reamed out for using soft wrist restraints

[newnurse012]

Upon listening to report from the daylight nurse, I was told that the patient was a DNR and was ordered to be on a non-rebreather to keep sats >90%. The confused pt had been continually pulling at his mask and refused to leave it on. On nasal cannula at 6l, pt dropped into the 70s and on roomair into the 60s. The daylight nurse stated that she did nothing because she considered this patient refusal.

I felt that since the patient was confused, he was not in the right mind frame to refuse. I notified the physician and he ordered soft wrist restraints bilaterally. I applied them and performed hourly assessments.

When night shift came on, the nurse who was following me listened to report. I asked if she had any questions and she said "Yeah, why the hell did you put restraints on that guy. You're just cruel." I then stated that his sats were low on both nasal cannula and roomair and that I couldn't just chart that I knew he was 60% on roomair and do nothing. She suggested that rather than record his sats on roomair, I should have held the nonrebreather on his face, obtained a good pulse ox reading, then let him remove the mask as he pleases for the rest of the shift. She then stated that she hopes that she never has a nurse like me who allows my patient to suffer and be restrained.

I honestly was trying to do what was best for the patient in restraining him. I suppose I figured it would be better to suffer in restraints than to suffer gasping for breath. But now I am second guessing my actions. Was I wrong in what I did? Does the fact that he is a DNR make a difference? What should I have done? Advice would be greatly appreciated. Thank you!

[Cinquefoil]

What I can't believe is that the oncoming nurse was seriously suggesting that you FAKE the O2 sat. And yes, I said FAKE. If you TEMPORARILY hold O2 up to someone's face and then record that as their REAL O2 sat to save your own bacon, that is FALSIFYING that person's sat IMHO

I wonder how many other VS that nurse has faked?

Go you for not doing that

I think you did all right with a terrible dilemma. Should a confused person have the right to refuse Tx? Well, yes, and legally they do, at least in the state I work in.

However....lack of O2 may create more confusion thru hypoxia. What is lost during hypoxia may or may not come back. Your actions helped prevent any more loss of cognition.

So, do you honor the decisions of the confused person, or honor the potentially lucid person underneath?

If the person is just confused, period, end of story, you might check in with family members esp. medical POA/conservators about wishes and instructions.

Then, if family wishes O2 not be forced, have family work with MD to draw up new advance directives. & meanwhile document document document

Just my 2cents

[nurse2033, MSN, RN]

Patient removing needed medical equipment is an absolute indication for restraints. Any nurse that allows a confused patient to remove oxygen under those circumstances should be written up at least. Refusal of medical care is based on informed consent, is she insane?

[kids]

Why not seek treatment for the 'pulling' behavior rather than restraining?

The pulling (at the O2 and PEG tube) were very likely pain/anxiety. In a situation like you discribe I'd prefer to try and treat the underlying causes before resorting to a physical restraint.

[drmorton2b]

You saw a problem, your evidence of the problem according to YOUR nursing judgement was serious enough to call the MD. The MD orders soft restraints and you assess and document per facility policy. SP O2 was in the 60s.... without the mask on.

Go with your nursing judgement.. you make it sound like the other nurse wants it to look like you didn't have an order.

So the other nurse's rational not to be cruel by NOT applying soft restraints as ordered is not CRUEL. Cruel would have been depriving a pt of adequate oxygenation.

I know the feeling... since nursing isn't always black and white.

[CareteamRN70]

I'd be interested to know what the 2nd nurse (the one you gave report to) did after you gave report. Did she remove restraints? did she leave them in place? did she get a Dr's order to dc restraints? either way what was the outcome for the pt at the end of her shift?

I was in a situation like that with a full code pt who was on 15L air and barely could keep SATs over 70. The pt had recently wished for a status change to allow for hospice and comfort measures but all the paperwork had not been finished. Midshift they were blue and gasping for breath pleading with me to help them.

This was in a LTC facility and I had no ativan or roxanol on hand (which hospice would have brought if they had finished his paperwork). Called Dr and was told to send pt to ER where they passed a few hours later. In the AM at report I was called cruel for not following the pts wish for a no code status.

I just couldnt equate allowing them to stay blue gasping for every drop of 02 as being kind and in the pt's interest. I did request morphine sublingual and ativan from MD but they said ship them out, technicly they are still a full code. That whole night still tugs at my mind and what was in the pts best interest.

[tferdaise]

Some nurses need a course on how to talk to people..

It sounds like you did the right thing to keep the patient comforable and not to go into distress, Next time this nurse "yells" at you, you let your charge nurse knows this, no one should be yelled. Verbal violence is on the rise at work, out work is tough enough.

Upon listening to report from the daylight nurse, I was told that the patient was a DNR and was ordered to be on a non-rebreather to keep sats >90%. The confused pt had been continually pulling at his mask and refused to leave it on. On nasal cannula at 6l, pt dropped into the 70s and on roomair into the 60s. The daylight nurse stated that she did nothing because she considered this patient refusal.

I felt that since the patient was confused, he was not in the right mind frame to refuse. I notified the physician and he ordered soft wrist restraints bilaterally. I applied them and performed hourly assessments.

