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!
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.
Harsh reality...but true....
Thanks for explaining Esme, it took me a while to get my head around it but that has helped me to understand what you're saying. I think you're right, there's probably a bit of a country barrier happening that is making it difficult. We also have increased documentation and observation requirements when restraint is used, but I think that that is seen here as an acknowledgment of the risks of restraint rather than as an additional cost to the facility.
This is a bit difficult to call.Was there medication for agitation?Had that been tried?Had all other options been tried.
I agree that a restraint should be the very last resort. With the pt sats dropping so long, were there no other ways for securing. Did you colleagues provide any help?
What's done has been done, but I'd still like to know if pt had medications for agitation.
CompleteUnknown
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Thanks for explaining Esme, it took me a while to get my head around it but that has helped me to understand what you're saying. I think you're right, there's probably a bit of a country barrier happening that is making it difficult. We also have increased documentation and observation requirements when restraint is used, but I think that that is seen here as an acknowledgment of the risks of restraint rather than as an additional cost to the facility.