| HOME | HELP | FEEDBACK | SUBSCRIPTIONS | ARCHIVE | SEARCH | TABLE OF CONTENTS |
|
|
|
|||||||
|
|||||||||
LETTERS |
I read with interest the article by Chang et al1 in the September 2008 issue. In this retrospective study, the authors viewed the relationship between unplanned extubations and restraints and the contributing risk factors. As a critical care nurse, I have been faced with this problem; whenever a patient self-extubates, health care providers must act quickly. As the authors note, 37% to 57% of these patients must be reintubated within the first hour, and 37% to 57% within 48 hours.
Ideally, the patient’s medical team would be the ones to decide when he or she should be extubated, but whenever a patient self-extubates, there is much concern and self-recrimination by the nurse caring for that patient. The nurse is aware of the many risks involved, such as tearing of the larynx, anoxia, or even death. These concerns could account for the frequent overuse of restraints by nurses in ICUs nationwide. Interestingly, sedation and physical restraints both were used in the study. The amount of sedation used is partly based on nurses’ discretion, which could have influenced the study’s results. Although drugs are not administered without a doctor’s order, some nurses’ use of sedation is heavier than others and based on subjectivity.
Currently we have a no restraint policy in the hospital where I work. However, we are allowed to apply untied mittens to patients’ hands, but only when absolutely necessary. Our first choice is the use of sedation or chemical restraint such as propofol, ativan, and fentanyl. We are asked to use the smallest amount of drugs to achieve our goal of sedation so the patient can be easily aroused.
The authors point out that sedation can reduce the incidence of self-extubation. They also mention that sedation increases the amount of time spent on the ventilator, thereby increasing the probability of unplanned extubation. In the study, restraints led to a higher incidence of nosocomial infections, which led to unplanned extubations.
The authors conclude that we must "develop effective standards for use of physical restraints" to prevent unplanned extubations. However, at our institution, we have been practicing without physical restraints and been doing so successfully. We have been using sitters and family members at the bedside for patients who are extremely agitated to help prevent them from extubating themselves.
Even when patients are intubated, some are capable of understanding what is happening and can be educated about the repercussions of unplanned extubations. Intensive care nurses must be vigilant in assessing their patients’ level of consciousness or anxiety and in using methods other than physical restraint to prevent self-extubation.
FINANCIAL DISCLOSURES
None reported.
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| HOME | HELP | FEEDBACK | SUBSCRIPTIONS | ARCHIVE | SEARCH | TABLE OF CONTENTS |
