Restraints - page 4
by mindlor | 6,936 Views | 42 Comments
Hey boss, My pt keeps disconnecting herself from the vent, can I get some mittens? Boss says, "no, we are a no restraint facility, just take a sheet, wrap it around her arms and then loop it around the mattress so she cant... Read More
- 0Jan 9, '13 by <Jenn>Quote from CapeCodMermaidWhere did y'all find the onsie? We have one who digs in her diaper and eats the poop and she can remove the hand mittsMitts are a restraint since anything that prevents free movement or free access to one's body IS a restraint.We used to have a resident who liked to strip and make poop paintings. We got an adult onesie and had to document it as a restraint.
- 1Jan 9, '13 by Esme12, BSN, RN Senior ModeratorQuote from bloody_traumaMany facilities in the civilian world no longer allow this type of immobilizing of patients hands. There has been many incidences of breakdown with litigation awards. This type of immobilization effort also need to be removed as per restraint protocols to prevent breakdown.....in civilian facilities and per the Joint Commission, and Center for Medicare Medicaid Services, The department of veteran affairs also provide policies for the restraint in their facilities.Oh RLY? some of you get way to worked up about all this, but you ask questions and you get answers. I had a pt with AMS who would rip off anything attached or inserted, bad sun downer, anyway... I wrapped his hands in kerlix to protects him from causing damage to himself, ie... pulling out a fully inflated catheter, pulling out his CVA... risk for infection. initiate a nursing order, wrap lightly around the wrist begin your fold at the volar aspect of his wrist, over the palm, twist over in between the 1st and 2nd digit, continue over the palm, wrap over the top and secure his thumb to his fore finger, and document. he wasnt at risk for breakdown, he had great circulation in his extremities, and when I did my q2 and 4 reassessments, I documented to that effect. he still pawed at his accouterments but was unable to grasp them and all was well...
and really you have a pt on vent who isnt sedated enough to prevent this? that would make me concerned and uncomfortable. how is it that your "boss" determines what care the patient does and doesnt get? ultimately it's the physicians responsibility to call it... speak up for whats right, you know how to do this, who ever the determining authority is, describe the Situation, provide the Background, Give your Assessment, and Recommendation. SBAR... if you fail to be heard twice and you still feel strongly, don;t let it die there, that how mistakes and errors occur. these incidences are preventable, why do we have to wait until something happens to enact change? but as always hindsight bias is 20/20...
Sounds to me like there should either be a change in policy from the totalitarian stance of "no restraint facility", OR, you should't have patients, who require the intervention, present in your facility, and requires a greater level of care.
Good luck, I hope your patient benefits from your persistence.
We need to remember that in different parts of the country different things are considered the standard of care ...so what is accepted as common place in one area will not be common place on another. We also need to remember how many different types of facilities there are and how tht4ey vary in their acuity.
There are places that have long term vents. There are places that have long term vents on medically complex patients that are difficult to wean but are rehabable....those places are called LTAC's/ Long Term Acute Care Hospitals. These facilities are accredited as any other acute care hospital....they have ICU's with invasive lines and drips. These patients are full codes and have goals to go home. They are actively being weaned and do not require, nor should they have, heavy sedation to snow them and decrease their changes of being removed form the vent.
The LTAC IS the facility where hospitals send their "failures", their complicated recoveries with multiple co-morbidities and complicated recoveries...including post open heart patients, craniotomies, burns, neuro events, with complex wounds. These are the patients who used to spend weeks in the hospital....they are now sent to LTACS within days....from the moment the are past "the usual" set days.
The OP works at one of these facilities....and LTAC. The patient does require intervention and is at the greater level of care. With the regulations by CMS it is difficult at best to continue to remain compliant in these situation for unfortunately they are considered "Long Term" regardless of the acuity which is a whole other set of rules. These facilities are new...ish and are mostly for profit. They do not necessarily have experienced nurses in charge....that understand the quirks of an LTAC.
So this patient is begin perfectly care for in an appropriate facility The issue here is the policy of the facility to be "restraint free" as a LTC....but have the acuity of a acute care facility. These facilities are in the throws of growing pains........and I think they are wave of future acute care employment....as new regulations evolve.
The great thing about AN is how we can all learn from each other with out leaving our home.
- 2Jan 9, '13 by Good Morning, GilMittens are a restraint where I work, and I'm surprised they are not elsewhere as the purpose of them is to restrict movement. This is the definition of a restraint lol. Anyway, wow....how do you do your job safely without restraints? If a patient self-extubates, that could have a not so great outcome. I end up having to restrain most of my vented patients; some are oriented, and understand why they can't grab at the tube, so they end up not needing them, but the majority that have regular brain activity require it. I'd be applying elsewhere if I were you. I know you posted what your boss said because it was so ridiculous it was funny, but also very scary.
- 3Jan 10, '13 by mindlorQuote from Good Morning, GilI have an interview at a traditional acute care hospital tomm at 10:00am. Wish me luck. I have to get out of this hellhole. Every moment I am on the floor my license is at risk. Other are leaving in droves and quite honestly I am not sure how they will keep the doors open.......we shall see. Soon, the senior RN on the floor will be a new grad with experience measured in weeks.....at least I have 6 months lolMittens are a restraint where I work, and I'm surprised they are not elsewhere as the purpose of them is to restrict movement. This is the definition of a restraint lol. Anyway, wow....how do you do your job safely without restraints? If a patient self-extubates, that could have a not so great outcome. I end up having to restrain most of my vented patients; some are oriented, and understand why they can't grab at the tube, so they end up not needing them, but the majority that have regular brain activity require it. I'd be applying elsewhere if I were you. I know you posted what your boss said because it was so ridiculous it was funny, but also very scary.
- 3Jan 10, '13 by CapeCodMermaid, RNEven the Massachusetts DPH known for being one of the most stringent of regulation watchers, allows for the use of restraints. They need to be medically necessary, have an assessment done, an MD order, and documentation that you've tried multiple other i terventions before applying the restraint. Of course once you've got the restraint in place, you're supposed to start tapering it off!!!My facility is a restraint appropriate facility. At the current time with our current patients, it is not appropriate for any of them to have a restraint. After the 6 new admissions come in, who knows.Just make sure you document.
- 2Jan 10, '13 by edmiaQuote from yiyayiyaThis is what I thought about when I read the OP. It reminds me of a patient whose vent kept popping off for apparently no reason, every 30 mins or so, until we saw that she was doing it herself. When asked, she finally said: "I'm done with this. I want to die."Mitts are very definitely a restraint. I have set up an a so that I refuse all restraints for any purpose. If that means not having life saving treatment - so be it.
She was so clear about it.
In the end, after family meeting, it was decided that she wanted off the vent she'd be forever dependent on and was transferred to hospice where she passed peacefully.
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- 2Jan 15, '13 by mindlorQuote from mindlorYesterday I was offered and accepted the job at the "Real" hospital Med/Surg/Tele. I took a 12 cent per hour pay cut but hey, sometimes one must take a step back to take two steps forward.I have an interview at a traditional acute care hospital tomm at 10:00am. Wish me luck. I have to get out of this hellhole. Every moment I am on the floor my license is at risk. Other are leaving in droves and quite honestly I am not sure how they will keep the doors open.......we shall see. Soon, the senior RN on the floor will be a new grad with experience measured in weeks.....at least I have 6 months lol
Wish me luck. After shadowing on my new unit my only concern is that I will be bored. I felt like the entire unit was in slow motion relative to my old job lol.......