holds vs. restraints

Nurse Ratched, RN · Apr 25, 2005

Are you talking about when you have an order to "force meds"?

Marie50 · Apr 26, 2005

Are you talking about when you have an order to "force meds"?

yes - medicare/CMS says, even holding to give an injection is a restraint!

peaceful · Apr 26, 2005

My gosh of course that is a chemical restraint!! Anything against a pt.'s will would be a restraint.

elkpark · Apr 26, 2005

I've been a psych surveyor for my state and the Feds for the last several years, so I've run into this in plenty of facilities. YES, holding someone down to give them an injection in an emergency situation or to administer a scheduled/routine medication against the client's will (but legally) is considered a behavioral restraint (even though it is a very brief restraint!) It may also be considered a restraint under your state rules/regs, as well. You must have a physician's (or other LIP's) order for the restraint, and you must have the physician (or LIP) face-to-face eval within one hour -- all the same requirements apply as for someone who is strapped to a bed for an hour. There is no difference, as far as CMS is concerned.

I have seen (and cited) many situations where staff were holding clients down to force meds, and there was no order for the restraint because someone felt that the restraint order was "implied" in the order for emergency or forced medication. CMS does not buy that; there is no such thing as an "implied" restraint order.

If you can avoid holding someone down to give a medication, great! That is always preferable, on many levels, to having to wrestle someone down. That kind of situation is a real challenge for your psych nursing, de-escalation, and communication skills. It's always better to talk your way out of a situation than to have to get physical. A "show of force" by staff often avoids having to intervene physically with clients who are still able to maintain or regain some behavioral control. Also, the more alert you can be to what is going on with clients on an ongoing basis during a shift, the more likely it is that you'll be able to pick up on and intervene in a situation before it gets to an "emergency" level. (I don't want to sound patronizing or condescending, and I apologize if I do -- you did ask for suggestions on how to avoid holds, and I don't know what you're looking for there. Good psych nursing is the best way I know of to avoid having to hold people down -- it's not foolproof or guaranteed, but ... :) ).

However, if it comes down to holding a client down to forcibly administer a medication, then all the CMS requirements for behavioral restraint need to be followed (as well as any state rules/regs that may apply). Also, just as a reminder, remember that, if you are putting someone in locked seclusion and have to physically take her/him to the seclusion room (as opposed to her/him walking there voluntarily), that also counts as a restraint and you need an order for the restraint as well as for the seclusion (although one face-to-face eval will do for both).

ARNPsomeday · Apr 26, 2005

elkpark,

A most educational posting. What does LIP stand for?

I've been a psych surveyor for my state and the Feds for the last several years, so I've run into this in plenty of facilities. YES, holding someone down to give them an injection in an emergency situation or to administer a scheduled/routine medication against the client's will (but legally) is considered a behavioral restraint (even though it is a very brief restraint!) It may also be considered a restraint under your state rules/regs, as well. You must have a physician's (or other LIP's) order for the restraint, and you must have the physician (or LIP) face-to-face eval within one hour -- all the same requirements apply as for someone who is strapped to a bed for an hour. There is no difference, as far as CMS is concerned.
I have seen (and cited) many situations where staff were holding clients down to force meds, and there was no order for the restraint because someone felt that the restraint order was "implied" in the order for emergency or forced medication. CMS does not buy that; there is no such thing as an "implied" restraint order.
If you can avoid holding someone down to give a medication, great! That is always preferable, on many levels, to having to wrestle someone down. That kind of situation is a real challenge for your psych nursing, de-escalation, and communication skills. It's always better to talk your way out of a situation than to have to get physical. A "show of force" by staff often avoids having to intervene physically with clients who are still able to maintain or regain some behavioral control. Also, the more alert you can be to what is going on with clients on an ongoing basis during a shift, the more likely it is that you'll be able to pick up on and intervene in a situation before it gets to an "emergency" level. (I don't want to sound patronizing or condescending, and I apologize if I do -- you did ask for suggestions on how to avoid holds, and I don't know what you're looking for there. Good psych nursing is the best way I know of to avoid having to hold people down -- it's not foolproof or guaranteed, but ... :) ).
However, if it comes down to holding a client down to forcibly administer a medication, then all the CMS requirements for behavioral restraint need to be followed (as well as any state rules/regs that may apply). Also, just as a reminder, remember that, if you are putting someone in locked seclusion and have to physically take her/him to the seclusion room (as opposed to her/him walking there voluntarily), that also counts as a restraint and you need an order for the restraint as well as for the seclusion (although one face-to-face eval will do for both).

elkpark · May 4, 2005

(accidental double post -- sorry!)

elkpark · May 4, 2005

A most educational posting. What does LIP stand for?

"LIP" stands for "licensed independent provider" -- CMS language for the other people besides physicians who can meet the requirements for ordering restraints and/or conducting the required evaluations. Nurse practitioners, PAs; CSs and psychologists in some cases.

ARNPsomeday · May 5, 2005

A "show of force" by staff often avoids having to intervene physically with clients who are still able to maintain or regain some behavioral control. Also, the more alert you can be to what is going on with clients on an ongoing basis during a shift, the more likely it is that you'll be able to pick up on and intervene in a situation before it gets to an "emergency" level. (I don't want to sound patronizing or condescending, and I apologize if I do -- you did ask for suggestions on how to avoid holds, and I don't know what you're looking for there. Good psych nursing is the best way I know of to avoid having to hold people down -- it's not foolproof or guaranteed, but ... ).

I apologize for picking your brain, elkpark, but you have the experience. So here goes. Good psych nursing is like wisdom, I suppose. A product of life experience and study.

