Restraining an intact patient

Nurses General Nursing

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Specializes in Neuro, Critical Care.

I work in the neuro ICU, we have our fair share of non intact pts that are restrained for typical reasons. However, at times we have totally intact pts, some of these patients have EVDs or LDs (brain drains).

I had a pt the other night who was completely intact. She was a picker though. Im sure you all know the type..picking at her IV (redressed it 4-5 times), picking at her foley, pulling off her O2 and BP cuff all night long..etc..all that I can handle, its a pain running back and forth between my 2 pts all night, but if she pulls out an IV, well then I can always put another in. HOWEVER....I spent many hours at the beg. of my shift and all during the shift explaining to her the dangers of an EVD and how it works by gravity..so sitting up or moving the bed down effects how it drains CSF. She verbalized understanding each time. I also tell her, don't touch the EVD bc its a huge huge source of infection.

I can only be one place at one time. THe next thing I know she is sitting straight up trying to get out of bed with the EVD attached. I almost have a heart attack. Still, again, I try and educate her, although this time stress that she could die if she dumps too much CSF. She verbalizes understanding.

Through the rest of the night I spend my time babysitting her, keeping her in bed and relatively still. I constantly remind her not to touch the EVD and she kept doing it.

By the time the resident rounded I was almost out of my mind and I felt my only option left was to restrain her. I know it might have kept her in bed and from touching the EVD (her drain was leveled at 20 so she wasnt at as much danger of dumping CSF as others with lower drains) but I just couldn't do it. This was the same pt that threatened to scream if I didnt give her something to drink while she was NPO or threatened to check herself out AMA if I didnt let her go to the parking lot to smoke (no way! esp. with an EVD????).

I had visions of her kicking and screaming and her BP way over 200...I just thought maybe through more education and careful watching I could avoid both potentially dangerous sitiations. Like I said though, by the time 0500 rolled around I was almost nuts. THe resident gave her the EVD talk and told the pt flat out if she didnt stop she would be restrained and if she wanted a raging meningitis infection to keep touching her EVD.

Sorry for the long vent, I guess my question is: have you ever had to restrain an intact pt. and how did you handle the situation, ie how did you approach them initially, how did you problem solve...guess just ooking for some advice on this sitation if i ever have to face it again, which im sure i will. Thanks.

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Specializes in ICU, telemetry, LTAC.

I dunno what kind of drugs you can or can't give a patient in that situation, so my first reaction may not be the appropriate one. I'd be thinking she needs some benzo's or something to calm her down and make her go to sleep.

I think "she ain't right" if she's hearing you folks say all that you've said and doesn't get it. Did anyone outright say "look missy, do you wanna die this week? no? then settle down and quit picking at your stuff ok?"

Yeah I've had to say things like that to post procedure patients who think they can do what they want with a femoral sheath in. I ask 'em how much fun they think it would be to bleed to death, and then educate 'em in a little more blunt layman's terminology. Then get some ativan in their IV and we're all happy.

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Assuming MD wants LOC constantly monitored and sedation wasn't an option I would have two options left.

1: restrain

2: one-to-one

I would let the charge/supervisor pick from those two options.

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Even though she had the correct answers there still was something wrong if she failed to understand that she needed to stop touching her drains and trying to get oob. For her own safety she needed to be restrainted just be sure to document her actions as well as her orientation. You hung in there far longer than I probably would have, I kind of go with the three strike policy.

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Pump her up with some Mephobarbital and we'll be all set for the rest of the night :lol2:

I've had to restrain an intact patient in the ER when I first started. She came in there all hyped up on sugar or something (she was only 15 or 16) and was complaining and severe nausea (every 10-15 minutes she'd be throwing up... come to find out it was from the strength of the antibiotic her MD prescribed her). Anyways, I started an IV and no sooner than I got back to the nurses station she screamed. I rushed back in there and she RIPPED her IV right out of her arm (now she was bleeding).

I called another nurse in to administer IV access while I stopped the bleeding. As we were doing that, she barfed all over the other nurse - so she had to go change immediately (young girls... sheesh what babies lol). I then called two other nurses in there to help put the IV in and clean up the mess. Now, here is where it starts: she then started to scream at the top of her lungs for no reason at all when we all were in there.

She started thrashing her legs and kicked one of the other nurses in the nose (so now she was dripping blood). We were all yelling at her to calm down so I just said "Enough!" - ran out to the nurses station, grabbed some leg restraints and tied her down! She stopped immediately and then I gave her the lecture of ripping IV's out and how abuse would not be tolerated. By then, someone called security and they were down there talking to her as well.

