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'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.
Well...after the big deal she made, turns out she left the restraints on the entire night (or at least charted that she left them on the entire night. At this point, I'm not entirely sure I can take what she charts for fact). Daylight nurse passed on to me the following day that the patient gave up on trying to pull off the oxygen mask and peg tube because he realized he couldn't and finally got some much needed sleep.
I did not ask for ativan as the pt had an allergy... asking for morphine did not cross my mind, although it would have been a good idea. I suppose I will know better for next time :)
Specializes in Critical Care, ED, Cath lab, CTPAC,Trauma.
Interesting.......do you strap patients to the transport stretcher??? THAT is a form of restraint.....is this just tying up for the sake of it????
Sometimes a patient just is unable to make that decision for themselves. If this patient had hypoxia induced confusion the patient in a hypoxic state cannot make that decision to leave the mask on.......just as soft wrist restraints are used on intubated patients until you are sure they will not extubate themselves......medically necessary restraint....:twocents:
Specializes in Spinal Cord injuries, Emergency+EMS.
Interesting.......do you strap patients to the transport stretcher??? THAT is a form of restraint.....is this just tying up for the sake of it????
is this an in hospital or out of hospital question ?
on ambulance stretcher restraints are used in motion same as seatbelts are used on the seats for crash safety purposes,- people are not tied to the trolley and can if they wish remove these 'restraints' certain types of ambulance trolley the risk assessment says they should be in use while the trolley is out of the vehicle - usually the types which unload to a raised state rather than those which unload in the lowered state by ramp or lift .
the fact is restraint as considered to be an acceptable practice by some US providers is specifically designed that it aids the care giver and the patient cannot release themselves from the restraint , thus depriving them of liberty in an extra judicial manner.
Sometimes a patient just is unable to make that decision for themselves. If this patient had hypoxia induced confusion the patient in a hypoxic state cannot make that decision to leave the mask on.......just as soft wrist restraints are used on intubated patients until you are sure they will not extubate themselves......medically necessary restraint....:twocents:
and i presume therefore you are considered adequately educated in making decisions under the legislation regarding mental competence and can document your decision in a legally sound manner
as for intubated patients - why have you got intubated patients who are not anaesthetised ? vs trache for longer term ventilation .. the only time it;s considered appropriate to have someone unanaesthetised with a tube in is during extubation - and consequently in the presence of suitable skilled personnel ...
Specializes in Critical Care, ED, Cath lab, CTPAC,Trauma.
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.
i couldn't have said it better myself.....well said.....:yeah:
in the acute care setting...there are times that a physical restraint accompanied by a chemical restraint are necessary to keep a patient safe and provide medical care to patient that is necessary to their well being.
when facilities (ltc/snf) go "restraint free" means they are concerned they cannot provide 100% compliance to joint commision standards and other standards of care in the use of physical restraint and the increased staff/patient ratio necessary to allow this practice.......so they don't do it at all........it has nothing to do with the "freedom" of the patient or dislike of physical restraint.....they just don't want to be held responsible and hire more staff to adequately provide care......:twocents:
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.
I haven't had the time to read through all the responses but did you address the personal attack? I have no problem with a peer who disagrees with my nursing judgment but I'll be damned if I allow someone to personally attack me the way that nurse did. Regardless of what she thought about your use of restraints she had no right to call you cruel and to say that she hopes you are never her nurse. Address the restraint issue but keep your personal opinions to yourself...how unprofessional.
On my floor, and actually in my hospital, there is a culture of avoiding restraints at all costs. If you would have contacted a doc for restraints in this particular situation, and he/she actually ordered them, well, you would have been strongly questioned regarding that decision. I'm not sure I disagree with our restraint philosophy, but it's what I have to work with.
First of all, as a charge nurse, if any of my nurses put a patient in restraints without discussing the situation with me, I would be livid. Again, in my hospital this is a huge deal. If I or one of my nurses were considering putting a pt in restraints, here are some questions I would be asking:
Is this pt possibly in pain? If so, can we medicate him appropriately?
