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!

[CathyLew]

was calling the family a possibility? perhaps seeing if anyone in the family would be willing to sit with the patient, and hold his hand, comfort him. or maybe ask his family how they felt about restraints?

It is hard to know what is right when a patient is between DNR and Comfort care... With a DNR we still end up doing all sorts of painful procedures and treatments. And many patients are not real specific in what they want and do not want.

[jerenemarie]

I've gotten orders for a low dose of Morphine for someone who is having resp. difficulty as this helps with the distessed respiratory status & it also helps with relaxing the patient. It works great, I think it is much better than ativan.

Thanks,

jerenemarie

[CoffeeRTC, BSN, RN]

Gosh...I haven't used a physical restraint in at least 10 or so years. I'm comming from a LTC perspective and I'm willing to bet that this pt will be there in a day or so and they would be dealing with the same problem that you were. Actually, sounds like he would be worse...more confused with the move, more uncofortatable with the new peg tube..etc.

The wrist restraints might have been a good idea for that shift until you got an order for low dose ativan or morphine for the resp/ anxiety/ pain issues. Like I mentioned..its been years since I've used them or got an order for them. (Do you still use the hand mits..could that have been an option?)

Other interventions....call in the family to sit, get the Resp T involved if you can (we haven't had rt in at least 10 or 15 yrs in the LTC), get the orders for roxinal or ativan..did he need a resp tx for sob? and above all...chart every intervention.

These type of pts are so difficult..I bet he had a foley and IV he was pulling on too!

[RN1980]

i would have told that idiot to take the damn restraints off herself as soon as i finish giveng her report if she wanted too. then the next morning i would inform her not to tell me about how often she had to hold the mask on the pts face cause he just kept pulling it off. people have got to understand that retraints are at times just as vital to pt care and saftey than any drug or medical equipment.

[NotFlo]

I think you did the right thing given the circumstances.

Which leads me to wonder how I would manage a similar situation at my job. It's SNF, and totally completely 100 percent restraint free. This is the land of "right to fall". I wonder if this would fall into "right to turn blue and gasp for air"?

[Emergency RN]

one of the worst things that the phrase "dee en are" has become over the years is it has mutated itself into a anti-nursing anti-patient phenomenon. like power sapping, destructive kryptonite to superman, once a nurse hears that phrase, he or she automatically shut off their brain and their mind already begins measuring coffin size for the "soon to be deceased."

stop!!!

dnr never, ever, ever means to withhold care; our nursing degree did not suddenly change to imply mortuary sciences.

in essence, dnr simply means that after a patient has died, we are then supposed to do nothing extraordinary to try to bring then back from death. but, up until that point, we are still obligated to pull out all the stops, intubate, fluids, transfusions, whatever... anything and everything to keep that person alive.

granted, there are some things that, given a patient's condition, may be deemed medically or clinically futile. however, that's a medical decision, and not a nursing judgment. over the years, dnr has somehow morphed itself in some nurses minds to imply carte blanche for them to deny care based on their nursing judgment; that couldn't be farther from the truth. the op in this case did the absolute right thing in calling the md, using non behavioral restraints with an md order, to facilitate airway and line protection.

op, as for your colleague's belittling comment of, "...hoping that she never gets a nurse like you" i would tell her to be really careful what she wishes for.

as for her suggestion to you to perform a necessary life saving function, record the positive results of that action, and then clandestinely, deliberately withdraw and withhold that life saving function knowing full well that the patient will die as a result?

that is called conspiracy to commit murder. :eek:

you did absolutely the right thing in ignoring her. further, if i were you, i would report her not just to your employer but to the state.

[Altra, BSN, RN]

1. Was BiPAP considered?

2. Were meds (Ativan, Morphine) considered?

3. Was consideration given to the fact that this patient is likely slipping down the slope from "DNR" to "actively dying" ... and was the physician and family contacted to consider what implications that had for treatment?

4. Have you followed up with your unit educator/supervisor/manager to discuss the other nurse's stated plan of care ... to intervene to allow documentation of x sat at x time, but allow the patient to remain hypoxic at other times?

