Physical restraints must occasionally be used for patients in critical care to prevent potentially seri- ous disruptions in therapy resulting from acciden- tal dislodgment of endotracheal tubes, IV lines, and other invasive therapies; to prevent falls; and to manage disruptive behavior. However, the use of restraints can increase agitation and puts the patient at risk for other potentially serious inju- ries, including falls, fractures, and strangulation. Alternatives to physical restraints must always be sought and tried fi rst (Box 2-9). Standards on phys- ical restraint use are published and monitored by the Joint Commission and the Centers for Medicare and Medicaid Services. These standards are sum- marized in Box 2-10.
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B O X 2 - 9
Alternatives to Physical RestraintsEnvironmental Modifi cations • Keep the bed in the lowest position.
• Minimize the use of side rails to what is needed for positioning.
• Optimize room lighting.
• Activate bed and chair exit alarms where available. • Remove unnecessary furniture or equipment. • Ensure that the bed wheels are locked. • Position the call light within easy reach.
• Ensure that the patient has needed vision and hearing aids.
Therapeutic Interventions
• Frequently assess the need for treatments and discon- tinue lines and catheters at the earliest opportunity. • Orient the patient to invasive medical equipment.
Help the patient explore the equipment by guiding the patient’s hand over it. Explain the purpose of the equipment, as well as the meaning of any alarms that may sound.
• Disguise treatments, if necessary (eg, keep IV solution bags out of the patient’s fi eld of vision, apply a loose stockinette or long-sleeved gown over IV sites).
• Ensure comfort by meeting the patient’s physical needs (eg, frequent toileting, skin care, pain manage- ment, hypoxemia management, positioning). • Mobilize the patient as much as possible.
• Allow the patient to make choices and exert some degree of control when possible.
Diversionary Activities
• Enlist family members or volunteers to provide company and diversion.
• Facilitate solitary diversionary activities (eg, music, videos or television, audio books).
Therapeutic Use of Self • Use calm, reassuring tones.
• Introduce yourself and let the patient know he or she is safe.
• Find an effective method of communicating with intubated or nonverbal patients.
• Reorient patients frequently by explaining treatments, medical devices, care plans, activities, and unfamiliar sounds, noises, or alarms.
B O X 2 - 1 0
Summary of Care StandardsRegarding Physical Restraints
Initiating Restraints
• Restraints require the order of a licensed indepen- dent practitioner who must personally see and evalu- ate the patient within a specifi ed time period. • Restraints are used only as an emergency measure
or after restraint alternatives have failed. (The restraint alternatives that were tried and the patient’s responses to them are documented.)
• Restraints are instituted by staff who are trained and competent to use restraints safely. (A comprehensive training and monitoring program must be in place.) • Restraint orders must be time limited. (A patient must
not be placed in a restraint for longer than 24 hours, with reassessment and documentation of continued need for restraint at more frequent intervals.) • Patients and families are informed about the ratio-
nale for the use of the restraint. Monitoring Patients in Restraints
• The patient’s rights, dignity, and well-being are protected.
• The patient is assessed every 15 minutes by trained and competent staff.
• The assessment and documentation must include evaluation of the patient’s nutrition, hydration, hygiene, elimination, vital signs, circulation, range of motion, injury due to the restraint, physical and psychological comfort, and readiness for discontinu- ance of the restraint.
C A S E S T U D Y
M
s. J. is a 40-year-old pregnant woman whois admitted to the hospital at 34 weeks, 5 days of gestation with complaints of vaginal bleeding, painful contractions, and nausea and vomiting. Until this time, she has received routine prenatal care, and the pregnancy has been uneventful. Before her admission to the hospital, she was eating lunch at work when she felt a “pop” in her abdomen; shortly afterward, her symptoms began. She states that the last time she felt fetal move- ment was earlier in the morning. At the hospital, an external fetal monitor and portable ultrasound detect no fetal heart tones. There is blood in the vaginal vault and no active bleeding, and the cervix is long and closed.
Ms. J. is admitted to the labor and delivery unit with the diagnosis of a fetal death in utero, prob- ably due to an abruption of the placenta, and the plan is to deliver her by induction of labor. Shortly after admission, she complains of increasing pel- vic pressure. Examination reveals that she is fully dilated, and she spontaneously delivers a stillborn male child. Delivery of the placenta, as well as a 250-mL clot, follows, confi rming the diagnosis of placental abruption. Despite administration of med- ications to assist the uterus to contract and control bleeding, Ms. J. begins to bleed steadily. Clinicians decide to perform dilation and curettage (D&C).
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The Patient’s and Family’s Experience With Critical Illness C H A P T E R 2 17
R e f e r e n c e s
1. Curtis R, White D: Practical guidance for evidence based ICU family conference. Chest 134(4):835–843, 2008 2. Borges K, Mello M, David C: Patient families in ICU:
Describing their strategies to face the situation. Crit Care 15:P527, 2011
3. Davidson J, et al.: Clinical practice guidelines for support of family in patient centered intensive care unit: An American College of Critical Care Medicine Task Force 2004–2005. Crit Care Med 35(2):605–622, 2007
4. Miracle V: A closing word: Critical care visitation. Dimens Crit Care Nurs 24(1):48–49, 2005
5. Curtis JR, Patrick DL, Shannon SE, et al.: The family confer- ence as a focus to improve communication about end-of-life care in the intensive care unit: Opportunities for improve- ment. Crit Care Med 29(2 suppl):N26–N33, 2001
6. American Association of Critical-Care Nurses: Family presence during CPR and invasive procedures. Practice alert. Retrieved October 20, 2006, from http://www.aacn. org/AACN/practice Alert.nsf/Files/FP/$fi le/Family%20 Presence%20During%20CPR%2011–2004.pdf
7. Nelson J: Family meetings made simpler: A toolkit for ICU. J Crit Care 24:626e7–627e14, 2009
8. Jansen MPM, Schmitt NA: Family-focused interventions. Crit Care Nurs Clin N Am 15(3):347–354, 2003
9. Dogan O, Ertekin S, Dogan S: Sleep quality in hospitalized patients. J Clin Nurs 14:107–113, 2005
Following the D&C, Ms. J.’s uterus becomes well contracted, bleeding decreases, and coagulation parameters begin to improve. Her estimated blood loss is 8000 mL.
Ms. J. begins to bleed again later that evening and is again transferred to the operating room, where a uterine artery embolization is performed. Ventilation becomes diffi cult, and she is intubated. She is transferred to the critical care unit for closer surveillance, ventilatory support, and fl uid resuscitation. Clinicians make an additional diag- nosis of disseminated intravascular coagulation (DIC). Ms. J.’s husband stays with Ms. J. through- out the night during her fi rst 2 days the critical care unit. On day 3, Ms. J. is extubated and is hemodynamically stable. She is transferred to the progressive care unit after she is weaned from the ventilator.
1. Mr. J. stayed at his wife’s bedside throughout her fi rst 2 days in the critical care unit. How does this demonstrate the critical care staff’s commitment to meeting both the patient’s and the family’s needs?
2. Describe actions the critical care nursing staff can take to ensure that Ms. J. and her husband view this diffi cult time in their lives in the most positive way possible.
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3
I
n the critical care setting, it is always a challengeto meet the educational needs of patients and fami- lies because of the life-threatening nature of criti- cal illness. The nurse must deal with the anxiety and fear that is associated with a diagnosis of critical illness while trying to teach diffi cult concepts in an environment that is poorly suited to learning. In the current healthcare environment, it is not unusual for a patient to be discharged home directly from the critical care unit, placing even greater responsi- bility on the patient and family to provide for com- plex care at home and further increasing the need for adequate patient and family education.