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!
I am a hospice nurse and get very upset when my patients are physically restrained. But, our orders allow for ativan and haldol, so often our patients are chemically restrained. I think this is part of my own claustraphobia- the idea of being tied down with a mask on my face makes me anxious, I can not imagine what those patients who are also confused must be going through.
That being said, I do not know what your orders allowed, but if the pt was properly medicated for anxiety/agitation/pain and was still pulling at tubes/mask, it is your job to keep the therapy going, especially as they were still pursuing aggressive treatment. I think in the hospital setting I would have done the same thing. And NEVER, NEVER chart vital signs the way the other nurse reported.
Specializes in Trauma Surgery, Nursing Management.
OP, I agree with the other posters that expressed that they thought you did the right thing. I would want you to be MY nurse!
The pt was anxious and pulling at everything because he was hypoxic. I have seen this very scene many times. I agree that some Ativan would have helped with the situation, but if a doc won't call you back and push has come to shove in this case, I think the appropriate measures were taken by the OP.
Forgive me, I scanned through the responses so fast that I did not see if the doc had, in fact, ordered Ativan. OP, did you suggest an order for Ativan?
Please OP-I beg you to not even give the oncoming nurse's suggestions one ounce of rental space in your head. She is obviously in the wrong, and I pray to God and all that is good in the world that she will never take care of me or mine. Her cavalier attitude and condescending tone while talking to you speaks volumes regarding her bankrupt conscience.
Live today knowing that you did what was right for your pt at the time. The rest is static. You embodied the implementation of patient advocacy in this scenario, and you protected your confused pt. You have my respect, honey!
You stated you still intubate DNR patient's at your facility, if they haven't "died" yet? I think at my facility a DNR patient would not be intubated if they were desating. We do not have DNI. We sometimes have Limited resuscitation and there are specifics like " no shock" but "pressors" or intubate but no shock.
How is it at other facilities all All nurse posters?
Specializes in burn ICU, SICU, ER, Trauma Rapid Response.
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.
*** i was horrified when i read the on-coming nurse's suggestion. we all make mistakes. we have all made, or will make bad mistakes that may cause harm to a patient. in these situations what we do is own our accountability and take it as a learning experience. we share our mistake with our coworkers and managers in the hope that the system can be altered to help prevent similar mistakes. we have all made errors in judgment, or despite a good assessment, simply missed something. these things happen and they are learning / teaching opportunities.
however to delerably misrepresent a patients condition to the physicians and record it in the documentation and to knowingly allow a patient to suffer while at the same time lying about the patients condition........ wow, just wow. i am so disappointed that there are nurses out there willing to do such things.
You stated you still intubate DNR patient's at your facility, if they haven't "died" yet? I think at my facility a DNR patient would not be intubated if they were desating. We do not have DNI. We sometimes have Limited resuscitation and there are specifics like " no shock" but "pressors" or intubate but no shock.
How is it at other facilities all All nurse posters?
I agree it is a gray area -- cardiac arrest and respiratory failure will both result in death. I have worked at hospitals where DNR was definitely interpreted to include DNI. At my current hospital, the two orders are sometimes separated, sometimes both implemented, and sometimes orders are written for every possible permutation: compressions only ... meds but no compressions ... CPR but no intubation ... pressors but no antiarrhythmics ... etc. I don't think patients and families are well-served by these "options" ... but that is a whole other thread ...
I dont have experience at all and I was wondering if the Dr. had ordered ativan or morphine to calm the pt what will you do it if for instance the pt refuse to take it or denied that he has anxiety? just wondering in case in the future I come across to such patient.
I almost can't believe that a nurse would advocate raising a patients O2 sat to record a good sat, then simply leave the pt, knowing the pt will certainly pull the O2 off and quickly desat, but I do believe it. Please report this nurse to whomever you can, as what she proposed is almost torture, and beyond unethical.
OP, I for one would also have restrained, and would have called the family. Sometimes family can have a very soothing effect on a restless pt and allow restraints to be taken off. It would not matter if visiting hours are over, I'd ask one to come in. As others have stated, ativan or something may have helped too. Good job.
We were no longer allowed to restrain people where I last worked. In a situation such as you described, we would ask a family member to sit w/ pt. If no one was available, then they just pulled the mask off, etc. Institution policy said no restraints, no matter what the consequences, period. They wouldn't provide extra staff to help either, so if family didn't look after them, Que Sera, Sera.
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!
I HOPE I NEVER HAVE A NURSE LIKE HER -- for myself, my family, my friends, maybe even an enemy!
The way SHE would chart her pulse ox is LYING! It's UNETHICAL! It's not a legitimate reading!
Was the patient confused because he was hypoxic? Did he have a recent ABG? Why was he DNR?
I think second-guessing yourself is appropriate ONLY in the context of what else you could have done to improve his confusion. Otherwise, soft restraints are 100% APPROPRIATE if a patient is interfering with treatment. Being DNR doesn't mean "STOP doing things to keep me alive"!
If this weren't a proper website, I would be calling the nurse who received report from you some NASTY names!
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.
You balanced legality with the patient's wishes. Sadly, the law interferes a LOT with our best nursing judgement. I can understand this situation tugging at you. It's easy to give my input without having experienced it. But it sounds like what you did was incredibly appropriate.
Patients often want to be DNR in theory. When that obvious knowledge of IMMINENT death looms, though, they often change their mind. The fact that your patient was asking for help shows you were doing more than just protecting yourself legally. You were being a patient adoviate. Kudos
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.
I may be biased, coming from an ER, and a crazy one at that, but they are very useful and often necessary. Everyone's suggestions about trying other things first, I absolutely agree. Restraints are intended to be the last resort, absolutely. So, when you get to that point, feel proud that you have your patient's best interests in mind.
:eek: 
I don't think patients and families are well-served by these "options" ... but that is a whole other thread ...
ErinS, BSN, RN
347 Posts
I am a hospice nurse and get very upset when my patients are physically restrained. But, our orders allow for ativan and haldol, so often our patients are chemically restrained. I think this is part of my own claustraphobia- the idea of being tied down with a mask on my face makes me anxious, I can not imagine what those patients who are also confused must be going through.
That being said, I do not know what your orders allowed, but if the pt was properly medicated for anxiety/agitation/pain and was still pulling at tubes/mask, it is your job to keep the therapy going, especially as they were still pursuing aggressive treatment. I think in the hospital setting I would have done the same thing. And NEVER, NEVER chart vital signs the way the other nurse reported.