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Summary: The decision to use or not use restraints must be made with caution and good judgement. Their intended purpose must be to protect either the patient or others who may be injured by the patient including the staff caring for the client. The ultimate determination of necessity is left with the physician. Often, the moment to moment necessity is determined by the nurse. In this case a nurse did not feel restraining the patient was necessary. When an injury occurred, the patient sued.
"Each year, an estimated 2 million people sustain a head injury. About 500,000 to 750,000 head injuries each year are severe enough to require hospitalization. Head injury is most common among males between the ages of 15-24, but can strike, unexpectedly, at any age. Many head injuries are mild, and symptoms usually disappear over time with proper attention. Others are more severe and may result in permanent disability." 2
Following the head injury, the patient was visibly confused and frequently became agitated. During the course of his admission, an order for "soft" wrist restraints was obtained and implemented to protect the patient from injury related to mental status (personality) changes.
"Personality Changes-Apathy and decreased motivation. Emotional lability, irritability, depression. Disinhibition which may result in temper flare-ups, aggression, cursing, lowered frustration tolerance, and inappropriate sexual behavior."2
"What Is Restraint?
"Restraint" is physical force, mechanical devices, chemicals, seclusion, or any other means which unreasonably limit freedom of movement. hospital staff may use four types of restraint to restrict patients who are acting, or threatening to act, in a violent way towards themselves or others.
Physical restraint--holding a patient for over five minutes in order to prevent freedom of movement.
Mechanical restraint--using a device, such as 4-point or full sheet restraint, to restrict a patient's movement (excludes devices prescribed for medical purposes).
She based this decision on her observation of the patient's mental, physical state and level of consciousness. It is common procedure and protocol in facilities for patient's to be released from restraints when the danger of violence is felt to have passed.
"How Long May Restraint Continue?
When an emergency no longer exists, the patient should be released. Thus, staff should release a patient who, upon examination, appears calm. The total time which a patient may be restrained is limited:"3
In the initial trial, the jury was instructed to view the nurse's role as an "error in judgement." Based on this and on testimony on the proper use of restraints, standards of care, the court found for the facility.
The patient appealed.
Questions to be answered:
3. Were the standards of care governing restraint use adequately maintained?
The plaintiff's arguments sought to convince the jury that poor judgement was exercised by the nurse. It was contended that removal of the restraints and ambulation of the patient put him in harm's way.
The purpose of the restraints had not been to "keep the patient from falling out of bed." The removal of the restraints then, could not be deemed as negligent. There was no duty of care breached in allowing the calm patient to remain unrestrained.
The order was in place to ambulate the patient when stable. In the nurse's opinion, the patient was ready. Another nurse may not have agreed with her actions. The patient under a different nurse's care might have been kept in restraints. A nurse could have "held off" on the order to ambulate.
There was no causative relationship between removing the restraints and the patient's fall. In carrying out orders for ambulation, the nurse was providing proper nursing care.
It's not difficult to picture a lone nurse with an unsteady patient losing control and having the patient slip away. Would this be a breach of duty owed to the patient?
One could argue that the nurse had no business trying to move a patient by herself. One might also observe the staffing patterns at the time and realize the nurse was doing "the best she could."
"Historically, conventional wisdom supported using physical restraints, including bed side rails, to "protect and safeguard" residents. Ironically, little documented evidence exists that restraints prevent falls and risk of injury from falls. Clinical studies demonstrate that restraints, conversely, in some instances, precipitate or exacerbate fall risk."4
Both nurses in the above situation would be acting within their scope of practice. Each would be adhering to standards of care.
This was clearly not the case. The actions of the nurse were in good faith and exercised reasonable concern for the well being of the patient. The fact that the patient suffered a fall is unfortunate, and reasonably unforseeable.
It can be compared to the actions of a physician when dealing with an acute patient. Depending on which course of treatment that physician chooses, the patient might or might not have a favorable outcome.
In either case, as long as the physician exercises reasonable judgement based on established principles of practice, a finding of negligence is unlikely.
It has been well established that Medicine is not an exact science. Outcomes are not guaranteed when prescribing courses of treatment.
They are the result of standard medical practices and individual patient responses. These responses are not always predictable. Basically, the caregiver can only hope for the best.
The same principle applies to Nursing care. Regardless of how accurate assessments are and how diligently orders are carried out, patients may or may not experience favorable outcomes.
When outcomes are unfavorable, it is the constitutional right of the patient or patient's estate to sue anyone felt to be involved.
There exists today intense pressure from family members, governmental agencies and regulatory agencies to limit restraint use to "only when absolutely necessary." As soon as they are put in use, the plan of care must include provisions for their removal.
1. RRNL 2 (July 1997)
2. Family Caregivers Alliance Clearinghouse. Revised November 1996. Fact Sheet: Head Injury. Retrieved May 30, 1999 from the World Wide Web: http://www.caregiver.org/factsheets/head_injury.html
3. Mental Health Legal Advisors Committee. No date given. Your Rights in Hospitals Regarding Restraining and Seclusion. Retrieved May 30, 1999 from the World Wide Web: http://www.psychiatry.com/mhlac/basicrights/restraintandseclusion.html
4. Braun, Julie A. & Quish, Clare J. 11/10/98. Illinois Institute for Continuing Legal Education. Physical Restraints And Fall-Related Injuries. Retrieved May 30, 1999 from the World Wide Web: http://www.iicle.com/articles/braun11_10_98b.html
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