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  1. 1. ‫الرحمن‬ ‫ا‬ ‫بسم‬ ‫الرحيم‬
  2. 2. Restrain Dr. Safaa Hussein Ali Lecturer of geriatric medicine Ain Shams university Cairo – Egypt Senior registrar of geriatric medicine Prince Mansour military hospital Taif-KSA
  3. 3. Restraint Definition • Physical Restraint • Chemical Restraint • Emergency Chemical Sedation
  4. 4. Medico-Legal Questions • Does the patient need to be restrained? • Which is safer, chemical or physical restraint? • How do I minimize my medical and legal risk in these cases?
  5. 5. Restraint Definition • More subtle restraints may also be employed, for example removing walking aids from an individuals reach, or ensuring that the environmental temperature in certain areas within care settings discourages loitering. The application of electronic tagging devices can alert staff to the movement of an individual out of a desired area and thus enables their apprehension. Chemical restraint of individuals may be achieved by the use of sedative medications, on either a short or long term basis.•
  6. 6. Definition Seclusion • Involuntary confinement of the patient alone in a room or an area where the patient is physically prevented from leaving. Does not include confinement on a locked unit where the patient is with others. May only be used for the management of violent or self destructive behavior.
  7. 7. INDIVIDUAL AUTONOMY • While the foregoing measures breach individual autonomy, that is; the right to make ones own decisions, then the justification in health and social care settings is usually that restraint is in the service users best interest (the ethical principle of beneficence) and/or is carried out in order to prevent the individual coming to harm (the principle of non-maleficence). If a further rationale is provided, it may be that, while autonomy is a prima facie principle (that is, at first sight appears to be one that should be upheld), it is predicated upon an individual having insight into the consequences of their actions.
  8. 8. TYPES OF PHYSICAL RESTRAINTS • Physical restraints include: Straps, Vests, Mitts, seat belts, side rails, and beds with high padded walls usually used for seizure patients.•• Restraints also include casts, range of motion machines and any medical device where the patient’s movement is restricted if the patient can’t free themselves from the device.
  11. 11. Chemical Restraints • include: Drugs such as Valium, Xanax, Ativan, & Versed or any drug that reduces the patient’s level of consciousness or impairs the patients motor function.•
  12. 12. ENVIORNMENTAL RESTRAINTS • An environmental restraint is anything that prevents a patient from obtaining clothing, car keys, walkers, canes and other devices used for mobility. Confining a patient in a locked room. Certain behavior modifications, for example refusing the patient access to something or preventing the patient from leaving their room or facility because of anger issues or displaying “clinical” behavior. An angry outburst could be construed as “clinical” thus restricting the patient for a day outing or even leaving their room.
  13. 13. THE PROBLEM WITH RESTRAINTS • Restraints just cause more problems than they prevent and is also a major legal risk as well. Both physical an chemical restraints lead to falls, soft tissue skin injuries, problems with circulation, neurologic and orthopedic impairment from nerve damage and fractures. Environmental restraints can cause patient injury when the patient tries to remove themselves from the restraint. For example, if a patient with post-op knee surgery is using a range of motion machine and tries to remove the device, they may fall when trying to use the bathroom. They may not call for assistance for fear inadequacy or they may feel a loss of dignity.•
  14. 14. The Legal Risks of Restraints• • The patient may be harmed physically and emotionally. The problem with using restraints is that it opens up a whole plethora of legal issues in a way that violates the patients rights, and can also lead to charges of false imprisonment, at the same time failure to use restraints when they are indicated may violate the nurse practice act as well. When using restraints you need to understand how to document properly and accurately as it shows that you have followed the correct procedure when using restraints on patients.
  15. 15. How to Document for Restraints•
  16. 16. How to Document for Restraints• • First off, you should do a head to toe assessment of the patient and do a cognitive assessment as well, this will show that you are aware of the patients current condition-if changes occur after restraints it will show that you took the appropriate steps in documentation and will give a clear “before and after” picture. • • Restraints should only be used as a last resort, not just because a patient is ventilated or combative there are other measures that can be used instead of restraints.
  17. 17. Alternatives to Restraints • When restraining a patient it is always a good idea to consult with another colleague in this matter. For instance a consult with a physical therapist may yield alternatives such as:• Using a different or special bed, keeping the call light easily within reach, using an alarm bed that sound when the patient tries to leave unsupervised and frequent physical and cognitive assessments. If restraints are your only alternative you should discuss it with the family or guardian and know your facilities policy and procedures. EXCEPT in an extreme emergency-you must get a physician’s order and informed consent to apply restraints
  18. 18. The Physician’s Restraint Order • Hospitals and Facilities have orders that must comply with the Joint Commission Guidelines on restraint use. The order states the type of restraint to use such as a vest, soft wrist, or leather. • The order should also include when to apply it, duration, and frequency of assessment during restraint. • Restrained patients should be kept close to a nurses station with the door open so you can see and hear what’s happening. • Although facilities vary in protocol the usual is to check every 15 minutes. Circulation, skin integrity, motion and sensation need to be assessed and documented. You should check your previous shifts documentation to make sure they are following protocol.
  19. 19. Assessment During Restraints
  20. 20. Assessment During Restraints • This case demonstrates if you restrain a patient in an emergency, your documentation should show the same detailed attention. • Always document why such an intervention took place, the name of the physician you spoke with, the orders you received, and your reflected actins. • Your documentation must show that your patient received competent care. • You must also obtain informed consent, this reduces your legal exposure but know that informed consent can be revoked at any time either in writing or verbally. Document that you provided both patient and family about the use of restraints, their purpose, and duration of time. Be thorough as possible.
