First time using restraints...

[cleback]

My psych nurse job was my first job after graduation, and I've been working now for about 5 months. I recently had to put my first patient in behavioral restraints. It was just me, a travel medical nurse, and a orientee working, so it was quite the new experience for all of us. Two questions come to mind:

1) The security guard and the nurses had to physically take her down to the floor because she was drop-kicking the plexiglass out of the front doors. There were only four of us-- three to hold her down and myself to give the injectables. Two more security guards were on their way, probably only 2-3 minutes away. My thought was to wait until the others arrive to give the IM medications. To me, the three alone wouldn't be able to hold her at that point and since the medication doesn't start to kick in for at least 15-30 minutes after administration anyway, it wasn't worth taking my hands off her and risking a needle stick injury. However, the nurse and the guard were yelling at me to give the medications right away. Would you have given the medications right then or waited the 2-3 minutes for the additional hands?

I ended up sitting on her knee while giving the injections in her hip, but it didn't feel safe.

2) I'm having serious doubts about the place I work. I had a heck of a time finding a provider that would give me an order for the restraints. The psychiatrists out and out said they didn't want to be bothered at night. The person we have on nights is the medical doctor on call, and he told me I shouldn't be calling him with that (our medical MDs I think don't feel comfortable with psych issues and don't believe they should be called for them). After he chewed me out, I had to call the on-call MD for the medical floors (he had no idea why I was calling him either). I got the order, thank goodness, but then he wouldn't call me back to give the face-to-face report. I had to stay past my shift until the psychiatrist came in in the morning. I addressed with the director and he said

not to get an order right away but wait til morning until the issue can be clarified . Have you ever heard of that???? I then approached the nursing director who told me to call the MD that refused to give me the order in the first place.

Sorry it's a long post. The second one is probably more of a rant-- lol. But your thoughts would be appreciated!

[Davey Do]

cleback:

Rant away! You've got yourself some valid concerns here.

Restraining an individual can be a dangerously traumatic experience for all involved. The staffing situation was not the best. But, now that you've experienced the process, you are learning from the experience. The School of Hard Knocks graduates usually excell.

First, SOMEONE is in charge during the restraint process. From experience, it's almost always the RN. Others may make suggestions, but the RN is ultimately responsible. And the Institution's Nurse usually carries more clout than an Agency Nurse.

If you were able to inject the medication without incident, it was a successful administration. Injections should be given at the safest window of opportunity, as many times, the behavior will not cease without it. It sounds like you were creative in your approach and got the job done.

Sometimes, the mere act of the injection has an almost immediate therapeutic effect on the individual's erratic behavior. Whether it be a decline after a crescendo, or the medication taking effect, is anyone's guess. But it happens.

It's a sticky wicket when those in control are not reality-oriented or user friendly. Approaching the Director with your concerns and perspective on the situation is a good move. Documentating the situation with your concerns, separately from the patient's chart, and giving a copy to the director, is also a good idea.

Document everything of concern for communication and proof. Without breaching confidentiality, of course.

Request a copy of the Policy and Procedure guidelines that gives the variables in dealing with situations such as this. You obviously want to do the best job you can. A well-versed employee is a better employee.

Personally, and professionally, it appears that you handled the situation well. Keep on with what you're doing.

Dave

[Davey Do]

Hey cleback-

I wanted to clarify something in post script: When immobilizing the knees, it should be done from a lateral approach and never from a frontal/patellar approach.

You're probably aware of this. I guess if you gave the injection in the gluteus, you couldn't have very well sat on the patient's patella.

Oh well. For whatever it's worth.

Dave

[mentalhealthRN]

A few thoughts come to mind here.........I would find out what both your state OMH regulations are as far as time frames for getting a verbal, getting it signed in person, having the pt seen by a provider--and what providers can do this--MD, NP, PA, etc.......these things may vary by state so it would be kinda pointless for me to tell you what our laws are in NY. lol Its always nice when a doc gives you a hard time and refuses to do something when you can pull out regulations from the OMH (office of mental health) for your state and be able to tell then exactly what you need from them--per the regs! they usually respond better. That way too you can blame it on the regs.

I have had kinda a similar situation where there was a differing opinion as far as when to give an injection with a violent patient.

On several occasions this happened. The patient would get taken down by security/staff--nurse, techs, sometimes docs--and it was a tough take down with a lot of struggle. The patient doesn't settle at all. Is fighting hard and staff are really struggling to hold the person down. The patient is on the floor. Additional staff have gone and brought a stretcher with restraints on it to where we are. The staff wants to move the pt to the stretcher and get on the restraints then give the med. I suggest multiple times that we medicate on the floor then move the pt once it kicks in a bit as it is too dangerous to move the pt--dangerous for all doing the restraining and the patient. They argue with me. then in the end we end up--crazy thought--medicating the pt on the floor! lol and hey it works--great. But the idea had to come from the charge nurse who had been there for 20+years and no one listened when I suggested this. This was in the Psych ER so the patient had not been seen yet and had not been assigned to a nurse yet. When not assigned yet generally the charge would run the situation. However, usually the nurse assigned to that patients care would run the situation--do the talking to the patient. So yeah even though the charge is the charge its important to listen to ideas and thoughts from all staff involved. I had not been there in the psych ER but for a few months when this first came up. So a good suggestion of the best and or safest way to do things can come from anywhere--you have to work as a team....this works best to keep all safe. In general I would say wait for more help before you give an injection. If no one else is coming then sometimes you do have to make do.

I was once alone with one other nurse on nights and a geri patient became violent--the other nurse restrained him alone and got a gash over his eyebrow that needed stitches. He wanted me to give an injection before security got there--ummm no we will hold him for a few. When they get thereI will give it--Im not getting hurt, no way!

You will get more comfortable the more restraints you do.

I hate all the paperwork so it makes me that much better at verbal de-escalation to avoid them all together! lol