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I might be in trouble. I will not use restraints, care planned or not.

Geriatric   (4,197 Views 24 Comments)

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We had a very demented gentleman, very childlike, who is a one assist since he's rather unsteady. Because we can't get him to sit still the charge nurse care planned a geri chair with a tray (for those in the UK, the big, padded recliners on wheels).

He's had a lot of back pain for which he has Tylenol 3 Q6H PRN, and for his agitation Ativan 0.25 mg Q6H PRN. He also has IM Haldol. And, of course, no one ever uses these meds because they're controlled substances and if you actually use them you get a reputation for overusing PRESCRIBED meds.

Well. I work with "perfect nurse." You have one. She writes up everyone for everything and does everything according to the very rigid book. SHE asked me this mornig if he had an order for anything injectable. I told her I was giving him an Ativan. I also gave him a T3 for his back pain - hardly an obtunding combo.

It immediately calmed him down. Pleasant all AM.

After lunch things were hectic, as always. Perfect Nurse was floating TX between 2 units. I TOLD her I'd take care of our PM tx's - they are three neds, a cath, and an inhaler. She insisted on doing it all. I had kiddingly told her at lunch that I would chemically restrain demented wanderer with Ativan and T3 at 2. I did plan on repeating the dosages, but geeze Louise, hear the sarcasm, no?

Well. He won' sit still. We're busy. I have 5 minutes until being done with my med pass. They want him in the geri-chair. I knowm how badly this distresses him so I say, "give me 5 minutes and I'll take him over." They insist that there aren't 5 minutes. An aide grabs the chair, Perfect Nurse grabs him, and they indicate the tray and say, "Sue? Well?" I got to grab him and he's flailing and striking and yelling, "NO!"

I let him go. I said, "Okay, buddy. It's okay." The aides are yelling at me that they'll get into trouble if he falls. I told them that I had obviously accepted responsibility for him. Gave him his meds. Within 5 minutes he was calm and smiling again.

This affectionate childlike man now flinches when anyone goes to touch him.

Perfect Nurse goes to the charge nurse, repeats what I said about chemically restraining him, and explains that I refused to follow the care plan. I told her to fire me on the spot because a care plan wasn't carved in granite and I was not going to in effect chain the nut to the radiator because he was inconvenient. I then burst into tears - I feel very passionately about this issue. Talk about indignity!

I'm not going to survive LTC.

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Nascar nurse has 25 years experience as a ASN, RN and specializes in LTC & Hospice.

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My first instinct is to ask if the Tylenol and Ativan are working so well, why doesn't some call the Dr. and get an order for both to be routine (they don't necessarily have to be given at the same time). Why let this poor guy get all worked up! Either of these medications every 6H is far from excess - the excess comes from "tackling him into a chair" once his behavior has been allowed to escalate out of control. I believe there is a time and place for restraints, but this isn't it.

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Seems to me you did the required pain assessment.

You treated his pain and he was quiet because he was comfortable.

When you said, "chemical restraint" they tool it seriously.

And the care plan couldn't have said you can't wait five minutes to complete your medication administreation before getting him into the chair.

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10,263 Posts; 57,544 Profile Views

And the care plan couldn't have said you can't wait five minutes to complete your medication administreation before getting him into the chair.

No, Perfect Nurse said that. And then went STRAIGHT TO THE CHARGE NURSE to complain about me. Luckily, the charge nurse know who this woman is - she has a reputation as a rhymes with rich.

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Jo Dirt has 9 years experience.

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The last thing people need to worry about with elderly and confused nursing home patients is addiction. He needs routine medications and they need to stay in his system or else he will be miserable.

I'm lucky the facility where I worked did not have any reservations about breaking out the ativan or pain meds. I hope if I ever get in such a shape I will be adequately medicated.

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Dolce is a RN and specializes in Day Surgery, Agency, Cath Lab, LTC/Psych.

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This is so sad. Everyone knows that nursing home residents are often in severe pain but are not always able to express that verbally because of their mental state. I think you did the exact right thing--I would have medicated him also. I agree with the above posters who suggest getting an order for scheduled T3 and Ativan for this guy. Maybe you can contact the doc about it out of earshot from Perfect Nurse.

