Terrible clinical day, nurses don't seem to care.

[Koyaanisqatsi-RN]

I may get a lot of flack for this from the more experienced nurses, but I would like some help in understanding this situation.

Today, I walked by a patient's room in the hallway. Keep in mind she is not my particular patient today. She calls out to me in a frail voice for help, and sounds like she is in very bad shape. I go in to see her and she is crying, and very frail. She must have been in her 80s or even higher. She stated that she could not move her arms, and that she was desperate for some water. My first thought was that she might have been having acute MI or something similar because she couldn't move her arms, I really didn't know. I held her hands quickly and asked if she could feel my hands in hers. She said she could, but that she can't move her arms, and continued to cry and beg for water. She kept saying that she did not know where she was or why, and to please help her.

At this point, I noticed the restraints. She was strapped into her bed, this is why she couldn't move her arms. I was horrified. This is a med/surg floor, not a pysch ward. I asked one of the tele people what was going on and they stated 'it's just some crazy old woman, she's weird don't worry about her'. I asked her nurse and this was the same answer I got from her, again. She stated this woman had previously tried to pull out her IV and so they restrained her.

So...

Help me understand. They clearly had to get an order for these restraints. Why did they not choose a chemical restraint or sedative instead of strapping her into the bed? Why does no one care about this woman, writing her off as a crazy old lady; when she is, in reality, a frightened human being who was strapped into her bed in a strange place and scared to death. Not to mention thirsty, as she was apparently NPO and no one would explain to her why.

I went into the stairwell and cried for about 5 minutes. This is not why I wanted to go into nursing. I see things like this every day, but never this bad before. Restraints! They strapped this poor woman down and wouldn't explain anything to her. I spent some of the rest of the day talking to her and trying to help her relax even though all she wanted was to get out of bed and get some water.

It broke my heart. And if this is what nursing means, that eventually you become so burned out that a fellow human being suffering in one of the worst possible ways becomes just some 'crazy old lady', then I want no part of it.

[Koyaanisqatsi-RN]

Why do you assume no one has explained to this patient why she is NPO? It is entirely possible that it has been explained to her many, many times.

It was not an assumption. At least the nurses I spoke to, they told me that no one bothered to tell her, because she wouldn't care or remember anyway.

Sitters are great but--as someone already said--most budgets can't afford a sitter for every confused patient.

I stated before that I have never seen anything like this. I am not suggesting that every single patient who is confused needs a sitter. But I couldn't find anyone willing to even look into it.

How is that not a problem?

[canoehead, BSN, RN]

You brought up a lot of questions, I may miss some, so bear with me.

She was restrained because she kept pulling her IV out. The IV is essential to her care apparently, and they may have tried all the tricks to distract her and this was a last resort.

Physical restraints were used instead of chemical- could be she's elderly and more likely to get unwanted side effects. Perhaps they need to moniter her mental status, if confusion is a problem for her drugs can make that worse, or she may have had a paradoxical reaction in the past. They may also have talked to her family and that was the choice made. Often we've used physical restraints during the day, and sedated people at night to keep a somewhat normal sleep schedule.

If she's restrained, and pulling out her IV I'm pretty sure they could have explained why she was restrained Q5 minutes and she still wouldn't remember. Families at the bedside are very helpful in situations like these, but it's not always possible. Sitters are a financial burden for the hospital, and usually not used. FYI sometimes ahving someone there reexplaining can result in delusions of being kidnapped or tortured. It's pretty close to the truth of what is happening, and rarely does anyone understand why they are restrained.

After trying many different alternatives to restraints, and finally having to actually tie someone down, staff is usually way behind in their other duties, plus they have about 30 minutes extra paperwork because they used restraints. That's why no one was in the room. They've done everthing they know to do, and sitting there talking to her doesn't provide a benefit because she couldn't retain anything.

You said medsurg was not where she belonged. Where else were you thinking of having her? If she's NPO she's probably got something going on and not appropriate for LTC or psych.

You spent a lot of your day caring for her. Did you find she stayed in distress because of the restraints? Did she retain any of the information you gave her? If you had 5 other patients that needed teaching you would have to prioritize. I spend the most time with people that can get the most benefit from the information. I agree that in the best world she would have a supportive person with her, but that is NOT healthcare reality. If I was her nurse I would repeat the information she needed during the mandatory restraint checks, and try to reassure her, and then expect her to forget it all within about 30 seconds. I would maybe give her ativan if she was frantic, but I'd want her to sleep at night so sedation wouldn't be a good choice, especially if she was sundowning.

I don't see a lack of care based on the information you gave. I do see a very sad situation, and a good reason to make sure my family knows my DNR status. If I'm ever that confused leave the IV out, let me wander, and then give me really good pain meds for my broken hip, and let me go.

[hikernurse]

Sometimes older people have greater reactions to sedating drugs; I've seen paradoxical reactions with older patients where they become more agitated and frightened than before the meds were given. Also drugs can take longer to clear out in older patient's kidneys.

