looking better every day.

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Your average British nurse will read this restraint stuff with incredulity, as any kind of mechanical patient restraint, other than handcuffs on a prisoner, is a no-no. We had a huge fuss some years back when a pregnant prisoner was handcuffed to the couch during the delivery of her child, despite having two female prison officers escorting her!

I once obtained a Posey catalog, with pics of leather/sheepskins cuffs, nets to restrain the elderly and even childrens' straitjackets! On showing it to my colleagues, their first reaction was invariably to ask if it was a spoof. I'm not saying it is wrong, just so totally different.

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Specializes in CCU (Coronary Care); Clinical Research.

We restrain all of our intubated patients...it is, of course, a case by case basis and if we have a patient that we are in the room with, can monitor, or can trust due to no sedation (is: long term vents/trachs) then they go without. I think, especially post op surgery (I am most familiar post-op cardiac sx) that the restraints are necessary. Who knows how or when the patient will wake up. You just can't be at a patients bedside at all times. The first thing someone wants to do when they wake up with meds still hanging on is go for the et tube/swan/CT...you know the picture...how is being unrestrained safe for the patient? Think of all that can hapen when even just one of those things gets pulled out by a patient...bad scene...We do have to fill out restraint slips that are good for 24 hours and document Q2 hr checks with soft restraints...

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What happens when the patient is being injured by the equipment that you're supposed to be protecting him with? Or when the patient tries to tell you that he/she is in distress and can't because you have their hands tied down and their throats jammed with a tube?

Melinda

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Our vent protocols include restraint protocols, and luckily our pulm docs insist on restraints for intubated patients. I applaud them for standing up and taking responsibility for this. I find the current 'no restraint' push to be a no win situation, because if patients harm themselves unrestrained it is our fault too. Nursing is getting harder and harder because of all these JCAHO, etc. rules and regs. 'Patient rights' have been carried too far, IMO. I suppose there might be somone here who is sure they can always calm down an unsedated unrestrained vent patient who really wants that tube out...but I don't care to take that on personally. I am good at my psychosocial skills but with a typical COPD claustraphobic control freeak, it's pretty much impossible without some form of restraint be it in chemical or physical form.

If someone intubated me and didn't give me something to calm down or protect my airway in some way I would consider that negligent. Course some docs refuse to allow even a tiny bit of sedation (even to help sleep a few hours at night) and I personally feel that is unnecessary and unkind to put it mildly. There are short acting agents that would help the patient rest nicely without ruining the chance for weaning in the am. JMHO. But...can't fight city hall.

We do the best we can.

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Specializes in Anesthesia.
Palpitations said:
What happens when the patient is being injured by the equipment that you're supposed to be protecting him with? Or when the patient tries to tell you that he/she is in distress and can't because you have their hands tied down and their throats jammed with a tube?

Melinda

I absolutely understand and have a respect for the risks of restraint use, Melinda. I also absolutely understand and have a respect for the damage that can be caused to a patient d/t self-extubation or pulling out a swan or other centrally placed line. It is sometimes a damned if you do - damned if you don't situation, but I think you have to pick the lesser of the two evils. I have seen patients self extubate and end up with all sorts of injuries including laryngospasm and laryngedema that caused difficult reintubations, or less immediately life-threatening but still disturbing consequences such as permanent damage to the vocal cords. I have also seen inotrope and vasopressor dependent patients crash and burn when they have ripped out their central access. Pneumothorax and air emboli are just another couple of the life threatening complications that are possible in these situations.

I agree with you mattsmom81. It is often a no win situation from the nursing view point, because when that unrestrained patient pulls something important out, the first person that gets blamed is the nurse for not restraining the patient. *Sigh*

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Specializes in CCU (Coronary Care); Clinical Research.
Palpitations said:
What happens when the patient is being injured by the equipment that you're supposed to be protecting him with? Or when the patient tries to tell you that he/she is in distress and can't because you have their hands tied down and their throats jammed with a tube?

Melinda

Melinda...IMO, I would *HOPE* that the nurse in charge of care for the patient is doing frequent assessments for proper restraint use, patient comfort/pain level/signs of distress. If the patient is intubated, but seems like they are trying to make a point, I will bring out the letter board, try a pen and paper, or untie their hands and have them point/stretch or whatever they need. Unfortunately, sometimes one is too busy to be as adamant about this kind of nursing care...but the main goal is to keep the patient safe and comfortable so they can heal. It is a risk vs. benefit situation. Hopefully, we are doing our job by keeping a close eye on the patient to prevent injuries from the restraint use. I think it is nicer if the patient can be at least a little sedated just for comfort (but this is a case by case basis...). I don't personally know how uncomfortable it is to be intubated, but it doesn't look comfortable, but in my mind having the patient restrained unitl the patient is proven to be safe is important because self extubation or pulling out lines after surgery is a great risk to the patient. It is my feeling that if the patient is on multiple sedative/pain meds or just after surgery that the restraints are necessary for safety.

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I'm not sure what they do in our ICU...am now curious & gonna ask, lol. I work on an Orthopedic floor with lots of med/surg overflow. If someone is at risk for hurting themselves, we can restrain them, call the MD to get a phone order, and then have them sign when they come in. We have to have the order updated every 24 hours as long as the patient is restrained. Restraints are removed every 2 hours and the patient is reassessed.

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