Physical Restraints Use In Health Care

Afza.Malik GDA

Health Care and Use of Physical Restraints

Physical Restraints Use In Health Care

Physical Restraints,Prevalence of Physical Restrains,Believes About Restrains and nursing Home,When and Where Restrains Needed,Alternative of Restrains ,Nurse Specializing In Restrains,Physical and Psychological Impact of Restrains,Reduce Restrains Use or Make Free from Restrains,Impact of Reduction/Elimination of Restrains,Current Approaches to Retrains,Objection on the Use of Restrains,Monitoring During Restrains,Physiological Variables.

Physical Restraints

    A physical restraint is any device or object attached to or adjacent person's body to a that cannot be removed easily and restricts freedom of movement. Bilateral full-length siderails and some types of furniture are also considered restraints when used to limit movement. 

    Although this entry focuses mainly on physical restraints, it is important to keep in mind that these devices are often used in conjunction with psychopharmacologic drugs. 

    When such drugs are given for the purposes of discipline or convenience and are not required to treat specific medical or psychiatric conditions, they are considered chemical restraints.

Prevalence of Physical Restrains

    The prevalence of physical restraints in non-psychiatric settings, estimated in 1989 to affect 500,000 elderly persons daily in hospitals and nursing homes, led many to conclude that a restraint crisis existed.     

High prevalence in the United States was sharply contrasted with what at the time appeared to be lesser use in several countries in Western Europe. 

    The historical antecedents for these differences appeared related to American beliefs that were embedded by the end of the 19th century: restraint use was therapeutically sound, necessary to control troublesome behavior, and prevented tragic accidents and injuries.

Believes About Restrains and nursing Home

    For nearly 100 years those beliefs were largely unchallenged; debate concerning the efficacy of physical restraint was limited, and alternative interventions were rarely considered. 

    The efforts of advocacy groups and committed clinicians, change in nursing home regulation and standards for accreditation of hospitals, warnings from the Food and Drug Administration (FDA), and research demonstrating successful restraint reduction have forced a complete reexamination of their use. 

    Although prevalence has declined in the US. nursing homes to approximately 8.86%, restraint use and the problems associated with it remain a global concern.

When and Where Restrains Needed

    Physical restraints are applied in hospitals and nursing homes primarily for three area sons: fall risk, treatment interference, and behavioral symptoms. 

    To date, no scientific basis of support demonstrates the efficacy of restraints in safeguarding patients from injury, protecting treatment devices, or alleviating such behavioral symptoms as wandering or agitation. 

    Several recent studies, in fact, suggest relationships between physical restraints and falls, serious injuries, or worsened cognitive function ( Capezuti , Strumpf , Evans, Grisso , &Maislin , 1998).

Alternative of Restrains 

    However, health care professionals and other caregivers see few alternatives to restraint use in some situations. Misplaced fears about legal liability, lack of interdisciplinary discussions about decisions to restrain, and staff perceptions about individual behaviors also influence restraint practices. 

    Insufficient staffing levels and the costs of hiring additional employees have long been regarded as obstacles to minimal use of physical restraints. 

    Hospital studies offer indirect links between staffing levels and restraint use by demonstrating that weekend days and night shifts are the most frequent times when restraints are used ( Bourbonniere , Strumpf , Evans, &Maislin , 2001; Whitman, Davidson, Sereika , & Rudy , 2001). 

    Several reports of restraint reduction in nursing homes and one clinical trial show that prevalence of physical restraints can be significantly reduced without increasing serious injuries or hiring more staff (Evans, LK, et al., 1997). 

    Data show that caring for nursing home residents without restraints is less costly than caring for residents who are restrained (Phillips, CD, Hawes, & Fries, 1993).

Nurse Specializing In Restrains

    Hospitals and nursing homes often do not have personnel with expertise in aging or with the requisite skills for assessing and treating clinical problems specific to older adults. 

    Studies provide promising evidence that a model of care using advanced practice nurses specializing in geriatrics can reduce restraint use in nursing homes and hospitals through staff education and consultation (Evans, LK, et al., 1997; Sullivan Marx, Strumpf , Evans , Capezuti , &Maislin , under review).

Physical and Psychological Impact of Restrains

    Continued use of physical restraints is paradoxical in view of mounting knowledge about their considerable ability to do harm. 

    Physical restraints are known to reduce functional capacity and exert physical and psychological effects (Castle &Mor , 1998; Ev - ans , LK, &Strumpf , 1989). Furthermore, restraint use can lead to accidental death by asphyxiation (Miles, SH, & Irvine, 1992). 

    Persons who are likely to be restrained are usually those of advanced age who are physically and mentally frail, prone to injury and confusion, and experiencing, invasive treatments. The evidence is compelling that prolonged physical restraint further contributes to frailty and dysfunction.

Reduce Restrains Use or Make Free from Restrains

    Restraint-free care can be accomplished through implementation of a range of alternative approaches to assessment, prevention, and response to the behaviors routinely leading to restraint. For such practices, however, changes in fundamental philosophy and attitudes among institutions and caregivers must occur. 

