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My facility is restraining a resident and I feel that I can't help.

Nurses   (1,309 Views | 21 Replies)

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MunoRN has 10 years experience as a RN and specializes in Critical Care.

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19 minutes ago, mmc51264 said:

If someone has a HR of 48, I am holding the dose of a BB and telling the provider. I guess I am just use to inpatient care not LTC. Forgive me. 

As an inpatient, are you saying you're only taking their vitals because they are on a BB?  Wouldn't you be taking them whether they're on a BB or not?

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VivaLasViejas has 20 years experience as a ASN, RN and specializes in LTC, assisted living, med-surg, psych.

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5 hours ago, MunoRN said:

As an inpatient, are you saying you're only taking their vitals because they are on a BB?  Wouldn't you be taking them whether they're on a BB or not?

Not in long-term (intermediate) care facilities, unless the resident's doctor orders VS to be taken routinely, or a nurse using nursing judgment deems it necessary. As someone else already said, the facility is the resident's home and part of making a place home-like is to minimize medical interventions unless their condition requires it. Personally, I take four B/P medications and rarely check my vitals at home; every now and then I get curious and do a set, but my pressure has been in range for years now so I don't worry too much about it. (Still, if things went sideways I'd be sure to check it more often.) Some of these old folks have been hypertensive and on meds for decades, and most of the people you see in ICF/RCF have some form of blood pressure problem. Can you imagine how you'd like someone doing vitals on you every shift, every day, for the rest of your life?

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Tenebrae has 8 years experience as a BSN, RN and specializes in Mental Health, Gerontology, Palliative.

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Working in long term care, we would routinely do a full set of obs TPR and BP on all patients once a month and more often if clinically indicated eg patient feeling unwell, neuro obs post fall. 

The last facility I worked in the doctor wanted a pulse pre admin of digoxin, I've worked in other facilities where the doctor didnt want a pulse pre admin of digoxin

Particularly in long term care, stop for a moment and think about what you will do with the information and also look at the bigger situation. For example I experienced a situation where an patient was having hypo's. The charge nurse obtained an Drs order for AC BGL and administration of rapid acting insulin. Makes perfect clinical sense right?

Unfortunately looking at the entire situation revealed that this patient was going into the end of life stage and hadnt eaten more than a mouthful of food for several days and often when the body begins to shut down it looses the ability to effectively regulate body processes. Understandably the patients BGL was low. 

Which raises the point, with a dying patient, do we continue to stick the patient three times a day and administer insulin to try and rectify what is in essence the patients body shutting down? Or do we go 'right, this patient is dying, lets focus on keeping them comfortable?"

You mentioned your lady has severe dementia. I've noticed often patients with servere dementia can be very resistive to nursing care including things such as having their blood pressure taken and how would having a daily BP taken impact on that patient. More importantly would that information actually make a change in how the doctor chooses to treat their patient?

Your nursing focus is usually very different in a community/long term setting as opposed to acute clinical care

hope that makes sense

Edited by Tenebrae

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K+MgSO4 has 12 years experience as a BSN and specializes in Surgical, quality,management.

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I hate copying a full post so I'll just say big props to @Tenebrae a great answer. 

 

With regards to restraint have a look at this link https://www.bettersafercare.vic.gov.au/resources/clinical-guidance/older-people/guidance-on-use-of-bed-rails which came out today. I appreciate it is Australian but SCV has been working with IHI.

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On 10/30/2019 at 9:03 PM, Nursingstudent___ said:

Thank you for the reply. I learned in my pharm class that we were supposed to assess bp and hr prior to giving a beta-blocker. However I also understand that what we are taught is not always the same as how something is done in the real world. I appreciate it a lot. 

You are supposed to assess bp and hr prior to giving a beta blocker for a baseline. However what's most important is the vital signs during the peak level. If the bpm is lower than 50 you hold. A baseline is still important so I'm a bit shocked that so many people just give as ordered and don't bother to check. I've learned that in nursing school as well and I have been on beta blockers myself for 4 years now. I have passed out because of it. I am still in school like you so I can only share what I know as a patient and not as a nurse but I would say just go with what you learn in school because that's what going to help you pass the NCLEX. I too have noticed a lotttt of things at my clinical site that completely go against what I've learned in school to the point where I've contemplated reporting it. 

