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.
Sounds to me like you did just fine! Does your hospital use elbow immobilizers at all? They are not considered restraints and you don't need an order.....they just go on the arm at the bend of the elbow and keep the patient from bending their arm, keeps them from pulling out IVs, and also if they pull off O2, etc. I try and use those first before restraints....I mean, a wrist restraint won't keep a patient from getting out of bed. If possible, I might have also changed bed assignment a bit so this patient was as close to the station as possible. Sometimes that is quite difficult if the unit is very busy. If they are able to sit in a chair, sometimes they can stretch out in a recliner by the station. We finally got some nice ones...they don't have the tables (which are considered a restraint) but are pretty comfortable and can be ok to sleep in if needed, and keep the patient in view.
All that being said, you did a great job....honest!
Specializes in OB, ortho/neuro, home care, office.
Last week, late in the week, I had a similar situation. Where I am not completely certain I did the right thing.
I had 6 patients, 2 fresh post-ops, 2 2 day post op, 1 stroke/seizure patient, can't remember the last one.
One of the 2 day post op (back surgery) was older. He started the night out acting very paranoid, like I was part of a scheme of something (couldn't quite figure out what). But in either case, things progressed to the point he hit one of my aides, hit me, and was verbally abusive to me in particular, but also to everyone else who entered his room. Refusing all treatments, Oxygen, pulled his IV's out earlier in the day. Just went basically nuts. I called his son in to sit with him, which wasn't much help, in fact, everytime he acted up his son would just come tell us and leave the room!
So after several attempts at getting the patient calmed down in every way possible, I got the order for restraints as well as Haldol. I didn't really want to restrain the patient, and had talked to his daughter several times during the night by phone, realized this was the furthest from normal this patient usually was. I realized he didn't want me in the room, but was not adversely affected by the aide (a male) in the room with him, so I requested a 1:1 from the charge nurse. The aide sat in the room the rest of the night.
I avoided the restraints and chemical sedation, but caused the majority of the floor an uproar. My post op patients were barely seen, and my post stroke/seizure patient fell twice because I was so caught up with this other patient (he was also confused). I'm beginning to feel like I work in psych ward instead of the floor I do work on! Not that I would mind, but I would prefer it be one or the other!
Should I have restrained the patient? Or did I do the right thing? I kinda feel I should've although no harm came to him, my other confused patient fell twice (no injury either time).
I just don't know. I have mulled it over and over. Just not having any luck on deciding.
That does sound tough. One reason I really didn't want to use the restraints is because I had a different pt a couple weeks ago who was very confused and had to be restrained, but when he was, he got so agitated that the day nurse thought he was going to hurt himself with the restraints, he was constantly fighting them. So they took the restraints off, dc'd his foley and IV and the pt was a lot less agitated. He was oriented most of my shift, but then he did fall that morning. It was a tough situation because it seemed like he was going to get hurt whatever we did to him. This lady seemed similar and I thought this lady would probably hurt herself with the restraints. She's not on the floor anymore, I don't know what finally happened to her.
Agree with Jollygreen..doesn't sound like she was oriented enough to be able to consent to leaving AMA...if she had a big drug history then she probably was having withdraw. I probably would have given the Ativan a try. Restraining her probably would have made her more agitated. I think that you did the best you could. It sound as if you were already short staffed but another option for the future would be to get an order for a 1:1..someone to sit with the patient..we usually use available CNA's or PT/OT techs that want make some extra cash. As always..document, document, document....
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AtlantaRN, RN
763 Posts
you are NOT a failure...we all can feel that way sometimes...
if you can reorient the patient, that is a GOOD thing! If there is no dealing with the patient, then sedation is the way...
you did fine, we all have nights, and days like that
hang in there!
linda