restraints? What would you have done (Long)

[jessnurse05]

Hi,

I had the longest, hardest night of my life just a couple nights ago. I've been off a couple nights since then, but it's still really bothering me.

This was only my second day off of orientation and I'm a new grad. I had two pts in the same room. Bed 1 was A&O x1 and pleasant, bed 2 was A&Ox1 usually, but sometimes she could be reoriented and day shift had told me that she had been agitated and had thrown her pills back at the nurse. We had an order of Ativan and day shift had used it once and it hadn't done much. She was in with dehydration, but had a hx of drug abuse and had tested + for opiates when she came in. Her son had told us that she would take 30 + pills for pain. Well I barely got out of report before I heard commotion from that room and ran down there. 2 had gotten out of bed to the bathroom, dragging her foley, phone and IV all tangled together. I got her reoriented, untangled and on the commode. Then she pulled her IV out. So long story short I got her reoriented back in bed and got her IV restarted after 4 sticks. By that time she was A&O, calm and falling asleep. So I didn't give the Ativan. Around midnight she got up out of bed, pulled her IV out (was bleeding all over from it) and was saying she wanted to go home, how could we keep her here against her will etc. I got other nurses in to help me calm her down and get her back in bed. The nurse who was helping me wanted to let her leave AMA. I was kind of freaked out because I've never had a pt act like this and she woudln't listen to reason. I got an order for more ativan and to DC her foley before she yanked it out, but I was unable to restart her IV and neither was the ICU nurse. I asked my charge nurse for advice and she said to restrain her. By this time she was again calmed down and sleeping so I didn't restrain her. I called the doc and got an order for Ativan IM and to DC the IV. Since she was sleeping I still didn't give her the Ativan because and I thought she might refuse it if I woke her up.

I didn't have any problems with her for the rest of the night, except she threw her pain meds at the charge nurse when she tried to give them, but then went back to sleep.

I felt like a failure after that night. I had this out of control pt, she was also bothering my bed 1 pt, who kept climbing out of bed, even though she had never done that before. The whole floor was slammed that night cuz we just got admit after admit. There was also only 1 tech for the whole floor, so she couldn't help me much. I ended up staying over an hour late to finish charting cuz I had been in that room most of the night, then I got an admit at 5:30.

Looking back, I think I should've at least given the Ativan when I got the IV started, but she really was just fine at that time, pleasant and mostly oriented (she kept forgetting who I was).

I talked to my manager in the morning and she said I had a successful night since neither one of these pts fell and bed 2 didn't leave the hospital. Her opinion was that because this pt had an addiction that the answer to her agitation was the right meds and not restraints.

I still feel like I didn't advocate for my pt enough cuz when I called the doc, I didn't give her the whole addiction hx on the pt, I was just trying to take care of the immediate situation.

So I'm looking for more opinions/advice. I felt so clueless about this pt.

Thanks,

Jessica

[Town & Country]

I'd say you did a good job.

If she wasn't agitated at the time you got an IV started, I wouldn't have given Ativan, either.

I would probably DC someone AMA, rather than use restraints. What was the rationale for restraints? You have to be very careful whom you put restraints on these days. Danger to self or others is about it when discussing criteria. I'd say you just had a hard night.

[meownsmile, BSN, RN]

You had a difficult night,, one of many you will have over your career. Each situation is different. Restraint is the last option, calling family and giving them the opportunity to come in and sit with the patient is another option we utilize in med/surg. Then if there is a AMA situation, family is there and you arent releasing the patient without a responsible party to escort them. I probly would have gone ahead with the ativan even if she was calm at the moment because her immediate history told you this was behavior she had been exhibiting most of the evening and into the night.

But,, like i said,,evey situation is different. Sounds like you did as well as anyone else would have given the night you had.

[ARTLAN06]

You did all you can and I agree that I would have given her the ativan too. Be carful on putting on restraints on anybody without making sure you have a doctor's order. Sometimes nurses say to put one on and there's no order. It's your license. But good job and look forward to more of those fun nights.

[whipping girl in 07, RN]

Technically, you could have used med/surg restraints because she was interfering with treatment (by pulling out IVs, etc). BUT, you have to be very careful because lots of people have gotten hurt while restrained. I probably would have given the ativan, too, but then maybe I wouldn't have. You have to be in the situation to know what you'll do. We use restraints quite a bit in the ICU but I think in my facility, restraints on the floor are pretty rare. People are in and out of the room a lot more in ICU to check on the patients and there are tubes that if the patient pulls them out he could die. Not so many of those on the floor (not life threatening for her to pull out her IV, just annoying).

