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!
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.
I believe that was Esme12's point: when facilities eliminate restraints it is probably as much a cost-saving measure to eliminate the need for additional staff as it is any philosophical aversion to restraint use.
Specializes in burn ICU, SICU, ER, Trauma Rapid Response.
as for intubated patients - why have you got intubated patients who are not anaesthetised ? vs trache for longer term ventilation ..
*** A good question but not one a nurse can answer. Physicians are the one's who can write for sedation. Nurses can ask for it but if the provider chooses not to (when that happens I ask them to explain to me in detail why they are choose not to) we can't order them ourselves.
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
*** There are other appropriate times. Like for example to preform neuro assessments.
I believe that was Esme12's point: when facilities eliminate restraints it is probably as much a cost-saving measure to eliminate the need for additional staff as it is any philosophical aversion to restraint use.
Perhaps I'm misunderstanding you both, but I don't see eliminating restraint use as a cost saving measure as it is more demanding of staff time when restraints aren't used. I also do see a philosophical aversion to their use, as well as an acceptance that the use of restraint increases the risk of injury and poor outcomes rather than decreasing it (in most circumstances).
Really interested in this, and not trying to be a pain in the neck. :)
I see no problem with the way the situation was handled except that I probably would have asked for something to calm the patient and morphine for the breathing.
That said, I seem to remember it being an issue if someone dies while in any type of restraint. Does anyone know?
Specializes in Critical Care, ED, Cath lab, CTPAC,Trauma.
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.
I agree......It is a huge commitment....from the staff. I was refering to administration not wanting the Board of Health and Joint Commision issues, delinquencies and bad marks.......not the Staff. If restraints are used for multiple limbs...the frequent checks require more staff and the provision of 1:1 observations...that equals increased costs. They don't mind if you run your buns off the entire shift keeping everyone safe.....
Specializes in Critical Care, ED, Cath lab, CTPAC,Trauma.
Perhaps I'm misunderstanding you both, but I don't see eliminating restraint use as a cost saving measure as it is more demanding of staff time when restraints aren't used. I also do see a philosophical aversion to their use, as well as an acceptance that the use of restraint increases the risk of injury and poor outcomes rather than decreasing it (in most circumstances).
Really interested in this, and not trying to be a pain in the neck. :)
It's a compliance issue and documenting for Joint Commision and the Board of Health to prevent charges of unlawful restraint. The use of restraints require strict compliance policies that must have 100% compliance and a MD to re-write and have a face to face evaluation every 24 hours (your have to pay the MD to come every visit= money)to ensure the appropriateness of the use of restraint and re-write the order. The restrictions in long term care are more stringent in most states.
In the usage of restraint the are required staffing par's require to prove that there are enough bodies to conduct checks (more staff=more saleries=money) toileting, bathing and meals. In some usage of restraint a 1:1 observation requirement is present (again more staff=more money) Delinquincies can be fined and the loss of accreditation (=money). Most administrators aren't concerned about philosophical aversions of restraint.....just the bottom line...money.
If a patient falls that is your fault for not keeping them safe but the facility still gets paid. They lose accreditaiton, or have a deficient survey.... they don't get paid. The patient get a pressure sore from the restraints they don't get paid, that's negelect. The use of restraint causes and increase of the facilities insurance premiums....money.
Specializes in Critical Care, ED, Cath lab, CTPAC,Trauma.
as for intubated patients - why have you got intubated patients who are not anaesthetised ? vs trache for longer term ventilation ..
*** A good question but not one a nurse can answer. Physicians are the one's who can write for sedation. Nurses can ask for it but if the provider chooses not to (when that happens I ask them to explain to me in detail why they are choose not to) we can't order them ourselves.
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
*** There are other appropriate times. Like for example to preform neuro assessments.
In answer for Zippy
A post op open heart recovering and getting ready to be extubated.....or any patient weaning to be extubated...some patients are good about leaving the ETT alone while others will stop at nothing to get it out. I saw a patient once use his feet!!!! NOw that was something to see!
When I worked ICU we sedated our patients......we didn't anesthetize them.....and in an ICU you should have adequate skilled personnel.
Specializes in Critical Care, ED, Cath lab, CTPAC,Trauma.
I see no problem with the way the situation was handled except that I probably would have asked for something to calm the patient and morphine for the breathing.
That said, I seem to remember it being an issue if someone dies while in any type of restraint. Does anyone know?
Oh yeah! It's called negelect and liable and possibly manslaughter...Hence higher insurance rates and the increased staff to monitor=money
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 ...
For most patients, a weaning trial or sedation vacation are the only times where they will be less than optimally sedated with a tube in, although there are those patients where it really isn't needed. I've had patients who are quite happy to sit there and do the crossword while intubated, no sedation. I've even taken vented patient's for walks. In terms of restraints for those that do need sedation, sedation such as fentanyl and propofol can wear off very quickly. One way to address this is to pre-emptively give additional sedation even when you haven't seen signs decreased sedation, although with what we now know about the negative long-term adverse effects of common sedation drugs, using more than the bare minimum is bad practice.
Specializes in Critical Care, ED, Cath lab, CTPAC,Trauma.
is this an in hospital or out of hospital question ?
I saw you had out of hospital experience so I made a comparision about restraints and patient saftey. Have you ever picked up a less that cooperative patient and used you seat belts to help restrain them? Same difference the use of a restraint
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 .
If the patient refuses the use of the seat belts and you insist is that not a form of restraint against someone's will?? It has been my experience that not all patients are the model of cooperation and decorum. and do not always heed our advice here across the pond.
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.
Here in the USA we have laws that bind us to care for those who cannot or will not care for themselves. NUrse are amongst those who can place a person in restraint following specific guidelines with a mandatory MD eval in 12 hours. we also have laws that mandate the rstraint of a patient that is in danger of hurting themselves or someone else....required by law. this is my states requirement.
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
ABSOLUTELY
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 ...
Medical theories, as well as terminology, vary from state to state let alone country to country....we SEDATE or patients. Nurses unless specifically licensed cannot anesthetize patient legally.
What we have here is partially a language barrier. Or slang barrier....and country barrier. Ther are very specific laws the bind the use and misuse of restraints. Hospitals have specific criteria in the use, ordering and documentation of restraints and physical restraint is to be accompanied by chemical restraint (sedation)
We in NO way are trying to be....."depriving them of liberty in an extra judicial manner." in any way.......I hope this clears this up for you....:twocents:
:twocents:
I was hoping someone would clear that up! :uhoh21:
Altra, BSN, RN
6,255 Posts
I believe that was Esme12's point: when facilities eliminate restraints it is probably as much a cost-saving measure to eliminate the need for additional staff as it is any philosophical aversion to restraint use.