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When a Patient Needs to be Restrained• Let’s first examine the definition of what is a restraint?• The use of restraint in health and social care is controversial, both in legal and moral terms. Restraint is defined in the New Shorter Oxford English Dictionary (1) as the "deprivation or restriction of liberty or freedom of action or movement". Restraint may involve the physical containment of one individual by another person or persons, with or without the use of mechanical aids. It may comprise the use of equipment (for example door locks) to ensure that an individual cannot move out of a prescribed area.
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.•
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.
PATIENT AUTONOMY• This then is used to justify, for example, the restraint of a young child while they are given an injection, or of a vulnerable adult who attempts to leave a care setting. A further principle, however, that must be taken into the equation is that of justice, which may be applied in strictly legal terms, or may include the morality or otherwise of an action or inaction, aside from its legal repercussions.••
PHYSICAL RESTRAINTS• As previously noted restraints not only refer to physical restraining devices but also chemical treatments and environmental interventions that restrict the patients freedom to move.• Restraints are used when:• A patient is at high risk for self harm or is a threat to others. A physician’s order for restraints are placed in the medical record. These orders MUST comply with JCAHO regulations. If not, this can be a case of “battery” nonetheless.
TYPES OF PHYSICAL RESTRAINTS Limb Restraints• Limb restraints are physical restraints that are applied to a persons arms or legs. The application of limb restraints on both arms and legs at once is sometimes known as a four-point restraint.
THE “POSEY” VESTAlbeit not much of a vest, wearing an institutional straitjacket for longperiods of time can be quite painful. Blood tends to pool in the elbows,where swelling may then occur. The hands may become numb fromlack of proper circulation, and due to bone and muscle stiffness theupper arms and shoulders may experience excruciating pain.
TYPES OF RESTRAINTS USED• 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.•• 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.•
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.
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.•
§ 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.
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.
Documentation of the Restrained Patient • Before applying restraints the following needs to be documented: • The Patients skin turgor, bone structure, any existing breaks, tears or bruising noted on the skin and the patient’s ability to call for help. You should also compare the restraint ordered as to the appropriateness. For example, if a vest restraint is ordered for a patient that you know has respiratory distress or shortness of breath- you should question the order and tell the physician. If it comes down to a lawsuit you will be asked Nurse X, why did you put a vest restraint on a patient with known respiratory disease?
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.••
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.
Restraints And The Court• Although restraints are used as a last resort, it is appropriate for some patients at least for a while. In this case example the court concluded that the nursing documentation supported emergency use of restraints to protect an agitated patient.• White v. State of Washington- This case concerns a SNF patient who had become agitated. His history included burning himself with lit cigarettes by putting them in his pant pockets and also had a habit of eating plastic spoons and also scratched himself repeatedly. One day he was more agitated than usual and was becoming a threat to others.
Restraints And The Court• The nursing staff decided to place him in a posey vest to “prevent self harm” so said the nursing notes. The vest was used for a short time while nursing staff contacted the medical director. The MD declined to use the vest and instead ordered medication and had the vest removed. The Medical Director said the posey vest applied by nursing was an appropriate emergency measure but the reevaluated patient plan deemed other measures taken to deal with the agitation. The patient was not injured, nor the facility staff.
The Court Ruling• A former staff member brought suit against the facility for sub-standard care and patient abuse. The Washington Supreme Court noted the nurses temporary use of the vest was promptly reviewed by the Medical Director. The Court ruled that nursing used sound judgment about using physical restraints in an emergency to prevent harm to themselves and the patient. The nurses documentation and rationale for using the restraints where commended by the court and concluded this did not constitute patient abuse.
The Courts Conclusion• The court based its conclusion on two critical points, both of which apply to nursing documentation in emergencies:• The nursing documentation showed they weighed the need for restraints and the patients continued agitation, which failed to subside with more conventional interventions. These observations which the nurses documented, led them to consider the use of the vest.• Second the nurses immediately notified the Medical Director of the situation, documented this fact and then removed the restraints when instructed.
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.
A Checklist for Restraints Charting• When using restraints, things don’t always go as smooth as the case example, thus the need to make sure you document findings during the use of restraints. 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.
Conclusion• Determine that there is a valid need to restrain the patient. Consider your legal and ethical obligations, and realize that an individual shouldnt 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. 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.•••••