I work in the neuro ICU, we have our fair share of non intact pts that are restrained for typical reasons. However, at times we have totally intact pts, some of these patients have EVDs or LDs (brain drains).
I had a pt the other night who was completely intact. She was a picker though. Im sure you all know the type..picking at her IV (redressed it 4-5 times), picking at her foley, pulling off her O2 and BP cuff all night long..etc..all that I can handle, its a pain running back and forth between my 2 pts all night, but if she pulls out an IV, well then I can always put another in. HOWEVER....I spent many hours at the beg. of my shift and all during the shift explaining to her the dangers of an EVD and how it works by gravity..so sitting up or moving the bed down effects how it drains CSF. She verbalized understanding each time. I also tell her, don't touch the EVD bc its a huge huge source of infection.
I can only be one place at one time. THe next thing I know she is sitting straight up trying to get out of bed with the EVD attached. I almost have a heart attack. Still, again, I try and educate her, although this time stress that she could die if she dumps too much CSF. She verbalizes understanding.
Through the rest of the night I spend my time babysitting her, keeping her in bed and relatively still. I constantly remind her not to touch the EVD and she kept doing it.
By the time the resident rounded I was almost out of my mind and I felt my only option left was to restrain her. I know it might have kept her in bed and from touching the EVD (her drain was leveled at 20 so she wasnt at as much danger of dumping CSF as others with lower drains) but I just couldn't do it. This was the same pt that threatened to scream if I didnt give her something to drink while she was NPO or threatened to check herself out AMA if I didnt let her go to the parking lot to smoke (no way! esp. with an EVD????).
I had visions of her kicking and screaming and her BP way over 200...I just thought maybe through more education and careful watching I could avoid both potentially dangerous sitiations. Like I said though, by the time 0500 rolled around I was almost nuts. THe resident gave her the EVD talk and told the pt flat out if she didnt stop she would be restrained and if she wanted a raging meningitis infection to keep touching her EVD.
Sorry for the long vent, I guess my question is: have you ever had to restrain an intact pt. and how did you handle the situation, ie how did you approach them initially, how did you problem solve...guess just ooking for some advice on this sitation if i ever have to face it again, which im sure i will. Thanks.
I hate restraining pts, but sometimes it is the only way to protect them from themselves. I had a pt once that was almost fully there...he was a little bit off but not that bad. Had a PICC line in. I dressed it during the day and had to redress it later because he was picking at the opsite. I told him about the dangers of infection and stuff, went to lunch, came back and the entire line was neatly coiled on the bed side table. He said he just wanted to "tidy things up". I would think if I was pulling something out of my body that a doc had put in, and it was longer than about 6" I would probably think that it was there for a reason, but that's just me. Anyway, the doc refused restraints because she had a pt previously that died while in them. So, we called family in and asked them to watch him (just so he didn't pick) and it worked.
I hate it when patients are in that state of mind. Too alert and awake but not totally there to think straight.
Looks like the best option would be to have a 1 on 1 sitter. Seems like she does well with someone there to communicate with her.
Medical restraints might help but monitoring her LOC is just too important. I'm not sure I would go the physical restraint route. If the patient just gets to rowdy, that alone would just increase her ICP and BP.
I've never had any neuro ICU experience so that's a tough one.
Anyone that can't follow simple instructions that have been given repeatedly doesn't get a full Glasgow number from me... that 5 for verbal knocks down to a 4.
Drugs, sitter, or restraints: in that order, would've been my response - with an order of course :).
I had a pt the other night who was completely intact. She was a picker though. Im sure you all know the type..picking at her IV (redressed it 4-5 times), picking at her foley, pulling off her O2 and BP cuff all night long..etc..all that I can handle, its a pain running back and forth between my 2 pts all night, but if she pulls out an IV, well then I can always put another in. HOWEVER....I spent many hours at the beg. of my shift and all during the shift explaining to her the dangers of an EVD and how it works by gravity..so sitting up or moving the bed down effects how it drains CSF. She verbalized understanding each time. I also tell her, don't touch the EVD bc its a huge huge source of infection. .....
I'm guessing the definition you're using for "intact" and the one we'd use isn't the same, because that patient would be in a 1:1 situation in a heartbeat on our floor (med-surg). Perhaps not restraints, but absolutely most definitely a 1:1 at the least. And a GOOD aide, at that--not a sleeper as they oftentimes are, unfortunately.
This patient may have been alert and oriented x3, but you know, that's about the most minimum of criteria for sanity or clarity of mind there can be! I've had LOTS of patients who can tell you who they are, where they are, what day and time it is, but then proceed to tell you about the "herd of birds" that just flew into their room only that morning. Had a patient recently telling me (after the usual too-simple A&O questions) that her daughter was in the bed next to her, and could I get something to her? Ummmm....yeah.
The patient isn't able to stop hurting herself? Time for re-evaluating the situation.
I hate it when patients are in that state of mind. Too alert and awake but not totally there to think straight.
Looks like the best option would be to have a 1 on 1 sitter. Seems like she does well with someone there to communicate with her.
Medical restraints might help but monitoring her LOC is just too important. I'm not sure I would go the physical restraint route. If the patient just gets to rowdy, that alone would just increase her ICP and BP.
I've never had any neuro ICU experience so that's a tough one.
exactly. I thought if i restrained her it would just make her that more agitated and in turn raise her ICP. A sitter was just not an option, we dont have the staff for them.
If any of you out there had to restrain an intact pt and yes obviously she was not fully intact but in our neuro world a person of her alertness is usually as intact as it gets, rarely do we get someone truely totally intact.
