Physical Restraint Physical Restraint Reduction for Older Reduction for Older AdultsAdults

Physical Restraint Physical Restraint Reduction for Older Reduction for Older AdultsAdults

ObjectivesObjectives Define physical restraint and describe the Define physical restraint and describe the

characteristics of restraint use.characteristics of restraint use.

Identify the older adults most at risk of Identify the older adults most at risk of being physically restrained.being physically restrained.

Discuss myths and facts about physical Discuss myths and facts about physical restraint use.restraint use.

Discuss the reasons most frequently Discuss the reasons most frequently given by health professionals for using given by health professionals for using physical restraint.physical restraint.

ObjectivesObjectives

Describe morbidity and mortality Describe morbidity and mortality risks associated with physical risks associated with physical restraint.restraint.

Plan the nursing care of older Plan the nursing care of older adults, using restraint-free adults, using restraint-free strategies.strategies.

Explain alternatives to the use of Explain alternatives to the use of physical restraints.physical restraints.

DefinitionsDefinitions

Physical RestraintPhysical Restraint

Any manual method or physical or Any manual method or physical or mechanical device, material or mechanical device, material or equipment attached or adjacent to equipment attached or adjacent to the person’s body that he cannot the person’s body that he cannot remove easily which restricts remove easily which restricts freedom of movement or normal freedom of movement or normal access to one’s body.access to one’s body.

DefinitionsDefinitions

Medical ImmobilizationMedical Immobilization TemporaryTemporary Performance of and recovery from Performance of and recovery from

medical surgical treatmentmedical surgical treatment Surgical positioningSurgical positioning IV arm boardsIV arm boards Bulky dressingBulky dressing

Forensic RestraintForensic Restraint

Types of restraintsTypes of restraints Soft Soft

wrist/anklewrist/ankle Straps/beltsStraps/belts Two- three- or Two- three- or

four-pointfour-point Wheelchair Wheelchair

safety barssafety bars

MittMitt Chairs with Chairs with

lapboardslapboards Beds with Beds with

siderailssiderails BedsheetsBedsheets Vest/jacketVest/jacket

Restraint Use for Older Restraint Use for Older AdultsAdults

Nursing home residents = 15%Nursing home residents = 15% Acute care settings = 6% to 17%Acute care settings = 6% to 17%

IncidenceIncidence 65+ population = 18% to 20%65+ population = 18% to 20% 75+ and older = up to 22%75+ and older = up to 22% Depression, agitation, confusion, Depression, agitation, confusion,

withdrawal, anger = 20% to 50%withdrawal, anger = 20% to 50%

Who are at risk for Who are at risk for restraints?restraints?

Unsteady mobility or history of fallingUnsteady mobility or history of falling Increased severity of illnessIncreased severity of illness Multiple debilitating conditionsMultiple debilitating conditions Cognitive impairmentCognitive impairment Psychiatric conditionsPsychiatric conditions Recent surgical procedureRecent surgical procedure Medical devicesMedical devices

Myths and FactsMyths and Facts

““The old should be restrained The old should be restrained because they are more likely to fall because they are more likely to fall and seriously injure themselves.”and seriously injure themselves.”

““The moral duty to protect from The moral duty to protect from harm requires restraint.”harm requires restraint.”

It doesn’t really bother older It doesn’t really bother older people to be restrained.”people to be restrained.”

““We have to restrain because of We have to restrain because of inadequate staffing.”inadequate staffing.”

Reasons for using Reasons for using restraintsrestraints

Prevent falls and protect the Prevent falls and protect the patient from harmpatient from harm

Prevent interference with medical Prevent interference with medical treatmentstreatments

Protect medical devicesProtect medical devices Decrease legal liability and family Decrease legal liability and family

pressurepressure Control disruptive behaviorControl disruptive behavior

Morbidity and Mortality Morbidity and Mortality RisksRisks

Short Term ComplicationsShort Term Complications HyperthermiaHyperthermia New-onset bowel and bladder incontinence; New-onset bowel and bladder incontinence;

constipationconstipation Decreased appetiteDecreased appetite Pressure ulcersPressure ulcers Muscle weaknessMuscle weakness Injury to nerve and jointsInjury to nerve and joints Increased risk of nosocomial infectionIncreased risk of nosocomial infection Pneumonia and respiratory complicationsPneumonia and respiratory complications

