After Applying Medical Restraints To A Combative Patient You Should

Applying medical restraints to a combative patient is a serious intervention that should only be used as a last resort when all other de-escalation techniques have failed and the patient poses an immediate danger to themselves or others. Restraints are not a substitute for good communication, empathy, and appropriate medical management. This article will delve into the crucial steps that must be taken after medical restraints have been applied to a combative patient, emphasizing patient safety, monitoring, and the ethical considerations involved.

Initial Steps Immediately After Restraint Application

The immediate aftermath of applying medical restraints is critical. The focus shifts from the act of restraint itself to ensuring the patient's safety and well-being.

• Immediate Medical Assessment: A physician or qualified healthcare provider must conduct a thorough assessment immediately after the restraints are applied. This assessment should include:
  • Vital Signs: Heart rate, blood pressure, respiratory rate, temperature, and oxygen saturation should be checked and documented. These vital signs provide a baseline for ongoing monitoring.
  • Circulation: Assess the patient's extremities for adequate circulation. Check for pulse, skin color, and temperature in the restrained limbs.
  • Skin Integrity: Examine the skin under and around the restraints to ensure they are not too tight and causing pressure or skin breakdown.
  • Neurological Status: Evaluate the patient's level of consciousness, orientation, and any signs of neurological compromise.
  • Respiratory Status: Observe the patient's breathing pattern and effort. Restraints can, in rare cases, compromise respiratory function, particularly if the patient is in a prone position or has underlying respiratory issues.
• Documentation is Paramount: Meticulous documentation is essential. This includes:
  • The specific reason for applying restraints: Clearly document the behaviors that led to the decision to use restraints. Use objective descriptions (e.g., "patient attempting to strike staff") rather than subjective interpretations (e.g., "patient was aggressive").
  • Alternative de-escalation techniques attempted: Detail all other interventions that were tried before resorting to restraints.
  • The type of restraints used: Specify the material and method of restraint (e.g., soft wrist restraints, leather ankle restraints).
  • The time restraints were applied: Accurate timing is crucial for monitoring and eventual removal.
  • The patient's response to restraints: Document the patient's behavior and vital signs immediately after the restraints were applied.
  • The names of staff involved: Record the names of all staff members who participated in the restraint process.
• Positioning for Safety: The patient's position in restraints is critical for preventing complications.
  • Avoid the Prone Position: Never place a patient in a prone (face down) position while restrained. This position significantly increases the risk of positional asphyxia.
  • Elevate the Head of the Bed: If medically appropriate, elevate the head of the bed to improve respiratory function.
  • Ensure Adequate Space: Ensure the patient has adequate space to breathe and move slightly within the restraints.
• Debriefing the Team: After the immediate situation is stabilized, the team involved in the restraint should debrief. This debriefing should focus on:
  • What went well: Identify aspects of the intervention that were effective.
  • What could be improved: Discuss areas where the process could be improved in the future.
  • Emotional Impact: Acknowledge the emotional impact of the situation on the staff involved. Restraining a patient can be stressful and emotionally challenging.

Continuous Monitoring: The Key to Patient Safety

Once the initial steps are completed, continuous monitoring is crucial to ensure the patient's safety and well-being while in restraints.

• Frequent Vital Sign Checks: Vital signs should be monitored and documented at least every 15 minutes for the first hour, and then every 30 minutes to an hour thereafter, or more frequently if clinically indicated.
• Circulation Checks: Assess circulation in the restrained extremities at least every 15 minutes. Check for pulse, skin color, temperature, and edema.
• Skin Integrity Checks: Regularly inspect the skin under and around the restraints for signs of pressure, redness, or breakdown. Reposition the patient and adjust the restraints as needed to relieve pressure.
• Respiratory Monitoring: Continuously monitor the patient's respiratory status. Look for signs of respiratory distress, such as labored breathing, cyanosis, or changes in respiratory rate.
• Behavioral Monitoring: Observe the patient's behavior for any changes. Are they becoming more agitated, or are they calming down? Are they attempting to remove the restraints?
• Hydration and Nutrition: Offer the patient fluids and food as appropriate. Dehydration can exacerbate agitation and confusion.
• Toileting: Provide opportunities for the patient to use the toilet. Maintaining basic hygiene can improve the patient's comfort and cooperation.
• Documentation: All monitoring activities should be meticulously documented, including the time of the assessment, the findings, and any interventions taken.

Addressing the Underlying Cause of Agitation

While restraints may be necessary to manage immediate safety concerns, it is crucial to address the underlying cause of the patient's agitation. Restraints should never be seen as a long-term solution.

• Medical Evaluation: Conduct a thorough medical evaluation to identify any underlying medical conditions that may be contributing to the patient's agitation. This may include:
  • Review of Medications: Review the patient's medication list for any medications that may be causing agitation as a side effect.
  • Laboratory Tests: Order laboratory tests to rule out metabolic imbalances, infections, or other medical conditions.
  • Imaging Studies: Consider imaging studies to rule out neurological problems or other underlying medical issues.
• Psychiatric Evaluation: If a psychiatric condition is suspected, a psychiatric evaluation should be performed. This evaluation may include:
  • Assessment of Mental Status: Assess the patient's mood, thought processes, and perception.
  • Review of Psychiatric History: Review the patient's psychiatric history and any previous treatments.
• Environmental Factors: Assess the patient's environment for any factors that may be contributing to their agitation. This may include:
  • Noise Levels: Reduce noise levels in the patient's environment.
  • Lighting: Adjust the lighting to create a more calming environment.
  • Temperature: Ensure the patient is comfortable with the temperature.
• Communication: Continue to communicate with the patient in a calm and reassuring manner. Explain what is happening and why restraints are being used.

