“OUTSIDE THE BOX: Restraint Alternatives That Work in Acute Care” Geri Richards Hall, PhD, ARNP, CNS, FAAN, Retired Clinical Professor and Advanced Practice Nur, Behavioral Neurology, University of Iowa, *****************
Purpo: To provide nursing personnel with ideas for alternatives for the least restrictive protective measures that work in acute care ttings.
Objectives:
1.U a decision-making process to asss for the least restrictive alternative to maintain patient safety
2.Asss for altered thought process, developing a trajectory, using a reliable and valid clinical
asssment instrument
3.Describe three interventions for people with confusion
4.List four interventions to prevent falls
5.Describe pain management to prevent picking at wounds
招商活动6.Discuss 3 methods for managing tubes
7.Describe how to prevent scratching
8.Discuss fears about restraint reduction and liability手肌
USING A CLOCK TO PLOT CONFUSION
Step 1: Give the patient a piece of blank paper and a pen
网球教学
Step 2: Instruct the patient to draw a clock and t the hands at 4:30
Step 3: Score the clock as follows (10 possible points):
•Is the clock round and the circle clod? – award one 1 point
•Are all of the numbers prent inside the circle in the right order? -- award 1 point
•Is the center designated? – award 1 point
•Are the hands in the right place? (short hand between 4 & 5; long hand on 6) – award 1 point •Dra
w two perpendicular lines through the clock. Look at the numbers in each quadrant: -Award one point for each of the first 3 quadrants where the numbers are correct
-Award 3 points if the numbers are correct in the last quadrant
Step 4: Label the clock with patient’s name, number and date: Tape to flow sheet to demonstrate changes in level of mentation
AVOIDING RESTRAINTS WITH CONFUSED ADULTS
1.Take a history on all patients. The best predictors of confusion are one or more of the following:
-Age greater than 75 (especially if male or lives alone)
-Renal impairment (Creatinine > 2.0)
-History of confud episode (during hospitalization*) or memory loss
-Cardiopulmonary alterations
-Sensory loss (vision, hearing)
-Anesthesia
2.For patients at high risk
-Q 8 hour & PRN clock-draw asssment
-Check as needed
-Room alone within view of nursing station
-Limit visitors and people (staff) in the room
-No TV, human stimulus only!
-Nightlights in bedroom and bathroom
-Scrupulous pain management
-Bed in low position
-If patient is (or has been) married, line spou’s side of bed with pillows
-
½ side rail at head of bed where patient will get up.
-No lower siderails
-Rest periods alternating with activity throughout the day
-Family available during high risk times
-Have family bring patient’s pillow and familiar items
-Remove/hide tubes (e “tubes”)
-Consistent staff & routine
-Minimize extraneous stimuli
-Glass, hearing aid, dentures on
-Have pur (empty) in bed with patient
-Chair rest during the day
-
廉颇读音Activities
-Avoid re-orientation
平型关大捷时间
-Toilet patient at night consistent with habits at home
-Physical therapy to keep the patient walking throughout the hospitalization
IF THE PATIENT IS CONFUSED…..
Continue the preventive measures and ask yourlf the following:
1.What exactly is the danger to the patient or others?
A.Is the patient agitated or aggressive?
•Treat pain
•Avoid caffeine
•Pharmacologic options
•Time out
•Family stay with patient
•DO NOT REORIENT! It can increa agitation
B.Will the patient climb?
•Bed in low position
•Siderails down
•Shoes on in while in bed provides stability
•Clear path to bathroom
•Bed alarm
•Physical therapy
•Walk with the patient. If the patient walked in, make every effort to let them walk throughout the hospitalization and walk out at discharge
营销策划案•Mattress on floor
•Family to stay with patient round the clock
•Busy boxes, catalogues
•Recliner during day
•Patient at nursing station
•Do not give patient the call bell and expect to call you!
C.What about tubes and wounds?
•Minimize tubes, telemetry, etc whenever possible
•See “Tubes and Wounds”
•Excellent conscientious pain management
•Pharmacologic measures
2.Avoid all unnecessary stimuli
•No TV!
•Take down pictures on wall
•Cover mirrors
•No beepers/cell phones in room
•No vacuum cleaners with patient in room
•Physician rounds with more than one person outside the room
•Minimize night-time care. Schedule blood draws, medications, vital signs, and elimination at the same time to minimize times patient must be awakened.
• A “warm fuzzy” to hold
3.Provide continuity with past
•Reminisce
•Validate
•Have family and familiar items prent
•Do NOT reorient!