  21. 21. A Checklist for Restraints Charting • Follow your facilities P&P for restraint use. If you don’t have one a good rule is to check the patient and document these things every hour: type of restraint, reason for restraint, patient and family education with documentation, patient position, skin condition in pressure areas, circulation of extremities, re-application of restraints if needed, other safety precautions in effect, BR assistance, help with eating and drinking, reevaluate the need for restraints, observation there are no breathing restrictions.
  22. 22. Chemical restraints • Chemical restraints include "any drug that is used for discipline or convenience and not required to treat medical symptoms."'
  23. 23. Psychotropic Medications • Antidepressant Medications • Antipsychotic Medications • Mood Stabilizers • Anxiolytic Medications (counteract or diminish anxiety) • Sedative-Hypnotic Medications** (sleep inducers)
  24. 24. Consequences of Chemical Restraint • Increased Fall Risk • Orthostatic/Postural Hypotension • Memory Impairment • Functional Decline • Agitation • Withdrawal • Sedation • Movement Disorders
  25. 25. Gradual Dose Reduction • For drugs in the sedative-hypnotic • class, a gradual dose reduction is recommended at • least three times within six months before concluding that a gradual dose reduction is clinically contraindicated • Antipsychotic and antidepressant • medications require gradual dose reduction, but no time period is suggested
  26. 26. Case One • 26 year old male in booking. Drunk and probably intoxicated on other substances. He is running his head into the wall.
  27. 27. Medical and Legal Risk 1. Do nothing! 2. Tie him into a restraint chair for several hours 3. Emergency Chemical Sedation
  28. 28. • Chemical Sedation is safer than Prolonged Physical Restraint • Chemical Sedation does carry risk. • Do the benefits outweigh the risks? • How do the risks compare to physical restraint?
  29. 29. Chemical Sedation is safer than Prolonged Physical Restraint • Injuries Common in Physical Restrain, both to the patient and staff. • Death has occurred. • Injuries uncommon in Chemical sedation. • Deaths very rare.
  30. 30. Minimizing Legal Risk • Right Patient • Right Medication • Right Documentation • Conforms to established protocol • Physician Order
  31. 31. Right Patient • Acute Danger to self or others • The danger is immediate and apparent • Other treatment modalities did not work • The patient should refuse voluntary sedation • NOT to be used as a disciplinary measure
  32. 32. Right Agent--Antipsychotics • Haloperidol 5-20mg IM. Overall Best Agent • Other Possibilities • Droperidol. • Ziprosidone (Geodon) • Olanzapine (Zyprexa)
  33. 33. Antipsychotics Advantages • No Respiratory depression. • Safe, safe, safe. • “How much Haldol can you safely give IV push?”
  34. 34. Antipsychotic Potential Adverse Event • QT prolongation • Dysrhythmia exceedingly rare • Seizure threshold • Controversial • Neuroleptic Malignant Syndrome • Exceedingly rare • Dystonia. • Common but trivial
  35. 35. Right Agent • Benzodiazepines • Lorazepam 2-4mg IM. Best Agent. • Other possibilities: • Midazolam • Diazepam
  36. 36. Lorazepam--Advantages • “Antidote” to stimulant overdose • Works well in concert with Haldol • Recommended for use in children
  37. 37. Lorazepam--Disadvantages • Respiratory depression • Hypotension
  38. 38. Documentation • Need for Emergency Sedation • No reversible medical conditions • Refusal of less invasive alternatives • Physician order • Medication(s) given • Safe Onset of sedation • Retrospective review
  40. 40. Rethink Restraints • Patients who are restrained do fall and may sustain more serious injury because part of their body is tied to the bed or because they fall from a greater height after climbing up and over a side rail. • Patients have died as a result of being suspended from beds or chairs by straps or vest restraints, and by being entrapped in side rails.
  41. 41. Rethink Restraints • The risk of patients injuring themselves, sometimes fatally while becoming agitated and trying to escape from their restraints, is real.
  42. 42. Rethink Restraints • Restrained individuals often feel humiliated. They may become depressed, withdrawn or agitated when freedom of movement is taken away from them.
  43. 43. Rethink Restraints • Restraints pose special risks for people who are agitated, or who may fall while attempting to escape their restraints.
  44. 44. Identify alternatives • Physiologic cares, such as attention to comfort, pain relief, positioning, oral feedings in lieu of intravenous or enteral nutrition. • Close observation by staff (i.e. moving them to a room by the nurse’s station). • Environmental manipulation, such as increased light or presence of accessible call light or other means of communication.
  45. 45. Identify alternatives • Personal strengthening and rehabilitation program. • Use of “personal assistance” devices such as hearing aids, visual aids and mobility device. Use of positioning devices such as geri-chair, body and seat cushion.
  46. 46. Identify alternatives • Efforts to design a safer physical environment, including the removal of obstacles that impede movement, placement of objects and furniture in familiar places, lower beds, use of bed alarms and adequate lighting.
  47. 47. Conclusion • Determine that there is a valid need to restrain the patient. • Consider your legal and ethical obligations, and realize that an individual shouldn't have his or her movement restricted simply for the caregivers convenience. • Contact the patients physician, and get an order for the use of restraints. • Decide which type of restraint is most appropriate for the situation. Use the least-restrictive device you can.
  48. 48. Conclusion • Check on restrained patients at least every 15 minutes. Remove the restraint at least every two hours to check for skin irritation and proper blood circulation. • Get a new order from a physician if the patient needs to be restrained the following day. • By law, a doctors order for restraints expires after 24 hours.
  49. 49. Safe restrain
  50. 50. Nursing How To : Tie A Half-Bow Knot