So yes... I've had to restrain pt's :)

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Specializes in Psychiatric.

I would be questioning how much she really did understand if you taught her all that and then she went and pulled on all that stuff, so I would consider her a candidate for medical restraint...the best thing to be done in that situation is to document, document, document! Very interesting situation though...I have no experience in neuro...all my restraining has been on psychiatric units...

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Restraints should be used as a last resort, and if the pt is endangering themselves or others. Seems like this patient met all the criteria. I would have done the same thing. It's our job to protect our patients - even if it's from themselves.

I had a pt the other day, fresh post-op AKA who took off his gown, blanket, and kept grabbing at the dressing on his new stump. I explained and gave multiple reminders, and each time he verbalized understanding, promised he wouldn't do it, but 30 seconds later he was at it again. Eventually he managed to rip off his dressing and finally the restraints came out. Of course, I documented all the interventions I tried first. CYA!

Another option is to get a sitter (which are few and bar between) or ask family members to take shifts and sit with the pt 24/7. I love it when the family members emerge from the room and say they can't handle it - and why just doesn't the nurse sit with their Grandpa/mother, etc.? OK - A) Sometimes we have to make sacrifices for our family, just as they probably did for you and B) the nurse has a little more on her/his plate that takes higher priority.

It's great too when family members state that it's necessary for Grandpa to have his own nurse - even though he's walkie-talkie and totally fine. If that was even possible, wouldn't everyone have their own private nurse? We always give them a number for a home health nurse they can hire on their own - and suddenly it's not necessary anymore.

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Specializes in ICU, Research, Corrections.

Sorry for the long vent, I guess my question is: have you ever had to restrain an intact pt. and how did you handle the situation, ie how did you approach them initially, how did you problem solve...guess just ooking for some advice on this sitation if i ever have to face it again, which im sure i will. Thanks.

Yep, I have had to. The problem is you think they are intact, but they really aren't! I would have done the same thing as you with counseling and education. At the end I have them say "I promise I will not do it again". I reinforce them that "remember you promised me you would not try to pull out your a-line (or whatever)" When the promise is broken, I then restrain. If the pt is in serious harm of getting out of bed and my other pt is so busy that it is possible I can't respond to a bed alarm - I will put on a Posey vest. I follow all protocol and document to the max. I will not hesitate to give them everything prescribed to calm them down too.

If the patient is still extremely agitated after medicating and restraining, then I will call and wake up a doctor. After all, you have to keep everyone safe - the patient and yourself.

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Specializes in ICU, CCU, Trauma, neuro, Geriatrics.

Sounds like the patient needs a sitter. Get the doc to order one for patient safety. Family can be asked to sit with the patient also, many families are quite willing.

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Specializes in ER.

Lots of times we get patients that seem perfectly fine and cooperative, but they can't keep a thought in their head for 30 seconds. I try something they can remove and explain it is to "remind" them, and to use their call bell if they forget why it is there. Usually within two minutes I've got proof they can't be compliant, can't remember to use the call bell, and they are a danger to themselves without constant verbal cueing. I can usually get an order for a sedative out of it, and then an O2 sat with tight alarms will let me know if they so much as turn over after they settle. With this method a couple of patients that are close to each other can share a sitter, and everyone is at least half happy.

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Specializes in Neuro, Critical Care.

Yes, I should have restrained her. My dilemma was more on how to approach her and restrain her without her going completly nuts. We restrain people all the time in the N ICU, most of them completely NOT intact. While this pt was obviously missing something she was still alert and relatively oriented.

I knew she would fight me and I was worried that the stress of that situation would also be harmful to her...although getting you brain sucked through a tube seems like the worst possible thing that could happen.

Its just hard to tie down a pt that knows whats going on. I just thought that maybe if I was a bit more stern with her she would stop...She didnt so I ended up giving her benedryl for itching and it knocked her out until the end of my shift. I passed the info along but I don tknow what happened after I left.

I liked the idea one of the previous posters had about making them promise and then confronting them with the consequences.

Oh and getting a sitter is a great idea but we rarely almost never get them.

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Specializes in Psychiatric.

Again, I've never, ever worked neuro so I dunno what would work best, but the 'least to most' approach might be cool...try a verbal contract as one other person suggested, and if that doesn't work, go up to the drugs...maybe get her doc to write an order for Ativan or something (although Benadryl has its benefits too LOL; we use it in psych a lot too), and if that still doesn't work, the restraints would be the last resort...that way you've used the least to most method and given her the opportunity, anyhow...:)

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