Restraints. Act first, then order? A Judgement Call.

[ARose11]

On a rotation that I recently had as a student; a patient's O2 levels were dropping, and the patient was becoming restless and agitated. the O2 was ranging 93-88%. The patient was refusing to wear the BiPAP mask, but the nurse restrained the patient first, applied the mask with the respiratory therapist, and then proceeded to ask the physician for an order for restraints due to confusion related to hypoxia. I was wondering if this would be the correct way to handle this situation, because I wasn't sure that the patient was confused enough to not be able to make decisions on her own behalf. However, when I asked about why the process went down like that. The nurse replied that she wasn't going to do nothing while waiting on the doctor to get back to her.

[Asystole RN]

Professional assessment reveals that patient is unable to make decisions? If yes, continue.

Is restraining a reasonable course of action a reasonable nurse would take? If yes, continue.

Is restraining the prudent course of action to prevent harm? If yes, continue.

[ArtClassRN, ADN, RN]

I was wondering if this would be the correct way to handle this situation

Stop wondering. It is.

[AnnieOaklyRN, BSN, RN, EMT-P]

I have to say that I am guessing the patient was in respiratory failure and had very high CO2 levels, which was more of what was making him or her combative. I probably would have called a code or stat team, depending on what kind of floor you have, as it sounds like this patient needed intubation more than anything! Restraints are great and may have helped at least buy the patient some time with the CPAP or BiPAP, but again sounds more like a respiratory failure patient who was already beyond that.

When a respiratory patient starts getting restless and ripping the mask off, you better light a fire under everyones behinds, cause that is an ominous sign.

Just out of curiosity what was the outcome? Did the doctor call you back and order a blood gas? Intubate the patient?

Annie

[NOADLS]

I can see an argument for option one or two here in the absence of other information. Option three looks like it was quoted straight out of a textbook.

If the nurse in this scenario chose option one, it was because the nurse had the information to justify that decision.

[mrsboots87]

You will learn very quickly that some very confused patients can seem very with it when only encountering them for short periods of time. Nurses can apply restraints without an order under nursing judgement if their assessment warrants the need for restraints. Then after the commotion has settled, the nurse contacts the doctor for an order. But many a patient could severely harm themselves or others in the time it takes to get a hold of a doctor for a restraint order.

[ARose11]

Thanks so much for the thoughtful comments. Points taken.

[ARose11]

I was not on the floor the full day, so I dont know the outcome. The patient wasn't combative, just restless, old, and said that the mask scared her. Nevertheless, after this discussion I believe that it was a prudent course of action. I actually feel a little silly now...

[RNperdiem, RN]

Where I work, restraints are never used with bipap. It is considered unsafe because if a patient is going to vomit, the patient needs to be able to remove the mask or risk aspiration.

[GM2RN]

I agree that there are situations where you apply restraints first and get an order second but I'm not certain this is one of them.

I work in the ED and have had plenty of patients on bipap that get restless and agitated from having to wear the mask and have air blown into their faces, who then constantly try to remove the mask and refuse to put it back on. That doesn't mean they are confused.

Also, 88-92% is not that low. Some COPD patients live at 88% are completely alert and oriented.

I would need specific examples of "confusion" in this case in order to say that the nurse made the right call. Otherwise, this is a case of a patient having the right to refuse treatment.

[GM2RN]

Where I work, restraints are never used with bipap. It is considered unsafe because if a patient is going to vomit, the patient needs to be able to remove the mask or risk aspiration.

Also true in my ED, unless there is a sitter in the room or patient is 1:1 with an RN.

[Conqueror+, BSN, RN]

We cannot apply restraints before the order is given. I also ask myself, what happens if the doc does not give the order? Sure you take the restraints off right away but what have you done ?