Running Head: CLINICAL EXEMPLAR: PEDIATRIC RESTRAINT 1

Clinical Exemplar: Pediatric Restraint

Makeda deComas

University of South Florida

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Clinical Exemplar: Pediatric Restraint

Restraint in pediatrics is defined as the application of force with the intention of

overpowering the child without the child’s consent (Svendsen, Pedersen, Moen & Bjork, 2017).

Holding is one form of restraint which can be performed by healthcare workers or parents during

procedures. Studies of nurses and parent’s perspectives on holding and restraint have shown that

the more force is required when holding patient’s, the more discomfort is reported by parties

involved (Bray et al., 2014). Although children are more comfortable when being held by their

parents, parents report anger and dissatisfaction with care when parents are forced to hold their

children without being given other options (Bray et al., 2014). Restraint in children provides an

ethical dilemma, as children have limited ability to advocate for their desires, and the benefit and

consequences should always be considered when deciding whether it is necessary to restrain a

child (Bray et al., 2014).

Patient Background

The patient was a 4-year-old rambunctious boy alone in his room on hospital day 3 for

asthma exacerbation. The patient had normal vital signs with an spO2 of 98%, respiratory rate of

28 and heart rate between 90-100. The patient had expiratory wheezing and coarse breath sounds

throughout all lobes bilaterally. The patient appeared to be breathing comfortably with no

retractions and was cooperative during his assessment. The patient was ordered to have Albuterol

treatments every 4 hours and take oral prednisolone at 0900. The patient was stable until it was

time to receive his morning medications. As soon as I had the medication ready, the patient

jumped out of the bed, ran several laps around the room and dived under the bed. While the

patient was running, he managed to pull off his spO2 monitor, so we could no longer monitor his

oxygenation and heart rate. Also, after running he had a pronounced audible wheeze which was
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not present on his initial assessment and could be heard through the bed. The patient was at risk

for injury due to his position out of sight wedged between the bed, the floor and the wall.

Furthermore, the patient needed his medication.

Responding

Ideally, having the parent available to assist in decision making for how to bring the

patient safely out of hiding. From the patient’s own words, he was refusing to take medication

because he felt he was better. Although we attempted explanation, the patient was adamant about

not taking medication. The situation was not critical, but it was important to resolve the situation

as he was exacerbating his asthma with his actions and his position under the bed was unsafe.

Intervention was necessary to ensure the patient could get the treatment he needed. The

dilemma here was that there was no parent present to guide our decision and the patient was too

young to decide to refuse the medication he needed. My preceptor was able to pull him out from

his position as I slowly pushed the bed away from him. We were able to restrain the patient in

order to administer his medication, but he also managed to escape and run out of the room. This

meant that we had to restart the process and with the help of another nurse, we managed to catch

him and the two nurses and I restrained him during his albuterol treatment. At this moment, I

knew that this process could have been handled more smoothly After his medications were over,

he was able to calm down and the Child Life specialist brought him video games to play in bed.

Reflection

This situation could have been handled better. Although we attempted to calm the patient,

the ideal situation would have been to calm the patient down enough to take his medications

willingly. It would have been prudent to enlist another member of the health care team such as a

nurse or tech at the moment the patient ran under the bed. This is when the situation became
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potentially dangerous as we knew we needed to remove him and possibly administer his

medications unwillingly.

In this situation, we achieved the desired outcome of administering both his medications

but at the cost of the patient’s comfort. This was a learning experience for me on how to handle

difficult patient’s when no parent is present to assist. While I was able to adapt to the situation

and restrain the patient, I could have done better by assessing the needs of the situation early and

asking for help from available health care team members. Because we were not prepared, the

patient was able to run out of the room and risk transmission of his respiratory illness.

Conclusion

Completing procedures, even relatively minor procedures such as medication

administration, with young children can be challenging. It is important to consider the benefit

and consequences of any form of restraint, and question why it is needed. In this scenario, it was

necessary to give his albuterol treatment and medications, but there were other interventions

which could have been tried to avoid or lessen the consequences of restraining the patient. The

importance of taking a moment to reevaluate a situation when considering restraint was made

clear to me through this scenario. Although the patient was not responsive to conversation about

why his medicines were necessary, distraction was one method we could have tried, and getting

another pair of hands in the room would have been helpful. Furthermore, the patient was being

discharged with an albuterol inhaler and spacer, so it might have been appropriate to consult with

the doctor for an order to deliver his albuterol via inhaler instead of nebulizer, as this would have

reduced his restraint time significantly. This situation has had a permeant impact on me, and I

will ensure I always take the time to think of alternatives to restraining patients and ways to

reduce the stress of restraining patients.

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References

Bray, L., Snodin, J. & Carter, B. (2014). Holding and restraining children for clinical procedures

within an acute care setting: an ethical consideration of the evidence. Nursing Inquiry,

22(2)

Svendsen, E., Pedersen, R., Moen, A. & Bjork, I. (2017). Exploring perspectives on restraint

during medical procedures in paediatric care: a qualitative interview study with nurses

and physicians. International journal of Qualitative Studies in Health and Well-Being,

12(1), 157-167.