    In settings where restraints have been reduced, there is strong emphasis on individualized, person-centered care; normal risk taking; rehabilitation and choice; interdisciplinary team practice; environmental features that support independent, safe functioning: involvement of family and community; and administrative and caregiver sanction and support for change. 

    The presence of professional expertise, particularly expert nurses and physicians with education and skill in geriatrics, is crucial for sustained cultural change.

    Although legislation and other forms of external regulation or control do not in and of themselves change beliefs or entirely alter entrenched practice, the Nursing Home Reform Act, part of the Omnibus Budget Reconciliation Act (OBRA) of 1987 (enacted in 1990), helped to raise standards in nursing homes. 

    The FDA, in response to the known risks of physical restraints and reports of restraint related deaths, mandates that all devices carry a warning label concerning potential hazards.

Impact of Reduction/Elimination of Restrains 

    Following a decade of emphasis on restraint reduction/elimination in nursing homes, clinicians, researchers, and regulators have recently focused attention on these practices in acute care settings. 

    As with nursing homes, the Joint Commission on Accreditation of Healthcare Organizations and the Centers for Medicare and Medicaid Services define restraint use as both physical and chemical. Standards mandate that restraints be used only to improve wellbeing in cases where less restrictive measures have failed to protect the patient or others from harm. 

    In addition, continual individualized assessment and reevaluation of the patient by clinicians and consultation with the patient's own provider must occur with restraint use. Direct care staff must also be trained in proper and safe use of restraining devices.

Current Approaches to Retrains

    Current approaches to restraint reduction vary along a continuum from promotion of restraint free care to an attitude of tolerance for restraint use under certain circumstances. 

    To some extent, successful reduction of physical and chemical restraints in nursing homes underscores the need to achieve the same changes in hospitals, where a disproportionately high incidence of iatrogenesis occurs, much of it exacerbated by the use of physical restraints and adverse reactions to psychoactive drugs . 

    The resulting complications especially delirium, pressure ulcers, infections, and fall related serious injuries can add dramatically to the cost of care by contributing to further loss of function.

Objection on the Use of Restrains

    Although professional organizations in nursing and medicine have endorsed non use of physical restraints and appropriate use of psychoactive drugs as the standard of care in all health care settings, the intensity of debate surrounding physical restraint use in hospitals has escalated ( Maccioli et al., 2003 ).

    Clinicians caring for specialty populations, such as those found in critical care, trauma, neurology and neurosurgery, and hematology/oncology, are confronted with the need to identify, test, and implement interventions that reduce reliance on physical restraints. 

    A standard of least restrictive care will challenge professional caregivers to use comprehensive assessment to make sense of individual behaviors and to employ a range of interventions that enhance physical, psychological, and social function, as well as to acknowledge and affirm the uniqueness and dignity of the old person.

Monitoring During Restrains

    Physiological monitoring is used by nurse scientists to measure biological functioning in living organisms. Generally, it refers to data collected through an interface of technological instrumentation with a living organism. 

    Technological instrumentation can be relatively simple, such as a thermometer, or as complex as combined hemodynamic and clinical laboratory instrumentation used to measure oxygen utilization in the critically ill patient. Physiological monitoring is used to examine both normative functions (eg, homeostasis) and disordered responses (eg, illness and related manifestations). 

    Physiological monitoring occurs in vivo and in vitro, among animal models, in laboratory settings, and in clinical practice areas. Information about physiological parameters promotes understanding about the phenomenon with which nurses are concerned: health supporting and health restoring human responses.

Physiological Variables

    A variety of physiological variables are measured by nurses: 

(a) electrical potentials of the brain, heart, laboring uterus, and muscle

(b) pressures in arteries, veins, lungs, mouth, esophagus, bladder, vagina, uterus, and brain

(c) sound (mechanical) waves in the ear and heart

(d) temperature and the concentration of gases in the lungs and blood

(e) physical symptoms such as size and color of bruising, stool, and wounds

(f) serum levels of hormones, coagulation factors, and molecular proteins that influence local and systemic responses to injury, illness, and infection. 

    The most common physiological measures reported in nursing research are blood pressure, heart rate, weight, and temperature. Monitoring of physiological measures can be either direct or indirect, can be used continuously or at a particular point in time, and can include physical, electronic, and biochemical devices. 

    Physiological monitoring devices are found in the acute care setting, home health care settings, and outpatient and surgical environments and offer a rich data source for clinical research. Research by nurses using physiological monitoring has increased steadily since the 1980s ( Sechrist &Pravikoff , 2002). 

    Increased numbers of nursing scientists are pre-wall with a strong theoretical and experiential base for designing physiological studies. One aspect of their work has been to evaluate the accuracy, selectivity, precision, sensitivity, and error of physiological measures so that reliability and validity are supported. 

    Another important focus of physiological monitoring has been to link physiological responses to patient/client outcomes studies. A third and relatively new area of research is the examination of biomarkers, linking physiological monitoring with cellular and molecular responses to illness and interventions.     

    Examination of changes that occur as a consequence of nursing practice has produced a broad range of research, as evidenced by the variety of physiological studies listed by CINAHL and PubMed in the past 10 years.


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