During my year as a volunteer in a locked inpatient unit, I wasn't allowed to interact with patients. But I saw the difference that a united team can make. Explosive situations were defused right before my eyes.

In what other ways may I learn Good psych nursing? I have not been through psych rotation yet but imagine a good textbook can make a difference. This semester I will enjoy a break from the curriculum and instead take an online Abnormal Psychology course for the pleasure of it. And hope to work in a nursing home or similar setting for the experience, just this summer.

CharlieRN · May 11, 2005

Here are some hints toward "good psych nusing", some are things you can do on your own, others reguire team efforts that you can only contribute to. They are in no particular order. I could tell you horror stories to support each of them but that will take too long

Observe the patients. There is nothing like paying attention. If observations are scheduled, they need to be done on time and carefully.

Investigate, if a situation feels odd, get nosy!

Trust your gut!

Beware of good manners! In everyday life it is "good manners" to ignore a persons little quirks and oddities. There is no place for that in psych assessment. Quirks and idiosyncracys are often the first hint that things are getting weird.

Respect the patient. No matter how crazy he is there is a human in there.

Respect yourself and your peers. Take the time to be aware of your own feelings. Try to be aware of your own weaknesses. It is nearly impossible to be theraputic when you are dealing with a patient who is overwhelmed by the same issues which you have not successfully dealt with. If you are a closet drinker, the Chemical dependency unit is not going to be your ideal work environment. If you are physically afraid of your patients it will impact your theraputic value to them. If you have a poorly resolved history of sexual abuse, (one woman in three does) then the "women's special program" may very likely be too hot to handle. I'm serious. A total personality meltdown is a lot to sacrifice for a job. You do noone any good if you allow yourself to be destroyed by the work.

Again respect your peers. Particularly the ones who work the off shifts. They are professionals. It is not appropriate to believe a patients complaint against them without alot of supporting independent evidence.

Maintain a professional relationship with your patients. Be friendly but remember that they are not your friends. And certainly not your lovers! The three most important things are boundries, Boundries and BOUNDRIES.

It is not your job to make the patient feel better, but to function better. Sometimes that involves comforting him, some times it may involve setting firm limits.

MAGIK GIRL · May 11, 2005

Here are some hints toward "good psych nusing", some are things you can do on your own, others reguire team efforts that you can only contribute to. They are in no particular order. I could tell you horror stories to support each of them but that will take too long
Observe the patients. There is nothing like paying attention. If observations are scheduled, they need to be done on time and carefully.
Investigate, if a situation feels odd, get nosy!
Trust your gut!
Beware of good manners! In everyday life it is "good manners" to ignore a persons little quirks and oddities. There is no place for that in psych assessment. Quirks and idiosyncracys are often the first hint that things are getting weird.
Respect the patient. No matter how crazy he is there is a human in there.
Respect yourself and your peers. Take the time to be aware of your own feelings. Try to be aware of your own weaknesses. It is nearly impossible to be theraputic when you are dealing with a patient who is overwhelmed by the same issues which you have not successfully dealt with. If you are a closet drinker, the Chemical dependency unit is not going to be your ideal work environment. If you are physically afraid of your patients it will impact your theraputic value to them. If you have a poorly resolved history of sexual abuse, (one woman in three does) then the "women's special program" may very likely be too hot to handle. I'm serious. A total personality meltdown is a lot to sacrifice for a job. You do noone any good if you allow yourself to be destroyed by the work.
Again respect your peers. Particularly the ones who work the off shifts. They are professionals. It is not appropriate to believe a patients complaint against them without alot of supporting independent evidence.
Maintain a professional relationship with your patients. Be friendly but remember that they are not your friends. And certainly not your lovers! The three most important things are boundries, Boundries and BOUNDRIES.
It is not your job to make the patient feel better, but to function better. Sometimes that involves comforting him, some times it may involve setting firm limits.

great advice! it works in the er as well. that is where i work. :)

ARNPsomeday · May 11, 2005

Thank you for taking the time to reply and for sharing, CharlieRN. Your advice is very well taken.

Here are some hints toward "good psych nusing", some are things you can do on your own, others reguire team efforts that you can only contribute to. They are in no particular order. I could tell you horror stories to support each of them but that will take too long
Observe the patients. There is nothing like paying attention. If observations are scheduled, they need to be done on time and carefully.
Investigate, if a situation feels odd, get nosy!
Trust your gut!
Beware of good manners! In everyday life it is "good manners" to ignore a persons little quirks and oddities. There is no place for that in psych assessment. Quirks and idiosyncracys are often the first hint that things are getting weird.
Respect the patient. No matter how crazy he is there is a human in there.
Respect yourself and your peers. Take the time to be aware of your own feelings. Try to be aware of your own weaknesses. It is nearly impossible to be theraputic when you are dealing with a patient who is overwhelmed by the same issues which you have not successfully dealt with. If you are a closet drinker, the Chemical dependency unit is not going to be your ideal work environment. If you are physically afraid of your patients it will impact your theraputic value to them. If you have a poorly resolved history of sexual abuse, (one woman in three does) then the "women's special program" may very likely be too hot to handle. I'm serious. A total personality meltdown is a lot to sacrifice for a job. You do noone any good if you allow yourself to be destroyed by the work.
Again respect your peers. Particularly the ones who work the off shifts. They are professionals. It is not appropriate to believe a patients complaint against them without alot of supporting independent evidence.
Maintain a professional relationship with your patients. Be friendly but remember that they are not your friends. And certainly not your lovers! The three most important things are boundries, Boundries and BOUNDRIES.
It is not your job to make the patient feel better, but to function better. Sometimes that involves comforting him, some times it may involve setting firm limits.