Sounds like you did the best you could do with a rough night.

Konni

[NurseyBaby'05, BSN, RN]

After she pulled out her IV the second time, I would have probably have used soft wrist restraints and called immediately for an order. If she is a hard stick, it's important to keep that IV in. Also, it's not safe to have blood everywhere every time she is disoriented. What if it was a bloody washrag, etc that was thrown instead of pills. With her drug history, it's possible she may have the checkered medical history to go with it.

Many times I would almost rather use physical restraints rather than chemical ones. When the pt calms and becomes more oriented, they can be removed. With the drugs, you have to wait them out.

Like the other posters said, it's a judgment call.

[jessnurse05]

Thanks for the replies.

I forgot to mention that I did call the family, but couldn't get ahold of anyone. I also tried to get her to call her family since she was so set on leaving, I told her she needed to have someone take her home but she argued that she didn't need anyone and she would just walk home.

Restraints are used a lot on my floor, even though we have a big reducing restraints campaign going on. I think I would have used them if she had gotten agitated again. I wouldn't be surprised if day shift ended up restraining her since she was starting to act up again when I left.

If her problem was withdrawing from drugs, what would a good suggestion to the doctor be? We have an alcohol withdrawl protocol, but I learned in nursing school that any other drug withdrawl isn't life threatening so they don't do much for it.

Thanks

Jessica

[Pepper The Cat, BSN, RN]

You didn't mention the age of the pt. The ativan could be the cause of her agitation - Ativan and the elderly are not always a good mix. I've given Ativan to a restless pt in the past, only to have them go completely wild on it. I say if you got her calmed down without having to resort to any type of restrain - either chemical or mechanical - good for you! If the IV was only for hydration, then you could have looked at other options - does your hospital ever use hypodermaclysis? We use it quite often and it works very well!

[jessnurse05]

The pt was only 58. She was getting a little weird with the vicodin. I was almost wondering if she was faking some of her antics though, when my other pt got out of bed (this lady somehow managed to do it without the tab alarm or bed exit going off) this pt got up to help her. So that kind of made me think that her whole "this isn't a real hospital, what kind of game show is this" thing that she kept talking about was a little fake. Maybe not though.

What is hypodermaclysis? I've never heard of it. She had been getting IV fluids for more than 24 hours and her output was good, so I wasn't too concerned about her hydration. She was also taking PO fluids just fine.

Jessica

PS: Thanks for the responses. I'm glad that other people agreed with me about not restraining the pt right away.

[jollygreenRN]

I think you did just fine. If she was abusing pain rx at home, and refusing same in the hospital, she should of at least had opiate detox orders. Sounds like she may have been going into withdrawl. As far as AMA goes, if pt is not with it enough to understand the ramifications of leaving, or the "I'll just walk" comment you got, indicate that the patient AT THAT TIME was not capable of making informed decisions regarding her health care.

[zacarias, ASN, RN]

I think you did great! Your a new grad yet you sound like you've been doing this a while!

The thing is Jessica, sometimes I have nights where I feel like I did a good job and then I have other nights where I feel accomplished nothing for patients yet I was busy the whole night.

The trick is to realize that this is part of that which we call nursing. The fact that those two patients did not fall DOES reflect on you and your good care. Also, not being quick to use restraints is great. I hate restraints and believe that they should only be used as a last resort.

Hope your next day makes you feel good!

[Pepper The Cat, BSN, RN]

Hypodermaclysis is an infustion of fluid via a s/c needle rather than IV. We put a s/c butterfly in any area of the body that has a good supply of s/c tissue - usually the upper thigh or abd. We then infuse IV fluid - N/S or 2/3 & 1/3 at 50 - 75 cc/hr overnight.The fluid infuses into the s/c tissue and then slowly absorbed into the body. Its very effective. We like it because you don't have to access a vein which can be difficult on an elderly person who is dehydrated, and if they do pull it out, there is little damage and little risk of bleeding. You can also cap off the butterfly during the day and just re-hook the pt up at night if they need several nights of hydration. That way, they can be up and mobile during the day. And because it is s/c, if the pt does play with the pump or something, there is no risk of a huge bolus that could send them into CHF.We only use it on the elderly. Hope all this makes sense!