Cutting Clothes: ED SI/HI pt

Nurses General Nursing

Published

Hello,

ED RN here. Had an SI/HI pt in police custody. Pt refused to change into the required behavioral health attire; was verbally aggressive, threatening staff and officers that had pt in custody, if we attempted to remove pt's clothes.

In short, after every deescalation tactic and accomodations offered, I cut off the pt's clothes. Pt was cuffed to the stretcher and physically restrained by two officers and an ED tech.

Do you think its appropiate to cut pts' clothes off in this situation?

With the principles of "least restrictive measures" of restraints, "pt safety", and "minimal/least-invaisive force necessary" what are your thoughts on this? How would /have you handle/handled this situation? (Chemical restraints etc.?)

Specializes in Community Health, Med/Surg, ICU Stepdown.

I don't work in ED but I do work with many patients in psychiatric crisis. One thing to remember is that someone in a state of psychosis cannot be reasoned with. They are not being deliberately defiant, they just don't understand what is going on, are hallucinating or delusional, and most likely terrified. It may seem cruel to shoot someone up with antipsychotics against their will, but in my (personal) experience antipsychotics are effective when they are given to people with true psychiatric symptoms/disorders.

I am not ashamed to say I take antipsychotics to prevent bipolar mania, depression and psychosis. And I hope that if I showed up to the ED in psychosis I would receive medication for my condition like any other patient rather than be forced to comply with rules that I can't currently comprehend. This is not a response to shame the OP, I know dealing with psych emergencies in a medical ED is really difficult. I wish there were more psych EDs. The fact that you are thinking about the situation and asking for feedback is great ?

5 Votes

I don’t understand the cutting of the clothes. What if they were his only clothes or only had a couple of things. You’ve now destroyed one of the few things he has.

Many people with mental illness have a hard time keeping jobs and don’t have much money. Sometimes it’s necessary to cut clothes specifically in a trauma.

You can restrain a pt and remove their clothes without cutting if necessary.

I hope this is a homework question.

2 Votes
16 minutes ago, LibraNurse27 said:

And I hope that if I showed up to the ED in psychosis I would receive medication for my condition like any other patient rather than be forced to comply with rules that I can't currently comprehend.

What happens when the therapeutic intervention (in your example, the benefit of taking medication) is also something that the patient disagrees with or can't comprehend? Unfortunately we're back to the original problem at that point.

I am not trying to be contentious but these are situations where we're already beyond the easiest answers. When offering solutions to very difficult situations they need to be realistic to the situaton. So far we have heard that the patient should 1) be given a chance (I agree, although even multiple chances may not work) and 2) should be given medication if they can't otherwise comprehend what is being asked of them (which means it's also quite possible that they will not comprehend the therapeutic potential of the medication or wish to take it) which puts us back to forcing something vs. not forcing.

1 Votes
Specializes in Community Health, Med/Surg, ICU Stepdown.

I think sometimes it is OK to force medication when a patient can't comprehend why they need it or consent. Especially if they are at imminent risk of hurting themself or someone else. Just my opinion, open to feedback ?

3 Votes
1 hour ago, JKL33 said:

I am not trying to be contentious but these are situations where we're already beyond the easiest answers. When offering solutions to very difficult situations they need to be realistic to the situaton. So far we have heard that the patient should 1) be given a chance (I agree, although even multiple chances may not work) and 2) should be given medication if they can't otherwise comprehend what is being asked of them (which means it's also quite possible that they will not comprehend the therapeutic potential of the medication or wish to take it) which puts us back to forcing something vs. not forcing.

I still feel that if a patient says No it is no. This having been said in this case he was held down. Basically stripped of not only of his clothing but of his dignity. They may have been the only clothes he has. Is the hospital going to replace that clothing since they decided to cut off his clothing without a medical reason? I did not read that he was profusely bleeding and needed treatment for physical injuries did not read of any trauma that needed to be dealt with. He refused to change into their clothing.

On the medication, in this case yes it may have still been forced but it would have been for everyone's benefit including the patient. As long as he did not need medical intervention he would have slept possibly came out of whatever mental state he was. While he was sleeping whatever equipment that needed to be attached to him to monitor his condition, could have been put on in peace. Hopefully woke up more aware of what the circumstances were and would have changed into whatever hospital attire necessary.

Now he has this experience to add to whatever devils are chasing him. Another ptsd moment to live with the rest of his life and it will come back to haunt him.