When night shift came on, the nurse who was following me listened to report. I asked if she had any questions and she said "Yeah, why the hell did you put restraints on that guy. You're just cruel." I then stated that his sats were low on both nasal cannula and roomair and that I couldn't just chart that I knew he was 60% on roomair and do nothing. She suggested that rather than record his sats on roomair, I should have held the nonrebreather on his face, obtained a good pulse ox reading, then let him remove the mask as he pleases for the rest of the shift. She then stated that she hopes that she never has a nurse like me who allows my patient to suffer and be restrained.

I honestly was trying to do what was best for the patient in restraining him. I suppose I figured it would be better to suffer in restraints than to suffer gasping for breath. But now I am second guessing my actions. Was I wrong in what I did? Does the fact that he is a DNR make a difference? What should I have done? Advice would be greatly appreciated. Thank you!

[mama_d, BSN, RN]

Were they comfort measures only or were they a medical management pt? (Where I work, we use the term medical management to refer to pts who don't want CPR/defib/intubation but are fine with pressors etc.)

If comfort measures, I'd might have attempted to address anxiety/pain issues that might be complicating the issue, see if it would calm him enough to keep the mask on on his own, while staying at the bedside to keep it in place until the meds kicked in.

Medical management, most likely heck yes I'd have done whatever I needed to to address the oxygenation ststus, then moved on to underlying issues. Unfortunately for situations like this, most pain meds and anti-anxiety meds we'd use can cause respiratory complications, so I'd want a stable sat first. Was there a family member you could have called to come and sit with the pt? Preferably a POA, so they ould make the call of what to do...con't to "torture" with the mask or focus on straight comfort first until able to tolerate the mask.

Also, what was causing the hypoxia? And why did the nurse before you not address this? Even comfort measures only does not equate do not treat; we have many tricks in our toolbags to manage this kind of situation.

Hard to say if restraints were the absolute best choice in this scenario without knowing more, but the doc obviously agreed with you, so that at least should make you feel better. And I totally agree that what the other nurse told you to do was unethical.

[Esme12, ASN, BSN, RN]

there are medical restraints and behavioral restraints. [color=#0e774a]www.gbmc.org/documents/.../restraints_slp there are physical restraints and chemical restraints. http://www.enotes.com/nursing-encyclopedia/restraint-use. i personally don't usually physically restrain anyone without some kind of chemical restraint/anxiety control. the patient could have been pulling his mask off because of confusion due to hypoxia.

i think you did the right thing in attempting to help the patient because in his confusion could not judge whether or not he needed the 02. i might reconsider my thoughts if once he had an improved )2 sat and the patient was more agitiated and seemed that he was worse off with the 02 and restrained than he was hypoxic and confused. but i would still try to find to keep some 02 on like the cannula at sa higher flow rate.

i think that the other nurse who objected so strongly has other issues with why the restraints weren't necessary.......like performing the work involved in watching the saftey of a restrained patient and documenting the restraints properly. i has serious concerns about her solution......i mean really if your are going to lie then just lis. holding the mask on the patients face until you get the sat you want for the moment and then feeling you're in the clear until the next round is just ludacris and immoral.

dnr is not a do not treat.......i wouldn't let this other nurse bother you. you did the right thing if she is too......shall we say......"busy" to be interested in what is best for her patient.....then maybe you need to have a talk with your manager about your concern surrounding her statement and how you should handle it....you did good!!! :0)

[mindlor]

You did the right thing...

That said, please grab hold of Brumhilda and quickly let her know that you are not going to tolerate that sort of behavior...even mention the phrase "lateral violence".

Gotta let these battleaxes know that you can stand your ground. As soon as you are perceived as weak they will continue to target you....

She should have taken you off to the side and engaged in a thoughtful, rational, respectful conversation if she had any issues.....

[PMFB-RN, RN]

She suggested that rather than record his sats on roomair, I should have held the nonrebreather on his face, obtained a good pulse ox reading, then let him remove the mask as he pleases for the rest of the shift.quote]

**** What! She suggested what amounts to LYING in your charting. We can never lie. The solution is to record his sats, document his removing the mask, your attempts to keep the mask on short of restraining him, then your call to inform the physician and any orders s/he gives you.

If you get an order for restraints and in your nursing judgement it is an appropriate order (sounds like it was to me) carry it out and restrain him per your hospital's policy.

I would watch your coworker who suggested you LIE in your charting. This is obviously a person without much integrity. Also remember what she suggested next time you are getting report from her. I would never again believe her when in report she tells you a patients SPo2 is good, or take her word for much of anything. I would also consider reporting her suggestion that you falsify documentation to your nurse manager.

[merlee]

You did the right thing. I would agree with those who mentioned getting something for anxiety, but the doc didn't think about it either.

YOU DID THE RIGHT THING.

Now talk to your supervisor about dealing with the nurse who spoke to you inappropriately.

Keep on doing your good work. Best wishes!

[netglow, ASN, RN]

Who cares about any other nurse. You do as YOU see fit when you are with your patients. All you need from her is report. You and the patient/physician/family are all that matters when you are working.

This other nurse seems to think she can decide who is going to live and die. Many nurses start to go down that path feeling that they are advocating when it's just a power trip in reality, and very dangerous as from what I've seen, nurses like that nurse are not the brightest bulbs. They act without thinking on just about everything.