Hello everyone,

I wanted input from some med-surg type nurses. If you have a patient that is at a VERY HIGH RISK for falls. He has fallen several times at home and he is disoriented in the hospital and has fell over the side rails of his bed once and was found wondering in the halls, found in bathroom with his foley pulled out etc... However, one of his grand daughters talks with the MD and says she doesn't want him restrained. She, however, is not his power of attorney. Even if she was, don't we have an obligation to keep this patient safe and demand that either a family member stay with him or light restraints will need to be used to keep him from serious injury. Anyone know if JCAHO or hospital policies cover family not wanting patient restrained. Thanks for any input.

Theresa

Restraints will not necessarily keep this gentleman safe; in fact, they are likely to cause agitation at best, and injury or even death at worst. There are all sorts of nonrestrictive ways to prevent falls; where I used to work, we had CNAs doing 1:1 or 1:2 care, and sometimes we called in specially trained volunteers to sit with confused patients. We would also get folks up in gerichairs (yes, it's a restraint, but when they were at the nurses' station we could watch them) or have the CNAs walk with them. As a result, we had very few patient falls, and the only times we actually tied anyone down on Med/Surg were when we had combative patients we couldn't control any other way.

mjlrn97, I wish we had the resources that you describe, but alas, we do not. To the OP, do you have bedalarms?

thlnc said:

However, one of his grand daughters talks with the MD and says she doesn't want him restrained.

Hi,

I would suggest the following: Have someone sit with the patient such as a family member or a CNA; Utilize bed alarms (the kind of bed that alarms when one attempts to climb out of bed); Move the patient closer to the nurses' desk; More importantly, frequent monitoring, assessing patient for pain and comfort, re-orientation, providing diversionary activities such as TV or radio, looking at photo albums and magazines, doing puzzles, etc.

Decreasing the use of restraints should be one of our major goals. There are many studies that use of restraints can actually worsen the patient's conditon, including increasing risk for falls, nosocomial infection, decubiti, pneumonia, etc. Remember that everytime we restrain a patient, we are also violating their rights. Just my thoughts and humble opinion.

I know that this is a challenging issue, but Medicare and JCAHO advocate minimal use of restraints and if we do apply them, we must justify and use them as a last resort.

LCP

Another thing to consider is to make sure to attend to basic needs. When unmet, the patient will most often get up and try to meet them him/herself, unattended. Such as frequent toileting, offering snacks if allowed, water cup/picture full with water, to intervene on/ask about general discomforts, tv/magazines to reduce boredom, and to yes, get up and have a scheduled walk or two with a staff member if the dr order allows. Bed alarms....yes, but they too are not the answer. Reduce the sterile appearance of the hospital room by adding comfort items from home, which can also reduce loneliness, fear, and boredom. Also, I think families are often underutilized to sit with the patient when a sitter is needed. Make it part of your admission process to inform family to choose some family members to volunteer as the loved one's sitter if the need arises. Be creative.

QUOTE : "Even if she was, don't we have an obligation to keep this patient safe and demand that either a family member stay with him or light restraints will need to be used to keep him from serious injury"

I have a real problem with demanding or even expecting family members to provide care or monitoring while a patient is hospitalized. First of all, family members are not always willing or capable. Second, if the family member falls asleep or just isn't very reliable, the nurse may have a false sense of security.

I'd recommend that staff get o.t. to sit with the patient, or that the hospital train volunteers to be sitters if bed alarms, monitoring, low bed, etc aren't enough.

If the patient is harmed, and the family member is at the bedside, does that relieve the nurse of responsibility?

I agree...family as a sitter does not relieve the nurse....but, nor does bed alarms. Many a patient respond more readily and/or are more reassured by a family member than by a stranger. I simply invited us to view this from what the patient needs...not necessarily by what the nurse needs....a change of perspective.

At our hospital, the procedure goes somewhat as follows--

First, make sure that all needs are met, and that the pt isn't uncomfortable in some way.

Then, try a bed alarm and distraction (tv, folding washclothes, dominos, etc--we have a "distraction tub" that we use for this purpose, full of such items).

If a sitter is needed, we see if the family is available. It is dependent upon the family, but some woudl rather we do this, some would rather do it themselves. We are just up front about it and tell them that the pt is going to need a sitter, and if they want to come up and do this, great, if not, we will have hospital staff do it.

During the day, the sitters are often PCAs (our employees who clean the rooms and stock everything). At night, they are nurse aides.

We NEVER use restraints anymore. It just is more harm than it's worth. It just causes worse agitation in the pt, and is so potentially dangerous. It is also demeaning. There are other ways of dealing with an active, confused pt.

There are some patients who have fallen in our institution even WITH a sitter. They would fall even if you had every fifteen minute safety rounds. One pt who was an alcoholic going through d.t.s suddenly threw his legs over the side rail and before the sitter could get to him he slid to the floor. Bed monitors alarm and by the time you get in the room, the pt probably has already fallen. You cant drop one pt to run and check on another. We've had patients that we've taken to the bathroom, bathed, fed, turned tv on, left the room, and five minutes later they get up and fall. I got one patient up to the br, he was alert and oriented, I helped him sit on the toilet, he asked me to close the door as he couldnt "go" with me in the room. He had had a minor stroke and was slightly weak on the right side. I FIRMLY instructed him to call me BEFORE he got off the toilet, I stayed right outside the door, I heard a noise and opened the door, he had gotten off the toilet to wash his hands and fallen!! I felt horrible, for trusting him and he felt horrible for not listening, he wasnt hurt but could have been badly hurt. My point is just that all falls cant be prevented unless you have 1:1 for some patients (which we cant have), and even then, with agitated angry patients, it doesnt work!