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knock it off or i'm going to put you in restraints!

Posted

Specializes in Psychiatric/Mental Health. Has 5 years experience.

Experienced Psych Nurses....

Especially in a crisis unit, there comes a time when a patient is being a danger to themselves or others, and the need for restraint is necessary. For a psychotic person, I will typically say something like "I am going to put you in restraints right now to keep everyone safe and help you stay in control until the medicine starts working." Is this appropriate?

Now, for someone who is more aware of their actions, say, a behavioral group home adolescent or a medication seeker or personality disordered patient, how do you set limits and expectations without directly threatening them? It would not be therapeutic nor appropriate (or, I'm guessing, legal) to storm in the room with security and scream "STOP THIS NONSENSE RIGHT NOW OR I'M PUTTING YOU IN RESTRAINTS" ... so, how would I say it?

Always looking for ways to improve my communication skills so any input is appreciated!

Whispera, MSN, RN

Specializes in psych, addictions, hospice, education.

The only legally ok reasons for restraints are that a patient is acutely dangerous to self or others.

If that's the case in the first scenario, and talking/listening, isolation, show of strength (gathering of staff to show you, as a group, won't let any harm happen), medication, and other things I can't remember right now have failed, saying what you wrote is probably ok. I say probably because I can't know the whole situation from a few sentences.

In the second scenario, first, you can't restrain because the patient is med-seeking or has a personality disorder unless he's dangerous, right then, to self or others. You also can't threaten or it's assault. Don't do it. You can try lots of other things before you get to the point of needing restraints.

celery_juice

Specializes in Psychiatric/Mental Health. Has 5 years experience.

Thank you for your response. I think I didn't articulate my question right...I know that threatening restraints is assault, so if it has gotten to the point where restraints are imminent how do you tell the patient without it becoming an ultimatum/threat/assault?

Not an experienced psych nurse, but just finished my psych rotation. So this is an opportunity to state what I have learned and then in turn, you can help me learn.

Start with the non-threatening approach and use de-escalation techniques in the pre-assaultive stage. Explore feelings, concerns, problem solving techniques and do some boundary setting to avoid assaultive phase. Document the interventions and response.

Move on to the interventions for the assaultive phase, if necessary, document interventions and response.

Once the post assaultive phase has arrived, talk to the patient, other staff and re-evaluate where the patient is. Set further boundaries and have them "start over" so to speak.

Setting boundaries can still be therapeutic. Just keep it short and simple so it is clear.

With that said, I realize there is textbook and real world, but psych nursing revolves mostly around the "art" of nursing. I watched many nurses on the BHU this semester set clear limits to patients that were DTS/DTO and interestingly, could roam the halls in peace with the others. Its fascinating to me, really.

Forgot to add, set limits to show that there may be consequences without stating the consequence, and if you really know restraints are really going to happen, form the "show of force" squad and see if they start communicating, etc.

Davey Do

Specializes in around 25 years psych, 10 years medical. Has 42 years experience.

Bottom Line: "You have Two Options- One: Make a Commitment to Safety, do Nothing in Word or Gesture that could be Interpreted as a Threat of Harm to Yourself or Anyone Else, or Two: Be Restricted of Your Right to Freely Move About."

Edited by Davey Do
tense

celery_juice

Specializes in Psychiatric/Mental Health. Has 5 years experience.

""Bottom Line: "You have Two Options- One: Make a Commitment to Safety, do Nothing in Word or Gesture that could be Interpreted as a Threat of Harm to Yourself or Anyone Else, or Two: Be Restricted of Your Right to Freely Move About."""

thank you! thats more along the linea of what i was looking for.

Davey Do

Specializes in around 25 years psych, 10 years medical. Has 42 years experience.

thank you! thats more along the linea of what i was looking for.
You're Welcome, celery juice ! Rote Memory comes in Handy in Stressful Situations!

Safety Coach RN

Specializes in Behavioral Health. Has 8 years experience.

Bottom Line: "You have Two Options- One: Make a Commitment to Safety, do Nothing in Word or Gesture that could be Interpreted as a Threat of Harm to Yourself or Anyone Else, or Two: Be Restricted of Your Right to Freely Move About."

And this gives the patient the autonomy of choice.

Whispera, MSN, RN

Specializes in psych, addictions, hospice, education.

Keep in mind that the patient who is about to blow a gasket isn't likely to hear everything you say, so keep it short and simple. What they are likely to hear is any emotion in your voice. Your angry voice will probably escalate their anger. Your anger might ignite their "fight or flight" even more than it's already ignited. While you surely can be angry or afraid or feeling any other emotion, you have to keep that under control as much as you can for everyone's sake.

One last bunch of thoughts (for this group of paragraphs anyway), people can pick up your emotions by seeing your body language and facial expressions as well as your words. Your priority is to keep everyone safe, not punish the patient for mis-behavior that could be not within his control. If you need to restrain, keep that priority in mind. It's not about the surface emotions. It's about what's under it all.

