Restrictive and invasive: Clinical decision making

Nurses aim to provide patient care using methods that are the least restrictive and least invasive as possible, guided by the ethical principle of nonmaleficence, which means “do no harm.”

Restrictive care involves methods that limit a patient's movement; whereas invasive care includes procedures that involve entering the patient's body. Providing the least restrictive and least invasive patient care whenever possible allows nurses to successfully navigate patient needs within various clinical scenarios and is essential for providing safe, quality care and improving patient outcomes.

Alright, now, let's take a closer look at types of restrictive care starting with restraints, which refer to devices used or methods to restrict a patient’s freedom of movement, to prevent them from accessing certain parts of their body, or to alter their behavior. Some common uses include preventing agitated or aggressive patients from harming themselves or others or preventing confused or disoriented patients from interrupting ongoing therapy, like removing medically necessary tubes or catheters.

Restraints can be either physical or chemical. Physical restraints are devices, materials, or equipment that physically restrict movement or the ability to move freely. There are various kinds of physical restraints, including belt and vest restraints, which are used to confine a patient to a bed or chair to prevent them from wandering away or falling. Another example is mitt restraints, applied to the hands, which are often used to prevent patients from scratching at wounds or removing medically necessary devices. Patients can also be restrained by raising all the side rails on a hospital bed to prevent them from getting out of bed without assistance.

On the other hand, chemical restraints are medications, like sedatives or tranquilizers, that are not a standard treatment for a specific condition. Chemical restraints can be used to help calm anxious, agitated, or physically combative patients to protect them and those around them from harm.

Now, laws, standards, and guidelines regulating the use of restraints require that they're used only as a last resort when alternative methods to decrease risks to patient safety and safety of others have been unsuccessful. Some alternatives can include familiarizing patients with their surroundings; assigning a staff member or sitter to stay with the patient; providing diversional activities, like playing cards; and using relaxation techniques, like music therapy.

Other important strategies to help keep patients free from restraints and safe from falls is to use a chair or bed alarm and to routinely address pain, toileting, hydration, and nutrition needs, so patients are less likely to attempt to ambulate unassisted due to unmet physiological needs. To reduce tampering, medical lines and devices can be covered with clothing or stockinettes, which aren’t considered restraints.

When restraints are deemed necessary, the least restrictive type should be used first. For instance, if a patient repeatedly tries to remove their IV despite alternative interventions, mitt restraints should be applied before applying a more restrictive type of restraint.

Finally, when using restraints, nurses must follow legal guidelines and institutional policies for restraint use, monitoring, and documentation. To prevent patient harm, vital signs, mental status, skin integrity, neurovascular status, and range-of-motion, should be frequently monitored. Collaboration among the health care team, patient, and family is also essential to frequently review the need for the restraint and consider when to discontinue the restraint.

Okay, switching gears to invasive care - this involves diagnostic procedures or other methods of care that require entering the body in some way, like through an incision, puncture, or by placing medical equipment inside the body.

Examples of invasive care include procedures such as biopsies or endoscopies; inserting devices, like IV catheters, indwelling urinary catheters, or nasogastric tubes; and providing treatments such as epidurals and surgical procedures.

Now, invasive procedures carry risks, such as pain or infection, so invasive care should only be used when less invasive methods are not an option. Examples include measuring temperature via the tympanic route instead of rectally; opting for an ultrasound instead of an internal gynecological exam; and using laparoscopic procedures instead of open surgeries whenever possible.

When invasive care is necessary and unavoidable, the health care provider should obtain informed consent from the patient or the patient’s legal representative, allowing them to weigh the risks and benefits. The nurse should verify that informed consent has been obtained and can sign as a witness on consent documents.