Severe or Permanent Severe or Permanent InjuriesInjuries

Spiraling immobilitySpiraling immobility Risk for strangulationRisk for strangulation Hypoxic encephalopathyHypoxic encephalopathy DeconditioningDeconditioning Death from strangulationDeath from strangulation Psychological Effects: anger, Psychological Effects: anger,

aggressiveness, humiliation, aggressiveness, humiliation, demoralization, depression, low demoralization, depression, low self-worth, social isolationself-worth, social isolation

Restraint Research Restraint Research

““Perception of Restraint Use Perception of Restraint Use Questionnaire” (PRUQ)- revised Questionnaire” (PRUQ)- revised 19981998

““Subjective Experience of Being Subjective Experience of Being Restrained” (SEBR)Restrained” (SEBR)

Available at:Available at:http://www.nursing.upenn.edu/http://www.nursing.upenn.edu/centers/hcgne/H_tools.htmcenters/hcgne/H_tools.htm

Hartford Center of Geriatric Nursing Hartford Center of Geriatric Nursing Excellence Excellence University of Pennsylvania University of Pennsylvania School of Nursing School of Nursing

Available at:Available at:http://www.nursing.upenn.edu/http://www.nursing.upenn.edu/centers/hcgne/H_tools.htmcenters/hcgne/H_tools.htm

Hartford Center of Geriatric Nursing Hartford Center of Geriatric Nursing Excellence Excellence University of Pennsylvania University of Pennsylvania School of Nursing School of Nursing

Restraint-free guidelinesRestraint-free guidelines

Establish restraint-free standardEstablish restraint-free standard

Least restrictive but safest Least restrictive but safest environmentenvironment

Clinically appropriate situations; not Clinically appropriate situations; not “routine”; evaluate patient“routine”; evaluate patient

Rationale must be documented; Rationale must be documented; orders limited in duration to 24-hours.orders limited in duration to 24-hours.

Restraint-free guidelinesRestraint-free guidelines

Monitor for complication every 4 hours Monitor for complication every 4 hours and more frequentlyand more frequently

Educate patient and significant othersEducate patient and significant others

Medicate to mitigate need for restraintsMedicate to mitigate need for restraints

Consider weaning and early extubationConsider weaning and early extubation

Use adaptive equipment for impaired Use adaptive equipment for impaired mobilitymobility

Institute fall prevention strategiesInstitute fall prevention strategies

Restraint-free guidelinesRestraint-free guidelines

Behavioral management strategiesBehavioral management strategies

Modify medical devicesModify medical devices

Include family / surrogatesInclude family / surrogates

Become familiar with statistics and Become familiar with statistics and institutional guidelines, policies and institutional guidelines, policies and procedures; evaluate compliance at unit procedures; evaluate compliance at unit and institutional leveland institutional level

Alternative to restraintsAlternative to restraints Pharmacologic agents (NOT CHEMICAL Pharmacologic agents (NOT CHEMICAL

RESTRAINT) to RESTRAINT) to treat patient’s agitationtreat patient’s agitation

Early identificationEarly identification of source of patient’s of source of patient’s discomfort and agitationdiscomfort and agitation

Increase patient observations - video Increase patient observations - video cameras, move closer to nurses stationcameras, move closer to nurses station

Music and frequent reorientationMusic and frequent reorientation

Allow family greater access; visit Allow family greater access; visit audiotapes of familyaudiotapes of family

Alternatives to restraintsAlternatives to restraints

Alter the environmentAlter the environment Reduce noise levelReduce noise level Turn TV offTurn TV off Use bed exit alarmsUse bed exit alarms Relocate patient near the nurse’s Relocate patient near the nurse’s

stationstation Use family members and sittersUse family members and sitters Lower nurse-to-patient ratioLower nurse-to-patient ratio

SUMMARYSUMMARY Defined physical restraint, medical Defined physical restraint, medical

immobilization, and forensic restraintimmobilization, and forensic restraint Types of restraintsTypes of restraints Who are at risk for being restrainedWho are at risk for being restrained Myths and factsMyths and facts Reasons for restraining patientsReasons for restraining patients Morbidity and mortalityMorbidity and mortality Guidelines and strategies in promoting a Guidelines and strategies in promoting a

restraint-free environmentrestraint-free environment