NUR 448

Milieu Therapy

What is Milieu Therapy?

A healing environmentUse of the physical and social environment to

promote safety, optimal functioning, develop interpersonal skills, and to teach life management skills to use after discharge

Purpose

Promote mental health and rehabilitation Focus on group process Democratic Interdisciplinary approach

Functions

ContainmentSupportStructureInvolvementValidation

Nurse as Manager

Promotes atmosphere of Respect Safety Flexibility Open communication Predictability Active involvement

Components of Milieu Therapy

Orientation to environment Scheduled activities Rules for behavior Introductions to patients and staff

Community Meetings Welcome new members Set expectations Share responsibilities Plan activities Discuss conflicts

Components of Milieu Therapy

Limit settingSystem of positive and negative

reinforcement Privileges

Seclusion and restraint

Seclusion and Restraint

Used primarily to prevent physical injury to client, other clients, staff, and visitors

Sometimes a quiet area is used to reduce stimulation for a client who is overwhelmed on an open unit

Sometimes used to prevent major damage to a unit or major interference with a therapeutic environment

Assess the need for seclusion or restraint

Assess client needs and needs of othersTalk to client in a quiet areaIntervene early to prevent escalationUse least restrictive interventions principleNever use as punishmentDocument

Risk for injury what was tried before restraint or seclusion was

implemented Client response to those interventions

Continuum of least restrictive interventions

Verbal intervention Involve in activities if possiblePRN MedicationSeclusionMedication given IM without the client’s

consent (chemical restraint)Physical restraint as last resort

Use of Seclusion or Restraint

Assure adequate numbers of staff are available

Give choice to walk to the seclusion areaGive client a few seconds to decide if he or

she will walk to the seclusion areaIf client does not adhere, each staff member

grabs a limb and lowers the client to the floor (take down procedure)

Use of Seclusion or Restraint

Carry client to seclusion areaApply restraintsSearch client for dangerous objectsAdminister IM medication if ordered and

appropriate

After Implementing Restraints

Consult physician or ARNP or notify as soon as practical

Have physician or ARNP examine client within 1-3 hours and again every 12 hours

Explain reasons to client and familyOffer emotional supportDocument

Nursing Actions for the Client in Restraints

Observe at least every 15 minutes and document Level of consciousness Mental status Vital signs

Every two hours document Circulation in restrained extremities

Pulse Color Movement Sensation Edema

Nursing Actions for the Client in Restraints

Loosen 4 point restraints one at a time every 2 hours.

Provide meals (without utensils)Offer food and fluids every 2 hoursProvide for hygiene and toileting every 2

hours

Nursing Actions for the Client in Restraints

Release extremities (one at a time) every two hours and perform range of motion

Evaluate continued need for restriction Gradually release client“Debrief” or discuss the episode with the client

when s/he has regained control