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11 hours ago, Tenebrae said:

Working in long term care, we would routinely do a full set of obs TPR and BP on all patients once a month and more often if clinically indicated eg patient feeling unwell, neuro obs post fall. 

The last facility I worked in the doctor wanted a pulse pre admin of digoxin, I've worked in other facilities where the doctor didnt want a pulse pre admin of digoxin

Particularly in long term care, stop for a moment and think about what you will do with the information and also look at the bigger situation. For example I experienced a situation where an patient was having hypo's. The charge nurse obtained an Drs order for AC BGL and administration of rapid acting insulin. Makes perfect clinical sense right?

Unfortunately looking at the entire situation revealed that this patient was going into the end of life stage and hadnt eaten more than a mouthful of food for several days and often when the body begins to shut down it looses the ability to effectively regulate body processes. Understandably the patients BGL was low. 

Which raises the point, with a dying patient, do we continue to stick the patient three times a day and administer insulin to try and rectify what is in essence the patients body shutting down? Or do we go 'right, this patient is dying, lets focus on keeping them comfortable?"

You mentioned your lady has severe dementia. I've noticed often patients with servere dementia can be very resistive to nursing care including things such as having their blood pressure taken and how would having a daily BP taken impact on that patient. More importantly would that information actually make a change in how the doctor chooses to treat their patient?

Your nursing focus is usually very different in a community/long term setting as opposed to acute clinical care

hope that makes sense

I just wonder if we had been checking prior to administering the med she wouldn't have passed out. I know it's her home but she had to go to the ER after she passed out and had a ton of tests done.  She does have pretty bad dementia but she is very sweet and cooperative. I do understand what your saying though. 

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The answers to your questions re: VS and restraints are most likely covered in the state regulations that cover this level of care - not acute care, not SNF.  You likely will not find answers on this forum unless someone is familiar with your specific state regs for your specific level of care.

If you find those regs, you may find the answers there, or you can reach out to the agency that oversees your level of care for your state.  They sometimes have social workers, RNs or other specialists that can assist you.

What you are learning in pharmacology and nursing school apply to acute patients.

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Orion81RN has 7 years experience.

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On 10/31/2019 at 9:05 PM, MunoRN said:

As an inpatient, are you saying you're only taking their vitals because they are on a BB?  Wouldn't you be taking them whether they're on a BB or not?

When I worked rehab, we took vitals each shift. HR and BP had to be taken before administration of beta blockers and documented upon administration. You couldn't even click that you gave it until you entered a value. Otherwise, vitals could be taken at any point during the shift. I do agree though that in a home setting this is usually unnecessary. 

 

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Orion81RN has 7 years experience.

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On 11/1/2019 at 2:23 PM, Nursingstudent___ said:

I just wonder if we had been checking prior to administering the med she wouldn't have passed out. I know it's her home but she had to go to the ER after she passed out and had a ton of tests done.  She does have pretty bad dementia but she is very sweet and cooperative. I do understand what your saying though. 

Ok, well this is a good scenario for you, then. Lets say you graduate and begin work in LTC. And you aren't doing routine vitals. Then suddenly you have this happen. Using your nursing judgement you decide to tell the doctor you think its a good idea to start obtaining vitals before med administration and you ask him for parameters to hold. 

In this situation, there is no nurse to do an assessment. Med techs do not "assess." Once in acute care or even sub acute skilled care, this patient is definitely getting vitals taken. *Because something happened.* Vitals were not indicated before bc the patient was in her home environment and she was stable....until she wasn't. Thats when you use your nursing judgement and utilize the nursing process. 

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Glycerine82 has 4 years experience as a ASN, LPN and specializes in SNF/Rehab/Geri.

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On 10/30/2019 at 9:16 PM, Rose_Queen said:

But a patient at home doesn't do a daily check. For these patients, it is their home setting. I sure as heck don't check my HR and BP before popping my losartan.

This. 

I work in a SNF and we don't check BP prior to beta blocker administration. The rationale is that folks at home don't check their BP every day and by checking we end up with nurses holding the med for a systolic over 100 and a pulse over 60.  

Occasionally we'll get someone with parameters & we of course check it when the dosage has recently been adjusted. 

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