Can we switch him over to high flow NC, and possibly tape it to his face using those tabs used in the nursery to tape O2 tubing to infants' faces? NC is typically more comfortable than a mask. With a mouth breather, sometimes you can simply put the prongs in the mouth and have it be effective. Those tabs won't withstand a determined tug, but they often keep tubing in place when a confused pt rolls over or makes an errant swipe with a weak hand.
Is there another reason why he may be restless? Is he hungry? Has he been appropriately repositioned? Is he clean? Is he warm enough? Is it too dark in the room?
Is family available to sit, and keep him from pulling on his tubing? If not, does your facility have sitters available for this situation? Is this a pt that takes antianxiety meds at home? Can we give him a little ativan or something similar to calm him down?
If we had explored all these issues and the pt was still pulling at his tubing, then I would support your decision to get an order for restraints. If the patient is that badly off for more than a couple of days with no apparent improvement, though, I think a social work consult is in order. The DPOA needs to be apprised of the situation, and comfort care should considered, if it's appropriate based on the pt's previous wishes, diagnosis and prognosis.
how about actually using some nursing skills rather than tying people up ?
I believe I respectfully asked a pretty straightforward question, as I value your response. Otherwise, I would not have asked.
What would you do differently?
In evaluting the original post, I noted the OP's description of the patient's SpO2 with a non-rebreather mask on ... and on room air. Based on the information presented, I made the following assumptions:
1. whatever the patient's underlying disease process .. the patient is moving toward an actively dying state given the minimal effectiveness of current interventions
2. the patient's SpO2 even with significant supplemental O2 certainly warrants consideration of the fact that his agitation is due to hypoxia
3. I gave the OP the benefit of assuming that he/she had assessed for obvious possible contributing factors such as the need for toileting, warmth, etc.
When facilities (LTC/SNF) go "Restraint Free" means they are concerned they cannot provide 100% compliance to Joint Commision Standards and other Standards of care in the use of physical restraint and the increased staff/patient ratio necessary to allow this practice.......so they don't do it at all........it has nothing to do with the "freedom" of the patient or dislike of physical restraint.....they just don't want to be held responsible and hire more staff to adequately provide care......:twocents:
so...when you get anorder for restraints in the acute setting..are they still only good for 24hrs?
We don't even have restraints in ltc...I'll never forget someone trying to write me up for putting a sock (just a tube sock) on a residents hand to prevent thme from ripping out an ng tube, pulling at the O2, pulling at the picc line and foley or wound vac......no restraints are not a sub for staffing, but if it gave me 5 minutes to do a dressing change....
I couldn't have said it better myself.....Well said.....:yeah:
In the acute care setting...there are times that a physical restraint accompanied by a chemical restraint are necessary to keep a patient safe and provide medical care to patient that is necessary to their well being.
When facilities (LTC/SNF) go "Restraint Free" means they are concerned they cannot provide 100% compliance to Joint Commision Standards and other Standards of care in the use of physical restraint and the increased staff/patient ratio necessary to allow this practice.......so they don't do it at all........it has nothing to do with the "freedom" of the patient or dislike of physical restraint.....they just don't want to be held responsible and hire more staff to adequately provide care......:twocents:
Yes, there are times when some form of restraint is necessary to keep a patient safe but I don't agree with the last paragraph.
In my experience, it takes a lot more time, committment and thought from the staff to care for patients (in both the acute and long term setting) when restraints are not used. Harder and more time consuming for the staff, but better for the patient/resident.
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 !
Sorry, I'm more concerned about the way she spoke to you than the use of the restraints! That's some hostile person - I'm surprised she had the nerve to speak so rudely/harshly.
There are better ways of voicing a disagreement - I hope you didn't let that pass!
:twocents:
:eek: 
:yeah:
newnurse012
28 Posts
Well...after the big deal she made, turns out she left the restraints on the entire night (or at least charted that she left them on the entire night. At this point, I'm not entirely sure I can take what she charts for fact). Daylight nurse passed on to me the following day that the patient gave up on trying to pull off the oxygen mask and peg tube because he realized he couldn't and finally got some much needed sleep.
I did not ask for ativan as the pt had an allergy... asking for morphine did not cross my mind, although it would have been a good idea. I suppose I will know better for next time :)
Thank you, to everyone, for your input!