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.

[Been there,done that, ASN, RN]

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...

Don't feel "silly". It is a very good question. Many factors come into play with each scenario. In the future know your facility's policy for placing restraints. Usually the nurse can apply with a 1-4 hour window to obtain the provider's order.

In this case, I would NOT have strapped Bi-Pap on her and tied her down. There are other methods of oxygen delivery. A sitter and sedation would have been the better choice.

If the provider ordered Bi-pap.. the Provider can come and strap the LOL down. A doctor's order is a request.. not a command.

[Here.I.Stand, BSN, RN]

In my unit, we apply them first and then get the order all the time. Our MDs trust our judgment and know that if we apply them it is for safety reasons, and have never NOT given the order. With intubated admissions, it's standard in the admit orders (if they are not warranted, such as a GCS of 3 prior to intubation drugs, or paralyzed from either a c-spine SCI or a paralytic drip....we don't apply them.)

That said, as the previous couple of posts say, I don't know that they were warranted here. I have personally not seen hypoxic confusion at 88-93%, and if it was due to a critically high pCO2 she needed to be intubated. If she was with it enough to say the mask scared her, to me that sounds like a legit refusal.

I would have wanted to see her ABG: again, if her pCO2 was very high and she was acidotic she needed to be on a ventilator so they can control the volume and minimum respiratory rate, thereby blowing off excess CO2. Otherwise would have looked into getting her on a high-flow nasal cannula. It's a bigger gun against hypoxia than the common O2 delivery systems like nasal cannula/oximizer/face masks, but is much less equipment strapped to the face and for most feels better than the BiPAP. (Image courtesy of Google) [ATTACH=CONFIG]22870[/ATTACH]

[Here.I.Stand, BSN, RN]

And that picture got really big.

[BSN16]

I'm not sure about this situation...but

I work in the ICU and use restraints all the time. If i'm waking someone up from sedation and they get agitated and start pulling at their ET tube...i'm not gonna call the MD and ask him if i can put on restraints and waste more time by putting in the order. It's not safe for the patient. And really no MD is gonna tell me no. So i do say act and then get an order...

[GM2RN]

I'm not sure about this situation...but

I work in the ICU and use restraints all the time. If i'm waking someone up from sedation and they get agitated and start pulling at their ET tube...i'm not gonna call the MD and ask him if i can put on restraints and waste more time by putting in the order. It's not safe for the patient. And really no MD is gonna tell me no. So i do say act and then get an order...

Absolutely! This is pretty standard.

[canoehead, BSN, RN]

If her life or health is at risk, I'll restrain and then call. If not, I'll call and hopefully find some sedation that will work instead of physical restraints. It's a judgement call, and hard to say a nurse is right or wrong unless you witnessed the whole interaction.

[flipflopsNsweetTea]

In my unit, it would be a HUGE deal if we restrained first and then got an order. I work nights and the on -call docs and NPs DO NOT like to give orders for physical restraints. They will try every med in the pharmacy before they restrain. I'm not risking it. The day shift docs are a little more free with the restaint orders. In fact, we will fight with a patient all night and try to sedate the crap out of them, and day shift will have them in restaints by 0700.

Also, we can't restrain patients on bipap either without a sitter.

[YoutubeTheNP]

This is a no brainer. You have a pt becoming hypoxic who already has an order for bipap, his increased agitation and uncooperative behavior is likely a result of CO2 retention. Tie them up, put the bipap on, else, instead of calling the doc for further instruction you'll be calling a RRT instead, sooner or later waiting for a call back. Once you hear from the doc he/she may just say forget the restraints and give some Ativan, but restraining them temporarily does no harm.

I never sweat over an o2 sat >90, but it does get my attention once it goes

[GM2RN]

This is a no brainer. You have a pt becoming hypoxic who already has an order for bipap, his increased agitation and uncooperative behavior is likely a result of CO2 retention. Tie them up, put the bipap on, else, instead of calling the doc for further instruction you'll be calling a RRT instead, sooner or later waiting for a call back. Once you hear from the doc he/she may just say forget the restraints and give some Ativan, but restraining them temporarily does no harm.

I never sweat over an o2 sat >90, but it does get my attention once it goes

I disagree with the "no brainer" comment. Plenty of patients become agitated and uncooperative because they don't tolerate the bipap mask well, not necessarily because they are becoming hypoxic. Like previously stated, 88-93% spo2 isn't necessarily that low depending on other factors. There's not enough information given in the OP's scenario to determine if this is a "no brainer" situation or if it's just a matter of the patient not tolerating the bipap mask and refusing (as is his/her right) to continue to wear it. Plus, no information was given about whether or not a sitter was available to sit with a patient on bipap and in restraints. If not, then the patient is at great risk for aspiration or worse if the patient should vomit with the mask on, leaving the nurse and hospital liable.