IF, no one was going to acknowledge this patient's obvious actively dying state, and allow him some dignity in allowing that process to progress with supportive/comfort measures instead of futile interventions, THEN I agree with your use of restraints. Cruel? I hope I'm never subjected to the cruelty of being allowed to lie in bed gasping for air.

[Batman25]

1. Was BiPAP considered?

2. Were meds (Ativan, Morphine) considered?

3. Was consideration given to the fact that this patient is likely slipping down the slope from "DNR" to "actively dying" ... and was the physician and family contacted to consider what implications that had for treatment?

4. Have you followed up with your unit educator/supervisor/manager to discuss the other nurse's stated plan of care ... to intervene to allow documentation of x sat at x time, but allow the patient to remain hypoxic at other times?

IF, no one was going to acknowledge this patient's obvious actively dying state, and allow him some dignity in allowing that process to progress with supportive/comfort measures instead of futile interventions, THEN I agree with your use of restraints. Cruel? I hope I'm never subjected to the cruelty of being allowed to lie in bed gasping for air.

Excellent post. We always try and see if other measures will help before restraints especially in an already very anxious person. Sometimes a little med goes a long way here to ease the anxiety and can take away the need for restraints.

The nurse you work with is dangerous and needs to be reported. Given how she was so quick to suggest you falsify documents I would be petrified taking over a patient from her. Check everything she says and does until this issue is dealt with by management.

[Mulan]

What if he had pulled out the newly placed peg tube as well?

How can anyone consider a confused patient pulling off his O2 mask patient refusal?

If an alert and oriented patient were doing the same thing, would she just consider it patient refusal or would she notify someone?

Why are people so afraid of using restraints?

Sometimes restraints are necessary.

[rene072171]

I personally think you did the best thing you could. You did not want to falsify information, you went through the doctor and followed his order. I agree that talking to resp. therapy would be a good thing to do also. As for second guessing yourself, if you think you are never wrong you will never learn and grow. Take it in stride though, because that person who put you down would have really given fals information and taken the lazy way out - if the pt would have died due to your falsifying information - it would have been way worse I think. You do the best you can, which I think you did. Hang in there

[MunoRN, RN]

Patients can refuse an O2 mask, but only if they understand the indication for it and the potential risks in refusing treatment. If he can understand those things, but is not oriented to date, then he can still refuse, if not, then you can't consider him taking off his mask to be an appropriate refusal.

The DNR doesn't apply to this situation (yet), although you'd want to know at this point if he is DNI since he may be heading in that direction. I've had patients who refuse BiPap in the past, and are capable of doing so, in those cases there isn't much we can do except wait for unresponsiveness/decreased responsiveness and tube'em. DNI certainly makes that trickier.

One thing to consider about NRB masks is that they can be very uncomfortable, they're cheap aren't built for comfort or long term use. Sometimes some duoderm over the nose and cheeks helps. Sometimes High flow O2 NC is a better option. It sounds like restraints were working in your case, but sometimes it can just make their respiratory status worse by agitating them even further.

[CompleteUnknown]

Sounds like a very difficult and complicated situation. What was the cause of the hypoxia and was this able to be addressed? What were the sats with the mask on, and did the patient's general condition improve with the mask on?

From your post, it sounds as though the patient was confused, agitated, and trying to pull off the mask (or restrained to prevent this) for at least 24 hours. What was the reason for the PEG insertion? What was the patient's general condition and prognosis?

I think it would have been worth talking to the doctor about giving something for pain and/or agitation before, or as well as, the restraints. (Not saying you didn't do this, it's just it isn't mentioned in your post). Restraints so often just increase confusion and agitation. Not excusing for a second the reprehensible behaviour and attitude of the nurse who suggested you misrepresent the patient's condition in the documentation, but is it possible that the use of restraints in this situation may not have been the best option?

The older I get, the more I realise just how much grey there is in medicine and nursing and I think that we (the general we) don't do our patients and their families any favours when we pretend that things are black and white.