School of Healthcare, University of Leeds, Leeds, UK.
J Clin Nurs. 2020 Jan;29(1-2):5-19. doi: 10.1111/jocn.15052. Epub 2019 Oct 1.
To identify key determinants, which lead to the decision to apply physical or chemical restraint on the critical care unit.
Psychomotor agitation and hyperactive delirium are frequently cited as clinical rationale for initiating chemical and physical restraint in critical care. Current restraint guidance is over a decade old, and wide variations in nursing and prescribing practice are evident. It is unclear whether restraint use is grounded in evidence-based practice or custom and culture.
Integrative review.
Seven health sciences databases were searched to identify published and grey literature (1995-2019), with additional hand-searching. The systematic deselection process followed PRISMA guidance. Studies were included if they identified physical or chemical restraint as a method of agitation management in adult critical care units. Quality appraisal was undertaken using Mixed Methods Appraisal Tool. Data were extracted, and thematic analysis undertaken.
A total of 23 studies were included. Four main themes were identified: the lack of standardised practice, patient characteristics associated with restraint use, the struggle in practice and the decision to apply restraint.
There are wide variations in restraint use despite the presence of international guidance. Nurses are the primary decision-makers in applying restraint and report that caring for delirious patients is physically and psychologically challenging. The decision to restrain can be influenced by the working environment, patient behaviours and clinical acuity. Enhanced clinical support and guidance for nurses caring for delirious patients is indicated.
Delirium and agitation pose a potential threat to patient safety and the maintenance of life-preserving therapies. Restraint is viewed as one method of preserving patient safety. However, use appears to be influenced by previous adverse experiences and subjective patient descriptors, rather than robust evidence-based knowledge. The need for a precise language to describe restraint and quantify when it becomes necessary is indicated.
确定导致在重症监护病房决定使用身体或化学约束的关键决定因素。
精神运动激越和活跃性谵妄经常被认为是在重症监护中启动化学和身体约束的临床理由。目前的约束指南已经有十多年的历史了，护理和处方实践存在广泛的差异。目前尚不清楚约束的使用是否基于循证实践，还是基于习惯和文化。
综合回顾。
检索了七个健康科学数据库，以确定发表和灰色文献（1995-2019 年），并进行了额外的手工搜索。系统的选择过程遵循 PRISMA 指南。如果研究将身体或化学约束确定为成人重症监护病房激越管理的方法，则将其纳入研究。使用混合方法评估工具进行质量评估。提取数据并进行主题分析。
共纳入 23 项研究。确定了四个主要主题：缺乏标准化实践、与约束使用相关的患者特征、实践中的困境以及应用约束的决定。
尽管存在国际指南，但约束的使用存在广泛差异。护士是应用约束的主要决策者，并报告说照顾谵妄患者在身体和心理上都具有挑战性。约束的决定可能会受到工作环境、患者行为和临床严重程度的影响。需要为照顾谵妄患者的护士提供更加强化的临床支持和指导。
谵妄和激越可能对患者安全和维持生命维持治疗构成威胁。约束被视为保护患者安全的一种方法。然而，其使用似乎受到先前的不良经历和主观患者描述的影响，而不是基于强有力的循证知识。需要使用精确的语言来描述约束，并确定何时需要约束。