4 Votes

So is OP coming back to answer questions and give clarification or nah?

Cutting the patient's clothes off is a bit much. Give a cocktail, wait until it kicks in and reassess. If a patient, a psych patient at that, is already irate, going near them with scissors is only going to further irritate and/or traumatize them more. If they were already restrained it was nothing they could have done that required clothes being cut off. I need more info because as of now it's simply overkill.

4 Votes
Specializes in Mental Health, Gerontology, Palliative.

I had a scenario the other day. Giving a patient their 3 weekly IMI relprev. Policy says the patient needed to remain for 2 hours post injection for observation

Patient said "I'm not waiting, if you arent going to give me a ride home, I'll go myself"

It would have taken us 40 minutes to drive the patient home and in which time we were able to monitor, or face the patient disapering, and if they did have an adverse reaction possibly somewhere were they couldnt be found in time resulting in severe harm or worse. We made the decison to drive the patient home, and get what observation time we could get.

Just because its policy people doesnt make it right or best practice. Policy is often made by people in management who have no bloody idea how that plays out in actual clinical practice.

Was there a pressing clinical need to remove the patients clothes?

If not, give the patient some down time, try and get medication into them and try again. If need be, administer IMI medications and then try again.

Do I think it was appropriate to cut the patients clothes of in this situation. No. I think it also particularly could be trauma inducing and create more distress for the patient.

4 Votes
Specializes in school nursing.

I am not sure how I feel about cutting patient's clothing in the ED for this reason. However, yes it is common and expected practice for ED nurses to place a patient in a gown and remove all belongings and items that could place the patient at risk for suicide, including monitor wires, clothing, blankets. Strangulation is a common manner of suicide for SI inpatients. There was probably a better way to get the clothing removed from the patient, as others have mentioned-antipsychotics. But the truth is, the patient's safety matters most.

59 minutes ago, Tenebrae said:

Just because its policy people doesnt make it right or best practice.

Ideally we could keep everyone safe while maintaining very flexible policies. It doesn't usually play out that way given the numbers, the range of potential situations, the resources, etc.

1 hour ago, Tenebrae said:

I think it also particularly could be trauma inducing and create more distress for the patient.

I'm 99.9% sure I wouldn't have cut them off, myself. But, devils advocate: Being held down and given injections while terrified or paranoid seems about as awful as some of the other actions we're debating. Plenty of patients would say that is a traumatic experience and if that were the situation up for debate I'm sure we would hear similar sentiments to what we are hearing with this situation.

2 Votes
4 hours ago, trytounderstand said:

One problem is that the use of chemical restraints and/or physical restraints is not risk free for the patient. Some patients have been harmed by them, and in some cases patients have died. There are laws/regulations that govern the use of chemical restraints and physical restraints. Patients have legal rights.

Specializes in Psychiatry, Community, Nurse Manager, hospice.
8 hours ago, JKL33 said:

No I have never needed to do that.

Do you have any specific ideas about this? I've thought about it a lot over time and haven't had any great epiphanies yet.

How do you plan to ascertain this info, and what is your proposal for maintaining the safety of patient and others?

I've never worked in an ED where it wasn't the policy in this situation.

Yes, I have specific ideas. Patients should be able to wear their own clothes. Where there is real concern that a patient could hang himself with pant legs one to one staff should be used. Patients should also be allowed to wear wedding bands and to keep other items of great sentimental value.

Emergency departments should be staffed with trained psych nurses.

4 Votes
2 hours ago, FolksBtrippin said:

Patients should be able to wear their own clothes.

I have no issue with that to the extent that nothing about the clothing can be used to harm self/others or to conceal dangerous items.

Quote

Emergency departments should be staffed with trained psych nurses.

How would this work logistically?

I don't think it's correct to to compare the care delivered in a space that takes all comers of every age and diagnosis to that of a highly controlled space where concepts like "accepting (or not accepting) the patient for admission" and the words "not appropriate for our milieu" exist. The ED "milieu" is neither better equipped nor more appropriate. Complaints about the attempts of extremely-strained safety nets to handle these patients as best they can and calls for trained psych nurses are a little bit below the belt given the facts of the actual situation.

Perhaps psychiatric hospitals and facilities should be required to operate psychiatric emergency departments? That seems a little more logical than deciding that the general ED should be staffed with psych RNs (how many?)

2 Votes
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