So how do you approach this situtaion,...should i have j ust went inand said ok Ms. X you wouldnt listen so im restraining you. Then what? What if is she starts kicking and biting and screaming (which she would have done as she threatened to) and her BP shoots up to 200 and her ICP to way over 20. I tried all the drugs i had but as all of you know sometimes they dont work. After 2mg ativan and some dilaudid this woman was stillgoing strong. Finally she mentioned to me that she was itchy (possibly from the percoset i had also given her) so the genius idea of benedryl hit me and i got an order. Thankfully she fell asleep...but what if it didnt knock her out...then i would have had to restrain her and it would have been a mess.
I'm guessing the definition you're using for "intact" and the one we'd use isn't the same, because that patient would be in a 1:1 situation in a heartbeat on our floor (med-surg). Perhaps not restraints, but absolutely most definitely a 1:1 at the least. And a GOOD aide, at that--not a sleeper as they oftentimes are, unfortunately.
This patient may have been alert and oriented x3, but you know, that's about the most minimum of criteria for sanity or clarity of mind there can be! I've had LOTS of patients who can tell you who they are, where they are, what day and time it is, but then proceed to tell you about the "herd of birds" that just flew into their room only that morning. Had a patient recently telling me (after the usual too-simple A&O questions) that her daughter was in the bed next to her, and could I get something to her? Ummmm....yeah.
The patient isn't able to stop hurting herself? Time for re-evaluating the situation.[/quote/]
yep 1 on 1 is what she needed unfort. she jsut had me and i virtually watched her all night, unable to leave her bedside. My other pt was a bit neglected...i only have 2 pts so thankfully i had good neighbors who helped me out a lot that night...that unfortunate night.
I'm guessing the definition you're using for "intact" and the one we'd use isn't the same, because that patient would be in a 1:1 situation in a heartbeat on our floor (med-surg). Perhaps not restraints, but absolutely most definitely a 1:1 at the least. And a GOOD aide, at that--not a sleeper as they oftentimes are, unfortunately.
This patient may have been alert and oriented x3, but you know, that's about the most minimum of criteria for sanity or clarity of mind there can be! I've had LOTS of patients who can tell you who they are, where they are, what day and time it is, but then proceed to tell you about the "herd of birds" that just flew into their room only that morning. Had a patient recently telling me (after the usual too-simple A&O questions) that her daughter was in the bed next to her, and could I get something to her? Ummmm....yeah.
The patient isn't able to stop hurting herself? Time for re-evaluating the situation.[/quote/]
yep 1 on 1 is what she needed unfort. she jsut had me and i virtually watched her all night, unable to leave her bedside. My other pt was a bit neglected...i only have 2 pts so thankfully i had good neighbors who helped me out a lot that night...that unfortunate night.
I see from your other posts you obviously did your best. If that were to happen to me, in my own hospital situation, I'd have been on the phone to the nursing supervisor to GET ME someone. I don't care where they pull a tech from. Where they pull a security guard from, whatever. We've had that happen, and had security stay with a patient for a few hours in an emergency, or had a tech pulled from another unit to babysit. We not only aren't overstaffed, we're usually understaffed, but an emergency is an emergency, and this one would qualify. I'm NOT saying you didn't do everything you could, only you know your hospital's situation, I'm just sorry this didn't seem to BE an option for you.
I had a patient once that was not only confused and dangerous to himself and others, but strong as a bull. NOT a good combination. So he's wrapped in every restraint we can legally use, physical and chemical, with a sitter, and still security had to be called to wrestle him back to bed when he "escaped".
Sitters are great. I wish we had more. I had a patient one night who wasn't a neuro patient, so already I was out of my element. This pt. was a psych/medical pt. who swallowed an entire bottle of pills and she would eat things to get attention. This time she broke a tv ant. in 3 pieces and swallowed them ended up with a laryngeal tear. This pt was totally out of my leauge. She, other than obs having some psych issues was intact. We didn't have her restrained and being that she was on suicide precautions she was ordered by her MD a 24/7 sitter. Well, I couldn't even get one that night. I had to be the sitter. I just had her that night but I couldn't leave my desk all night.
Hmmm...when I've had to tell folks they were going to be restrained, we usually are already dealing with a takedown situation, and if I am the nurse in charge of talking to the patient, I tell 'em something like 'You can either go to seclusion voluntarily or we're taking you there...there will be no negotiation.' Then we go.
If they hit me or someone else, I say something along the lines of 'You are now being restrained for my safety and yours, and the safety of others on the unit, until you are better able to control yourself.' Then we begin the restraint protocol for our unit.
With the medical restraints, I usually go in with a couple of other people and try to explain to the person that they are being restrained for their safety, since they are pulling at the lines, etc (following our protocol, this is after all other methods have been exhausted)...Of course they're upset, but sometimes you just can't help that, but then again I've never had to work with head trauma pts for whom I've had to monitor ICP and BP, etc...I'm glad you had that Benadryl!
Is there another med she had on board that could've been causing the agitation, or was she just agitated secondary to her condition? Some meds will cause agitation and EPS-like reactions and Benadryl works wonders for it...I think we were discussing this on a thread about Compazine too...
Well part was her condition i'm sure, but part of it was just her. Im pretty sure she had some withdrawl sx's going on as well. Her male friend told me they both quit drinking the week before. She had some obvious impulsive behavior, her friends and family tell me that is how she usually is. So who knows.
lol
Had a patient recently telling me (after the usual too-simple A&O questions) that her daughter was in the bed next to her, and could I get something to her? Ummmm....yeah.
RN92
265 Posts
hand mittens are wonderful in this situation. it is the least level of restraint (in my opinion). and they cant pick at anything.