De-escalation Techniques While in Restraints

Even while a patient is in restraints, de-escalation techniques can still be effective.

• Verbal De-escalation: Continue to use verbal de-escalation techniques to calm the patient. Speak in a calm, reassuring tone. Use simple, clear language.
• Empathy: Show empathy for the patient's feelings. Acknowledge that they are likely scared, frustrated, or angry.
• Offer Choices: Whenever possible, offer the patient choices. This can help them feel more in control of the situation. For example, you might offer them a choice of drinks or ask them if they would like the lights dimmed.
• Redirection: Try to redirect the patient's attention to something else. This could involve talking about a pleasant memory or showing them a picture.
• Medication: Consider the use of medication to help calm the patient. Antipsychotics, benzodiazepines, and other medications may be appropriate, depending on the underlying cause of the agitation.

Gradual Release of Restraints

The goal is to remove the restraints as soon as it is safe to do so. The release of restraints should be a gradual process, guided by the patient's behavior and clinical condition.

• Criteria for Release: Establish clear criteria for when the restraints can be removed. These criteria should be based on the patient's behavior, vital signs, and overall clinical condition.
• One Restraint at a Time: Release one restraint at a time, starting with the least restrictive restraint. Observe the patient's reaction after each restraint is removed.
• Constant Monitoring: Continue to monitor the patient closely after the restraints are removed. Be prepared to reapply the restraints if necessary.
• Debriefing with the Patient: After the restraints have been removed, debrief with the patient about the experience. Explain why restraints were used and what they can do to avoid needing them in the future.

Ethical Considerations

The use of restraints raises significant ethical considerations. Healthcare professionals must be aware of these considerations and act in a way that is consistent with ethical principles.

• Autonomy: Respect the patient's autonomy whenever possible. Explain the reasons for using restraints and obtain their consent if they are able to provide it.
• Beneficence: Act in the patient's best interest. The use of restraints should be intended to protect the patient from harm.
• Non-maleficence: Do no harm. Use the least restrictive means necessary to ensure the patient's safety.
• Justice: Treat all patients fairly and equitably. The decision to use restraints should not be based on factors such as race, ethnicity, or socioeconomic status.

Legal Considerations

In addition to ethical considerations, there are also legal considerations related to the use of restraints.

• State Laws and Regulations: Be familiar with the state laws and regulations regarding the use of restraints. These laws may vary from state to state.
• Hospital Policies: Follow hospital policies regarding the use of restraints.
• Documentation: Maintain accurate and complete documentation of the use of restraints. This documentation may be reviewed by regulatory agencies or in the event of litigation.

Training and Education

Proper training and education are essential for healthcare professionals who may be involved in the use of restraints.

• De-escalation Techniques: Healthcare professionals should be trained in de-escalation techniques to help prevent the need for restraints.
• Restraint Application: Healthcare professionals should be trained in the proper techniques for applying restraints.
• Monitoring and Assessment: Healthcare professionals should be trained in how to monitor and assess patients who are in restraints.
• Ethical and Legal Considerations: Healthcare professionals should be educated about the ethical and legal considerations related to the use of restraints.

Special Populations

Certain populations may require special consideration when restraints are used.

• Children: The use of restraints on children should be approached with extreme caution. Children are more vulnerable to the physical and psychological effects of restraints.
• Elderly: Elderly patients may be more susceptible to complications from restraints, such as skin breakdown and respiratory problems.
• Pregnant Women: The use of restraints on pregnant women should be avoided whenever possible. Restraints can pose a risk to the mother and the fetus.
• Patients with Disabilities: Patients with disabilities may have unique needs that must be considered when restraints are used.

Alternatives to Restraints

Whenever possible, alternatives to restraints should be used.

• Environmental Modifications: Modify the patient's environment to reduce the risk of harm. This may involve removing sharp objects, reducing noise levels, or providing a quiet space for the patient to calm down.
• Increased Staffing: Increase staffing levels to provide more supervision and support for the patient.
• Diversion: Use diversion techniques to distract the patient from their agitation. This may involve offering them a favorite activity or talking about a pleasant topic.
• Medication: Consider the use of medication to help calm the patient.

Conclusion

The application of medical restraints is a serious intervention that demands a multifaceted approach after the restraints are in place. The immediate steps of medical assessment, thorough documentation, proper positioning, and team debriefing set the stage for continuous monitoring. Frequent checks of vital signs, circulation, skin integrity, respiratory status, and behavior are essential to ensure patient safety. Simultaneously, addressing the underlying cause of agitation through medical and psychiatric evaluations, environmental adjustments, and clear communication is paramount.

De-escalation techniques should persist even while the patient is restrained, and a gradual release of restraints based on established criteria is the ultimate goal. Ethical and legal considerations must guide every decision, with a focus on patient autonomy, beneficence, non-maleficence, and justice. Healthcare professionals require comprehensive training in de-escalation, restraint application, monitoring, and ethical/legal aspects. Special populations necessitate tailored approaches, and alternatives to restraints should always be explored first. By adhering to these principles, healthcare providers can minimize the risks associated with restraints and provide the best possible care for combative patients.