RestraintsDementia.PDBUUG%sRCH1DTGP@ @ B@ @ @ 65@ 8 @ 9 @ 9@ 9i 9u@ 9@ Nd-. t       VX VV WWVV.&. 6 HXBv *nwx~vv. xx"#!! "". dd $ee4f rJ`p   EFDD "EE2uu HvvXwxn r~ %%  ,, !!  !!PERMISSION is hereby granted to reproduce, post, download, and/or distribute this material for not-for-profit educational purposes only, provided The Hartford Institute for Geriatric Nursing, Division of Nursing, New York University is cited as the source. This material may be downloaded and/or distributed in electronic format, including PDA format. Available on the internet at www.hartfordign.org. E-mail notification of usage to: hartford.ign@nyu.edu.!!!!6o*!!  W 5  , q,M` _ <RBSbr   r  f!+!d "" $## 4 #$D##R## brTry This Dementia Series Volume 1, Number 1, Summer 2003 Series Editor: Cora Zembrzuski, APRN, MSN, CS, PhD (c) Avoiding Restraints In Patients with Dementia By Valerie T. Cotter, MSN, CRNP &Lois K. Evans, DNSc, RN, FAAN WHY: Use of physical restraints in older adults is associated with poor outcomes: functional decline decreased peripheral circulation cardiovascular stress incontinence muscle atrophy pressure ulcers infections, agitation social isolation psychiatric morbidity serious injuries and death. Older adults with dementia have the highest risk of all patients for being restrained when hospitalized. Impaired memory, judgment, and comprehension contribute to the difficulty these patients have in adapting to the hospital. Patients may feel lost and afraid, and try to escape or resist care, yet language deficits associated with dementia limit their ability to clearly express these concerns. Brain damage associated with dementia also places these patients at risk for delirium or acute confusional state, further increasing disorientation and confusion. TARGET POPULATION: Older adults admitted directly from home, nursing home or other non-hospital setting. At particular risk for restraint use are patients whose behavior (agitation, confusion, exiting the bed unassisted) is judged to be unsafe, i.e., contributing to falls and interfering with treatment and medical devices. BEST PRACTICE: Best practice supports individualized care that permits nursing the person safely and without physical or chemical restraint. There is no single instrument to assess the meaning of behavioral communication in hospitalized older adults with dementia. Knowledge about the patients usual behavior and function is critical to individualizing care. Standardized screening of cognition and to detect delirium should be done at admission and periodically (See Try This: Mini Mental State Exam; Confusion Assessment Method). ASSESS COMMUNICATION AND BASELINE BEHAVIORS; ASSESS RESTRAINT RISK Assess the message in the pts behavior Ask the patient what she/he needs: Many patients with dementia can still communicate needs. Consult knowledgeable others: Ascertain patients personal and medical history, typical communication style, behavior, daily routines, and abilities. Assess for unmet needs and behavioral changes: Use increased confusion and agitation to trigger assessment for changes in the pts health status Assess for hunger, fatigue, sleep qperiodically; Use any change from baseline to trigger further assessment Screen for cognitive function (e.g., Mini Mental State Exam-MMSE), delirium (e.g., Confusion Assessment Method-CAM), and mobility and transfer performance (ADLs). See The Hartford Institute for Geriatric Nursing website at hartford.ign@nyu.edu Assess behavior that places a patient at risk for restraint use: Fall risk; restraints do not prevent falls or fall-related injuries In catheters or mask, ventilators) Agitation, restlessness, bed exits USEFUL INTERVENTIONS TO PREVENT AND RESPOND TO PATIENT BEHAVIORS Match specific interventions to the individual patient and his/her needs Communicate clearly, slowly, calmly: Face the patient; always call the patient by the preferred name; use gestures; relax and smile Remove bedside rails or use only half rails; remove restraints Understand the patients reason for attempting bed exit: Most often, it is a need to toilet. Anticipate and meet needs by individualized elimination routine based on the patients history. Attend to bed safety: Lower height, alarms, bed-boundary markers, trapeze or transfer enabler. Remember, an alarm system is merely an alert for a potential emergency. Identify all patients on each shift that have bed alarms. Attend to chair and wheelchair safety: Use portable chair alarms Protect against falls and injuries Provide night light in bathroom, Preserve function with daily weight-bearing, comfortable seating, ambulation devices at the bedside, Provide non-skid slippers, Place fall risk alert on the bed or door frame, Be especially alert at change of shift times Modify the immediate environment, Reduce excessive noise and activity (TV off unless patient requests), Provide for interaction with and visualization of and by others, Provide appropriate light levels, Remove confusing art or other objects Provide surveillance: Move patient closer to nursing station or to a room with a window to the hallway; use monitors Reassess need for invasive treatment devices, Use the Least Invasive Method to Deliver Care, Repeatedly use verbal explanation, guided exploration and a mirror: Help the patient understand what is in place and why. Provide comfort care to the site: Oral/nasal care, anchoring of tubing. Use camouflage: Clothing or elastic sleeves, temporary air splint, Provide diversionary activities: Something to hold and squeeze; favorite music in a headset, Discontinue invasive treatments as early as possible. Provide for familiarity: Encourage use of family photographs, favorite personal mementos, audiotapes of family members. Assign the same staff to the extent possible. Encourage family and familiar others to participate in care: Frequent visiting, ADL assistance, and remaining at the bedside around the clock for 1-2 days post admission and/or during the evening. Strive for consistency of personnel, normal function and usual routines, e.g., toileting, eating, and personal hygiene care ORGANIZATIONAL STRUCTURE TO SUPPORT RESTRAINT-FREE CARE Establish a Restraint Reduction committee Review the organizations mission statement, policies; assure committed leadership Use geriatric advanced practice nurses, physicians, and interdisciplinary team consultation for complex patient presentations Provide staff education; consistent staff assignment; access to supportive equipment; technology to support reliable admission data and communication of care strategies Review pain evaluation and treatment protocols Test patient interventions through continuous quality improvement (CQI) REFERENCES: Capezuti, E., Talerico, K.A., Cochran, I., Becker, H., Strumpf, N., & Evans, L. (1999). Individualized interventions to prevent bed-related falls and reduce siderail use. Journal of Gerontological Nursing, 25(11), 26-34. DeProspero, P., & Bocchino, N.L. (1999). Restraint-free care: Is it possible? American Journal of Nursing, 99(10), 26-33. Strumpf, N.E., Robinson, J.P., Wagner, J.S., & Evans, L.K. (1998). Restraint-free care, New York: Springer. Sullivan-Marx, E.M. (2001). Achieving restraint-free care of acutely confused older adults. Journal of Gerontological Nursing, 27(4), 56-61. PERMISSION is hereby granted to reproduce, post, download, and/or distribute this material for not-for-profit educational purposes only, provided The Hartford Institute for Geriatric Nursing, Division of Nursing, New York University is cited as the source. This material may be downloaded and/or distributed in electronic format, including PDA format. Available on the internet at www.hartfordign.org. E-mail notification of usage to: hartford.ign@nyu.edu. 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