Sitters may not always be available; I haven't seen (at least where I've worked) volunteer sitters because of the liability. When I worked as a CNA, I sat with a lot of patients and with some of them, no matter how often I explained why the foley couldn't come out, why they were NPO and why they couldn't get out of bed, it did no good. I do think sitters are a good option and I spent a lot of time holding hands (another form of restraints, if you think about it) to help them calm down. But there's no way to know why this wasn't done with this patient.

Just something to think about, students don't usually have all the information nurses have and sometimes nurses don't have the time to really explain it. I often have students with me and I enjoy working with them, but some days, I can't do nearly as much teaching with them as I'd like because I am totally swamped.

I'm just trying to give you some additional info here. It's a long bridge between nursing school and real life nursing. There are many times the nursing school ideals get traded for getting the job done--still with safe and appropriate care.

Like Atheos said, her family should really bear some responsibility.

I know you're here asking and that's commendable. It's also commendable that you care and want what is best for your patients. Good for you :). That kind of attitude will take you far. Patients can tell when their nurses truly care for them and that's a great thing. It sounds like you'll make a great nurse :).

[rintin02]

I understand your emotional feelings regarding the treatment of this patient. However, restraining patients is not just a psych issue. I work on a neurology trauma unit and more often than not our patients are restrained either for their safety or the staffs safety. Chemical restraints aren't necessarily better than physical restraints. Some medications used for chemical restraints can also have the opposite affect on the patient. In the ideal world someone would have all the time to sit and try to redirect a confused patient, but some patients are confused and unable to be redirected and only need to be restrained for a short time period. With the amount of people working even having a person sit with a patient who is a patient care tech or cna or something similar to that there just is not always the staffing to do that.

[Atheos]

I can't speak to nurses but even after being a CNA for a while sometimes the caring slips.

Or, and I think this is worse, the caring doesn't slip so much as you get used to someone's behavior and ignore it.

Especially if you are already overworked.

If you are overworked then dealing with a hopeless situation that you already know about can put needless strain on you.

[Koyaanisqatsi-RN]

You brought up a lot of questions, I may miss some, so bear with me.

She was restrained because she kept pulling her IV out. The IV is essential to her care apparently, and they may have tried all the tricks to distract her and this was a last resort.

Physical restraints were used instead of chemical- could be she's elderly and more likely to get unwanted side effects. Perhaps they need to moniter her mental status, if confusion is a problem for her drugs can make that worse, or she may have had a paradoxical reaction in the past. They may also have talked to her family and that was the choice made. Often we've used physical restraints during the day, and sedated people at night to keep a somewhat normal sleep schedule.

If she's restrained, and pulling out her IV I'm pretty sure they could have explained why she was restrained Q5 minutes and she still wouldn't remember. Families at the bedside are very helpful in situations like these, but it's not always possible. Sitters are a financial burden for the hospital, and usually not used. FYI sometimes ahving someone there reexplaining can result in delusions of being kidnapped or tortured. It's pretty close to the truth of what is happening, and rarely does anyone understand why they are restrained.

After trying many different alternatives to restraints, and finally having to actually tie someone down, staff is usually way behind in their other duties, plus they have about 30 minutes extra paperwork because they used restraints. That's why no one was in the room. They've done everthing they know to do, and sitting there talking to her doesn't provide a benefit because she couldn't retain anything.

You said medsurg was not where she belonged. Where else were you thinking of having her? If she's NPO she's probably got something going on and not appropriate for LTC or psych.

You spent a lot of your day caring for her. Did you find she stayed in distress because of the restraints? Did she retain any of the information you gave her? If you had 5 other patients that needed teaching you would have to prioritize. I spend the most time with people that can get the most benefit from the information. I agree that in the best world she would have a supportive person with her, but that is NOT healthcare reality. If I was her nurse I would repeat the information she needed during the mandatory restraint checks, and try to reassure her, and then expect her to forget it all within about 30 seconds. I would maybe give her ativan if she was frantic, but I'd want her to sleep at night so sedation wouldn't be a good choice, especially if she was sundowning.

Well, what you have said here makes a lot of sense. As I said, I know we can't have patients pulling out their IVs. I guess I'm just lashing out a bit because I have never seen what I saw today, and I don't understand how it can work that way. What you said though helps me get closer to understanding it. I just wish that I had at least one single nurse today explain what you guys are here telling me now. No one did. No one cared. And yes I know everyone is busy but census was pretty low today, and I think the literally 3 minutes it takes to explain some of these things wouldn't have been missed too terribly. Maybe I'm wrong about that, too though.

You said medsurg was not where she belonged. Where else were you thinking of having her? If she's NPO she's probably got something going on and not appropriate for LTC or psych.

