Physical Restraint Reduction for Older Adults

1. Physical Restraint Reduction for Older Adults

2. Objectives • Define physical restraint and describe the characteristics of restraint use. • Identify the older adults most at risk of being physically restrained. • Discuss myths and facts about physical restraint use. • Discuss the reasons most frequently given by health professionals for using physical restraint.

3. Objectives • Describe morbidity and mortality risks associated with physical restraint. • Plan the nursing care of older adults, using restraint-free strategies. • Explain alternatives to the use of physical restraints.

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

5. Definitions • Medical Immobilization • Temporary • Performance of and recovery from medical surgical treatment • Surgical positioning • IV arm boards • Bulky dressing • Forensic Restraint

6. Types of restraints • Mitt • Chairs with lapboards • Beds with siderails • Bedsheets • Vest/jacket • Soft wrist/ankle • Straps/belts • Two- three- or four-point • Wheelchair safety bars

7. Restraint Use for Older Adults • Nursing home residents = 15% • Acute care settings = 6% to 17% Incidence • 65+ population = 18% to 20% • 75+ and older = up to 22% • Depression, agitation, confusion, withdrawal, anger = 20% to 50%

8. Who are at risk for restraints? • Unsteady mobility or history of falling • Increased severity of illness • Multiple debilitating conditions • Cognitive impairment • Psychiatric conditions • Recent surgical procedure • Medical devices

9. Myths and Facts • “The old should be restrained because they are more likely to fall and seriously injure themselves.” • “The moral duty to protect from harm requires restraint.” • It doesn’t really bother older people to be restrained.” • “We have to restrain because of inadequate staffing.”

10. Reasons for using restraints • Prevent falls and protect the patient from harm • Prevent interference with medical treatments • Protect medical devices • Decrease legal liability and family pressure • Control disruptive behavior

11. Morbidity and Mortality Risks Short Term Complications • Hyperthermia • New-onset bowel and bladder incontinence; constipation • Decreased appetite • Pressure ulcers • Muscle weakness • Injury to nerve and joints • Increased risk of nosocomial infection • Pneumonia and respiratory complications

12. Severe or Permanent Injuries • Spiraling immobility • Risk for strangulation • Hypoxic encephalopathy • Deconditioning • Death from strangulation • Psychological Effects: anger, aggressiveness, humiliation, demoralization, depression, low self-worth, social isolation

13. Restraint Research • “Perception of Restraint Use Questionnaire” (PRUQ)- revised 1998 • “Subjective Experience of Being Restrained” (SEBR)

14. Available at: http://www.nursing.upenn.edu/centers/hcgne/H_tools.htm Hartford Center of Geriatric Nursing Excellence University of Pennsylvania School of Nursing

15. Available at: http://www.nursing.upenn.edu/centers/hcgne/H_tools.htm Hartford Center of Geriatric Nursing Excellence University of Pennsylvania School of Nursing

16. Restraint-free guidelines • Establish restraint-free standard • Least restrictive but safest environment • Clinically appropriate situations; not “routine”; evaluate patient • Rationale must be documented; orders limited in duration to 24-hours.

17. Restraint-free guidelines • Monitor for complication every 4 hours and more frequently • Educate patient and significant others • Medicate to mitigate need for restraints • Consider weaning and early extubation • Use adaptive equipment for impaired mobility • Institute fall prevention strategies

18. Restraint-free guidelines • Behavioral management strategies • Modify medical devices • Include family / surrogates • Become familiar with statistics and institutional guidelines, policies and procedures; evaluate compliance at unit and institutional level

19. Alternative to restraints • Pharmacologic agents (NOT CHEMICAL RESTRAINT) to treat patient’s agitation • Early identification of source of patient’s discomfort and agitation • Increase patient observations - video cameras, move closer to nurses station • Music and frequent reorientation • Allow family greater access; visit audiotapes of family

20. Alternatives to restraints Alter the environment • Reduce noise level • Turn TV off • Use bed exit alarms • Relocate patient near the nurse’s station • Use family members and sitters • Lower nurse-to-patient ratio

21. SUMMARY • Defined physical restraint, medical immobilization, and forensic restraint • Types of restraints • Who are at risk for being restrained • Myths and facts • Reasons for restraining patients • Morbidity and mortality • Guidelines and strategies in promoting a restraint-free environment