4.Monitor physiologic well-being
•Hydration (In & Out; labs)
•Pain
•Renal status
•Respirations (worry if >24; then vs q 1 hour – if trended over four hours consider as indicator of psis)
•Arrhythmias
•Pul oxymetry
•Output
Relocation alone accounts for 37% of acute confusion, therefore consistency and continuity are critical!
“I’VE FALLEN AND I CAN’T GET UP!”:PREVENTING FALLS WITHOUT TIES Asss every patient for risk of falls:
•History of falls**大黄狗
•Incontinence**
•Polypharmacy & substance u**
•Limited mobility*
•Sensory loss*
•Altered mental status**
•Orthostasis (systolic drop >20 mm Hg, systolic and/or >10 mm Hg diastolic after 3-5 minutes standing)*
•Cardiac arrhythmias
•Dizziness or neurologic conditions
•Postural changes
•Anesthesia
*= strong association
Most fallers have more than one risk for falls!
WHEN THE ASSESSMENT SHOWS HIGH RISK, WHAT DO YOU DO?
You intervene by managing the specific risk factors for falling:
1.Walk the patient every opportunity possible! “If the patient walked in, we should make every effort
possible to keep the patient walking throughout the hospitalization.”
2.Physical therapy for walking, upper extremity strength, range of motion to neck
3.Bed in low position
4.Upper side rails only
5.Mattress on floor
6.Bathroom rounds
7.Bed near to bathroom door, run string to bathroom
8.Bed alarm (The best alarm only tells you there is an emergency)
9.Nightlights in bedroom and bathroom
10.Clean up spills
11.Minimize clutter, low stimulus
12.Patient sleeps with shoes on
13.Diversional activities (catalogues, puzzles)
14.Good fluid intake
15.“Detour”
16.Stop sign
17.Black half-rug at door of room
18.Wedge cushions
19.Rubber lace
20.Bolsters, lap buddies
21.Glass, dentures, hearing aides, and toupee on
22.Pur with patient
23.Assistive devices for walking devices nearby
24.Treat pain (no Demerol)
25.Family with patient
26.Minimize medications, especially dating or anticholinergic
27.Provide call bell, but don’t expect much
28.Bed checks, especially in evening and night
29.Understand that very few people spend all day in bed!
30.Kardex and call bell console ID for high risk patients
31.Occupational therapy for endurance
32.Interdisciplinary/multidisciplinary approach
33.Physiatry consultation
34.Minimize distractors (TV, group dining)
WHAT ABOUT LINES, WOUNDS AND TUBES?
1.Pre-operative teaching has shown to be effective in decreasing nervousness about airways and lines
2.Good ongoing mental status asssment
3.Confud people: hide lines:
•Place in an unobtrusive place
•U a topical anesthetic on site
•Overdress
•Run tubing up back so patient does not e it
•If in arm, u double surgical gowns with cuffs to preclude access
•Hand splints if necessary
4.Oriented person, explain lines and ET tubes
•If the patient is oriented and alert, provide a mirror so the patient can e and touch the tubes •Explain what will happen if the tubes are pulled
•Topical anesthetic on site
5.Excellent pain control
6.Remove as soon as humanly possible
7.G tubes – u as small a lumen as possible to minimize irritation, hand splints for confusion
8.Foley catheters
•Men – shave area just above pubis and tape catheter to pubis. NEVER cure Foley catheter to the leg (produces discomfort and can produce a fistula)! Run tubing around back and down the leg to a legbag. Have man wear underpants and pajama pants.
•Women – remove ASAP, Intermittent catheterization
9.Abdominal wounds
•Careful supervision for confud
•Overdress
•Application of an abdominal binder, backwards
•Hand splints if necessary
•Good pain management
-Scheduled regular low do narcotics, No Demerol in aged!
-Supplement with analgesics
-Topical anesthetic to prevent nsations (itching, pulling)
10.Scratching, picking
-Topical anesthetics
-Long sleeves
-
Stockinet
-Dermatology consultation
We have to stop thinking about critical care as a place where we care mainly for the patient’s body and the lines!
WHAT ABOUT AN AIRWAY?
1.Carefully documented mental status asssment
2.Pre-operative (with pictures and tubes) and post-operative education
3.No restraints while staff working with patient!
4.Let patient e and touch tube
5.Opponent hand splints with stockinet
6.Modified soft collar for tracheotomy protection
7.If the patient is lucid, take a deep breath and Let Go while nur in room!
8.Determine what can be done for long-term ventilation
TELEMETRY
1.Hide leads as much as possible洋葱头历险记免费阅读
2.U topical anesthetic
3.Hide box in back of patient
4.Ask “Is the telemetry really necessary?”
5.Have the family prent
“ATTENTION K-MART SHOPPERS!”