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nursemike has 12 years experience as a ASN, RN and specializes in Rodeo Nursing (Neuro).

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This is an issue I encounter on my neuro unit, too. Our fall rate is fairly appalling, at times, but I hate to use restraints. It goes against my innate belief in the dignity and autonomy due every human being, plus it's a lot of extra paperwork. Plus, a fair portion of our falls are patients who are alert and oriented. Comes a point where a person has the right to fall, if he or she so chooses.

Sticking with the ones who aren't able to make an informed choice, I will use restraints if it's necessary, but not for convenience. Most of the nurses I work with are on the same page, and we'll keep an eye on the problem pts for each other. Sadly, sometimes it just depends on census: if we're all carrying full loads and have multiple pts at risk, restraints are more likely.

Your story illustrates two facts. One, there are some people you just can't joke around.

The other lesson, which has become clearer to me than I ever thought possible over the past couple of years, is that you can't let the aides be the nurses. You (the OP and everyone else) probably knew that, but it has been a bit of a shock to me. I work with some very good aides, but the best of them isn't a nurse, and it shows.

I got my first hint of this before I ever started nursing school. We were bringing a fellow back from a test, and as I dropped his chart at the nurses' station, I heard an aide--one of my favorites--tell my partner to put his restraints on when we got him to bed. The fellow had fallen six times during the previous shift, but he was AOx4--just stubborn. I asked the nurse and she concurred that we couldn't restrain him, but to the aide it was perfectly obvious we had to commit false arrest, for his own good.

As a nurse, I've seen many other examples of aides--good, hardworking, intelligent aides--just not using good critical thinking skills. Things like getting a BP of 100/90, writing it down, and moving on without saying a word. At first, I was baffled, but lately I've been contemplating the shocking possibility that I actually learned something in nursing school.

By the way, I appreciate your unwillingness to go over the CN's head. Sounds like you two communicate reasonably well, anyway. I had an incident awhile back where an aide (not one of the better ones) was assigned to sit with a confused pt of mine as an alternative to restraints. He was NPO and complaining of thirst, so she wanted me to ask the doc if he could have ice chips. I got her some mouth swabs and said I'd ask about chips when I saw him next. An hour later, the CN tells me she paged the doc and the patient cannot have ice chips. Aide went over my head to get a doc paged for a question I already knew the answer to...grr!

Uh, this is starting to sound like a rant about aides, which isn't where I meant to go, so I'll finish with a universal peeve: people (including nurses) who threaten a patient with restraints "if you don't behave." I understand the temptation--I really do--but restraints are not to be used as punishment, or a threat. Again, I really hate to use them, but before I reach the point of threatening him with restraints, he's already tied down.

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Hopeslayer specializes in sub-acute.

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He's had a lot of back pain for which he has Tylenol 3 Q6H PRN, and for his agitation Ativan 0.25 mg Q6H PRN. He also has IM Haldol. And, of course, no one ever uses these meds because they're controlled substances and if you actually use them you get a reputation for overusing PRESCRIBED meds.

I find that rather strange. Why would a facility shy away from using PRN meds for pain and anxiety? Especially those small doses.(Except for the IM haldol)

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Soirry, but Perfect Nurse needs to be brought to the attention of your DON, as well as the physician when they make their rounds.

Who was actually on paper as being assigned that patient? If it was you, he was your responsibility and she actually needed to get permission from you to do anything to him. Look at it that way.

If you do not like the way things are being done in this facility, LEAVE. I am sure that there are many other places that would want you. You are what nurses should be like, not the behavior of that other one. And what in the world was she doing by telling you what you need to be doing. She is not an RN, therefore she can delegate to you. Was not her time or place for it. You told her what you were going to be doing, and she went around that. Not a good thing for her to be doing. Could actually get her fired from some places.

Wonder what she would be saying if it were her family member there?

Sorry, but I have no patience for people like that. She is the one that should have been reported, and even restrained.

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And if she is an LPN, she has no authority to delegate to you, or to take over your patient. You told her what you were doing and she did what she wanted, and it definitely was not the correct thing to do. She is the one that should be written up.

What she did was 100% wrong in any situation. If that is what people are going to do at that facility, move on to something better. You are worth it.

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