NURS 3020 Reflection 2 Melissa Jenkins 1

The Use of Physical and Chemical Restraints on Elderly Patients in Acute Care Settings
Identification
During the week that I was team leader, I helped on of the nurses on the floor care
for an elderly lady who had come to the hospital for a joint replacement after falling at
home. Before coming to the hospital she was living alone and to my knowledge still able to
complete many of the activities of daily living on her own. On caring for the patient I
noticed that she had been flagged as physically and verbally violent and had restraints
attached to her bed. My initial reaction to this discovery was one of curiosity. I wanted to
what events preceded the need to restrain this patient both physically and chemically.
Restraint use in hospitals, like Peterborough Region Health Center (PRHC), is generally a
least restraint policy like the one outlined by the Registered Nurses Association of Ontario
(RNAO)s BPG Promoting safety: Alternative approaches to the use of restraints (2012).
Knowing this approach to restraint use and having little experience in the use of restraints I
wanted to know more about how the decision is made to use restraints, and how the use of
restraints impacts patient outcomes.
Description
Reviewing the patients chart was essential in figuring out why a patient who
seemed like a wonderful little old lady ended up in restraints each night.
Esthetic Knowing
From my review of the chart I came to the conclusion that the patient was exhibiting
sun-downing behaviour that may be due to delirium or dementia. Sun-downing is
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described as when a patient becomes more agitated at night (McGaffigan & Bliwise, 1997).
I attributed this more to delirium than dementia because the chart made no mention of a
diagnosis of dementia and she was living at home alone before being admitted to the
hospital. Delirium is a sudden onset of changes in consciousness and cognitive dysfunction
that is out of the norm for the patient and occurs at the same time as a medical condition
such as surgery (Fricchione et al., 2008). It is common among surgical inpatients and
increases morbidity and mortality (Fricchione et al., 2008).
Personal Knowing
My knowledge of these conditions led me to treat the patient as I would any other
patient. As we were on morning shifts, it was it was unlikely that the patient would be
exhibiting any sun-downing behaviour, but could still be in a delirious state. By treating her
like any other patient I provided safe, competent and ethical care but also hoped not trigger
any agitation.
Also when dealing with this patient throughout the shift I kept thinking about what
it would be like to be this patient. How would I feel to be 90+ years old in an unfamiliar
environment like a hospital, especially if I had previously been living at home? I think I
would be scared and worried that I would not be able to go home again. With this in mind I
felt it very important to treat the patient with respect.
Ethical Knowing
The use of restraints, both chemical and physical is a contentious topic. A lot of
nurses have negative feelings regarding the use of restraints and struggle with patient
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autonomy and their desire to be safe while providing patient care (Chuang & Huang, 2005).
When to use restraints often places nurses in an ethical dilemma that is often guided by
hospital policies (Chuang & Huang, 2005). Following policies that are based on the least
restraint ideal help nurses deal with the ethical and emotional responses to having to apply
restraints knowing that all other methods of controlling an aggressive patient have been
tried (RNAO, 2012; Chuang & Huang, 2005).
Empirical Knowing
Elderly patients in acute care settings are already at risk for psychosocial, physical
and cognitive declined, when restraints are added to the situation they further promote the
decline of functioning but also limit the result of rehabilitation (Mott, Poole, & Kenrick,
2005). Restraints can also potentiate the circumstances that lead to restraint use in the
first place, for example by increasing agitation rather than decreasing it (Mott et al., 2005).
Restraint use like delirium increases the risk of morbidity and mortality among the elderly
inpatient population (Mott et al., 2005).
The use of physical restraints is associated with several negative patient outcomes
such as pressure ulcers and contractures (Mott et al., 2005). Physical restraints hold the
patient immobile limiting their participation in rehabilitation exercises recommended to
patients after joint repair. Patients who are restrained have longer length of stay and are
less likely to be discharged home than patients who are not restrained (Mott et al., 2005).
Chemical restraints may not have the effect that nurses desire and may produce any
number of undesirable adverse effects (Mott et al., 2005).

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Significance & Implication
The use of restraints among patients of any age will be a part of nursing practice
regardless of where you practice. Understanding the ethical considerations as well as the
long term outcomes of patients that are restraint is essential to being able to make
competent decisions when placed in a situation that warrants the consideration of
restraints. This situation allowed me to further explore the use of restraints among the
elderly population and in the acute care setting. It has broadened my understanding and
allowed me to explore my own response to the use of restraints.











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References
Chuang, Y., & Huang, H. (2005). Nurses feelings and thoughts about using physical
restraints on hospitalized older patients. Journal of Clinical Nursing, 16(3), 486-494
Fricchione, G. L., Nejad, S. H., Esses, J. A., Cummings, T. J., Querques, J., Cassem, N. H., &
Murray, G. B. (2008). Postoperative delirium. American Journal of Psychiatry, 165(7), 803-
812
McGaffigan, S., & Bliwise, D. L. (1997). The treatment of sundowning: A selective review of
pharmacological and nonpharmacological studies. Drugs & Aging, 10(1), 10-17
Mott, S., Poole, J., & Kenrick, M. (2005). Physical and chemical restraints in acute care: Their
potential impact on the rehabilitation of older people. International Journal of Nursing
Practice, 11, 95-101
Registered Nurses Association of Ontario. (2012). Promoting safety: Alternative approaches
to the use of restraints. Toronto, ON: Registered Nurses Association of Ontario