I guess what I meant by that is that these people didn't seem willing or prepared to handle it. That's just what it seemed like. Thinking about it now, I guess I see that there isn't a whole lot else that could have been done. But I would have been relieved for this poor woman if someone had just put in some more effort. And again, I'm not just assuming this was not done. I was straight told that in most cases she was just a crazy old lady and to not worry about it.

[Atheos]

Maybe you got a bad batch of nursing staff?

It happens.

[meluhn]

Sadly, it sometimes happens that we run out of options and people need to be restrained. The nurses may have seemed to have a very callous attitude about this to you who has time to worry about just your pt and maybe this woman too. But to someone who has 8 other pts, their priority is to make sure everyone is safe and cared for. Hopefully wrist restraints would be a last resort. Do not judge those nurses too harshly, it is hard to remain compassionate all the time when you are under enormous pressure all day. Unfortunately, it causes us to sometimes see our pt fear/anxiety/anger or whatever as just another problem we have to deal with. It is hard to be nice when your own basic needs for food, br breaks, and stress relief are not being met. As long as the womans restraints were released according to policy and she was allowed to stretch, move, eat, go to br, etc, the staff was not doing anything wrong, as long as they had an md order for restraints.

[firechalice]

I'm sorry that you had a bad day.

I cannot say why this happened as I don't know the situation. I will encourage you to remember it. Learn from it. You will become a better nurse because of it. For many people nursing is a job, for some a profession, and for a few it's a calling. This perception frequently colors a persons actions. I promise you will see many, many things with which you won't agree and you will have to decide which battles to fight. Work to make it what you feel it should be by becoming active in committees, health policy, management, etc. Don't give up on nursing and loving people as most of us truly care.

You are the future of nursing and people like that "crazy old lady" are counting on you. :redpinkhe

[leslie :-D]

Maybe you got a bad batch of nursing staff?

It happens.

unlikely.

rather, i'm thinking they were stressed and tired.

restraints are typically used as a very last resort.

it's probable that all interventions had been used, including reorienting and repetitive answers to the repetitive questions.

truly, when i've had it, i'm sure i've been known to respond to similiar inquiries in the same, exasperated, sarcastic manner...

keeping it short, sweet and crass.

either they could have been stressed/tired;

or maybe the floor's morale is extremely low;

or, maybe these nurses don't enjoy student nurses;

or, maybe they are genuine idiots.

who knows?

no one.

but as a student, it is these type experiences that will guide you into the nurse you want to be.

one can always learn from both positive and negative.

leslie

[Koyaanisqatsi-RN]

Maybe you got a bad batch of nursing staff?

It happens.

I guess so. It seems sad that it would happen all at once like this for this patient.

[catshowlady]

You don't really know what the situation was. Maybe they tried other methods for dealing with this pt. Maybe they didn't. Try not to judge what the staff was thinking, unless they outright told you they enjoy strapping down old people for fun.

That said, I'm not trying to discount your feelings. I have never felt comfortable restraining people, although I have done it, mostly as a tech.

Corporate culture may play a big part in what you saw. Keep in mind that unlicensed staff like the monitor techs don't have the training that you do. They are probably just repeating what they "learned" from the nurse. My first hospital that I worked at used a lot of restraints. I was a tech, and if the nurse told me to keep a pt in restraints, well, it was my job to take her direction. Also, I didn't really have any training in what else could be done to help keep a pt out of restraints. As a nurse, I now know that there are a lot of other options. And my current facility almost never uses restraints. A lot of what I learned about avoiding restraints, I learned at this job. If I had stayed at the first facility when I got my RN, I would probably still be using a lot of restraints, not even really thinking about it, because that is the culture at that hospital.

Staffing plays a huge part in restraint situations, too, I think. If you don't have enough CNA's to go around, it makes it harder to keep an eye on pts. In order to get a sitter, your facility has to be willing to pay a sitter. High nurse-pt ratios may also limit the time the nurse has to spend re-orienting a confused pt or restarting an IV for the fourth time in less than 12 hours (been there, done that). The nurse may be forced to use restraints out of lack of other options at this facility.

On chemical restraints/sedatives, remember that benzos often make the elderly worse rather than better. Sedatives also are not what you want to give a pt w/ respiratory compromise or a pt that needs neuro checks. Also, if you zonk them 24/7, they will get weak very quickly and be unable to progress ADL's, etc. There's no magic switch to throw that gets them awake and moving for ADL's and meals and keeps them quiet the rest of the time. Plus, if you zonk a pt during the day, you risk having them get their days & nights mixed up, so they are up all night (which generally just increases confusion).

I hear what you are saying. I know it is sad to see someone in restraints. Use this experience to help you be a better nurse. Learn about alternatives to restraints, and/or try to shadow at a restraint-free facility. You can use this knowledge to teach future coworkers about alternatives. Just for example, I never knew how great bed alarms were for fall risk pts until I came to my current hospital. Do you have any teaching projects due this term? Perhaps your instructor would let you do one on restraints, maybe even for the staff on this unit.

Hang in there. :icon_hug: