From the Guidelines
You can renew the bilateral upper extremity wrist restraint order for this patient and add mittens, as this combination will provide better protection against accidental chest tube dislodgement, which could lead to serious complications such as pneumothorax, subcutaneous emphysema, or respiratory distress. The use of physical restraints, including wrist restraints and mittens, is a common practice in the ICU setting to prevent self-extubation and medical device removal, although it is essential to weigh the risks and benefits of this practice 1. According to the clinical practice guidelines for the prevention and management of pain, agitation/sedation, delirium, immobility, and sleep disruption in adult patients in the ICU, physical restraints are frequently used for critically ill adults, but their use should be closely monitored due to the potential for unintended consequences, such as increased agitation and unplanned extubations 1.
When implementing these restraints, it is crucial to:
- Document the clinical justification (risk of chest tube removal)
- Perform and document regular assessments (typically every 2 hours) to check circulation, skin integrity, and continued need for restraints
- Use restraints as a last resort after trying less restrictive alternatives
- Renew orders typically every 24 hours according to most hospital policies
- Ensure the patient and family understand the reason for the restraints and mittens to maintain dignity and therapeutic relationship
It is also important to note that the levels of agitation and sedation of intubated patients have been shown to be associated with unintentional extubation, and patients with better levels of consciousness are at increased risk for unintentional extubation 1. Therefore, it is essential to closely monitor the patient's level of consciousness and adjust the restraint strategy accordingly.
From the Research
Patient Care and Restraints
- The patient has BUE wrist restraints and a chest tube, but is still able to grab and pull the chest tube 2.
- The use of physical restraints, such as wrist restraints, is a common practice in intensive care units (ICUs) to prevent patient-initiated device removal 2.
- However, evidence suggests that physical restraints are associated with adverse physical, emotional, and psychological sequelae and do not consistently prevent ICU patient-initiated device removal 2.
Chest Tube Management
- The management of chest tubes is crucial in patients with thoracic trauma or pneumothorax 3, 4, 5.
- The insertion of chest drains has a high complication rate, and incorrect positioning of the tube is the most common complication 3.
- The use of small-bore chest tubes (e.g., 14 French) is recommended for stable patients, while unstable patients should receive a large-bore drain (24 French or larger) 3.
Renewing Orders and Adding Mittens
- There is no direct evidence to support the renewal of orders for BUE wrist restraints or the addition of mittens specifically for patients with chest tubes 3, 4, 5, 2, 6.
- However, the use of physical restraints, such as mittens, may be considered as part of a comprehensive approach to prevent patient-initiated device removal, but this should be done with caution and careful consideration of the potential risks and benefits 2.