I like what epitome and Davey wrote. :D

It's important to debrief with your peers and the patient if restraint becomes necessary. I've seen some awesome nurses be the epitome of caring and kindness to a patient in full restraints. It matters.

I agree that, while it's unprofessional and a violation of state and Federal regulations to threaten people with restraints, I also feel that it's unfair to not at least make people aware that that is where they're heading (particularly people who are new to "the system" and may sincerely not realize that is a risk they are running). In those kinds of situations over the years, I have said to people, in a calm, reasonable tone of voice, something like, "I want you to understand that, if you aren't able to pull things together and change the path you're on right now, you're likely to end up in restraints. I don't want that to happen, and I want us to work together to figure out a way to keep that from happening." To me, that's v. different from threatening someone with restraints; I consider that providing useful information and offering them information about how to avoid ending up in restraints and a way out of the situation, and it's treating them with respect and connecting with them as another human being. (Of course, that approach isn't always successful :), but it is successful a good deal of the time.)

Mandychelle79, ASN, RN

Specializes in Psych. Has 2 years experience.

My objective of the patient is toeing the line is to eliminate the audience so I offer going back to their room or going into the seclusion room with the door open for a calm down period. When they make their choice we offer prns if ordered.

JustKeepDriving

Specializes in Forensic Psychiatry.

I've always described psychiatric nursing to my orientees and students as a massive game of chess between patient rights and unit safety. Patient's have the right to be obnoxious however both staff and patients have the right to feel safe on the unit. As the psychiatric nurse it is through our assessments and the observations from our staff that determines... "Is this person just being obnoxious... or this person is escalating and will become an imminent risk to themselves and others." Our assessments are more than just an assessment of the individual, but an assessment of the environment, our staff resources, and the other patient's on the milieu/milieu acuity as well. Sometimes an assessment will reveal, "yeah, this patient is being very obnoxious but we just have to deal with it", while the same behavior at other times will reveal, "This patient is acutely disrupting the milieu and the body language/verbal content of his peers is telling me that he is becoming an imminent risk to himself and might end up getting assaulted for this behavior."

Each patient is individual and different interventions work differently for different patients. Patients that have been there for a while are always easier to work with than those that are new because we have lots of documentation about their precursors to assault/self harm, multiple assessments displaying what to look for when assessing their aggression and self harm potential and identified staff members that have built rapport with them. New admits or short term stabilization patients are always more difficult because we know very little about their behavior and the staff hasn't built rapport with them.

Generally I start off by giving people the most amount of options possible, "It's okay to be upset... but you can't do this here. How can we help your coping skills right now so that you can continue the positive progress you've been making." If the escalation continues I narrow the choices available to them until I've either exhausted all the options available to me (Diversionary activities, PRN medication, Counseling/limit setting/problem solving, patient identified coping skills in their treatment care plan, offering patient quiet space) or the patient has escalated so much that they now Imminent Risk... and then it becomes, "We are here to provide a safe and therapeutic environment for all patients. Right now you are showing me that you're unable to follow staff directions and maintain safety on the milieu. Unless there is anything more we can do for you, I need you to walk with me to the side room (which is our term for seclusion), or we can escort you there" (which is generally done with a show of force with enough staff available in the event the patient makes the worst possible choice).

I go with the rule of thumb "least restrictive measures" so the last option is always the choice between entering seclusion safely or them becoming combative, leaving hands on as the only option and the patient entering restraints. Generally, I explain this as, "Show me you can go to the side room safely. Do not make any verbal or physical threats or we will have to go hands on and take more restrictive measures."

celery_juice

Specializes in Psychiatric/Mental Health. Has 5 years experience.

"I want you to understand that, if you aren't able to pull things together and change the path you're on right now, you're likely to end up in restraints. I don't want that to happen, and I want us to work together to figure out a way to keep that from happening."

yes! this! thank you!~

Also, when a person is being obnoxious or is escalating, it is usually too late to tell them about the restraints in a way that they will receive the communication therapeutically.

It is best to make this known very early. When I've done geri-psych or worked with sundowners who are fairly lucid during the day, I have had "the talk" with them at the beginning of the shift.

"I know that sometimes it is hard for you to act in a way that is safe to us and yourself, so we have the option of restricting your movements until you are able to be safe again. It is only temporary and once everyone is safe the restrictions will be lifted."

It works out pretty well.

SheriffLauren

Specializes in Adult Psych. Has 5 years experience.

Your totally correct I think, I use similar methods when dealing with acute patients on my units. I think its helpful and fair to be frank and honest with the patients, but never threatening. R+S is used when you have exhausted other methods.

Sometimes is literally is necessary to ensure safety, whether its a violent/paranoid patient trying to assault or a suicidal or self harming individual who will not/is unable to CFS. Some patients will push staff to the brink of R+S and then say, "im allright," but 10 minutes later start all over again. As an RN you need to assess 'whats really going on here?' or 'are they actually capable to being safe, do they even know how to calm down/be safe?' because often times the patients simply do not possess that skill.

The important thing and most difficult is learning when to draw the line and when it is truly necessary to initiate.