Terrible clinical day, nurses don't seem to care.

[Koyaanisqatsi-RN]

I may get a lot of flack for this from the more experienced nurses, but I would like some help in understanding this situation.

Today, I walked by a patient's room in the hallway. Keep in mind she is not my particular patient today. She calls out to me in a frail voice for help, and sounds like she is in very bad shape. I go in to see her and she is crying, and very frail. She must have been in her 80s or even higher. She stated that she could not move her arms, and that she was desperate for some water. My first thought was that she might have been having acute MI or something similar because she couldn't move her arms, I really didn't know. I held her hands quickly and asked if she could feel my hands in hers. She said she could, but that she can't move her arms, and continued to cry and beg for water. She kept saying that she did not know where she was or why, and to please help her.

At this point, I noticed the restraints. She was strapped into her bed, this is why she couldn't move her arms. I was horrified. This is a med/surg floor, not a pysch ward. I asked one of the tele people what was going on and they stated 'it's just some crazy old woman, she's weird don't worry about her'. I asked her nurse and this was the same answer I got from her, again. She stated this woman had previously tried to pull out her IV and so they restrained her.

So...

Help me understand. They clearly had to get an order for these restraints. Why did they not choose a chemical restraint or sedative instead of strapping her into the bed? Why does no one care about this woman, writing her off as a crazy old lady; when she is, in reality, a frightened human being who was strapped into her bed in a strange place and scared to death. Not to mention thirsty, as she was apparently NPO and no one would explain to her why.

I went into the stairwell and cried for about 5 minutes. This is not why I wanted to go into nursing. I see things like this every day, but never this bad before. Restraints! They strapped this poor woman down and wouldn't explain anything to her. I spent some of the rest of the day talking to her and trying to help her relax even though all she wanted was to get out of bed and get some water.

It broke my heart. And if this is what nursing means, that eventually you become so burned out that a fellow human being suffering in one of the worst possible ways becomes just some 'crazy old lady', then I want no part of it.

[VivaLasViejas, ASN, RN]

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Carry on!:)

[lamazeteacher]

By signing HIPAA, patients have given permission for anyone who is remotely interested in acquiring information about their condition, to have it. The records according to HIPAA may be accessed by any doctor, nurse or auxilliary personnel, government agency, police, court, or insurance company!

Read the small print. This law was changed from its original form, through the efforts of insurance company lobbyists. Originally, it was HIPPA, Health Information Privacy Protection Act. When it became HIPAA, Health Information Portability Protection Act, it changed to accommodate information becoming available for all insurance companies, government agencies, including courts, police, Public Health and any entity requesting the information. Also, all doctors, nurses and auxilliary personnel having an interest in the case have access to the poatients' records.

So it originated as the illogical permission that allowed healthcare providers to keep confidentiality, by another person (the patient) signing that. Since when does another person (the patient) signing a document asserting what others may not do with their information, assume credibility? It is insulting to professionals who have already taken oaths protecting their patients' confidentiality!

By maintaining portability of confidential records, insurance companies can sue patients for witholding information when applying for coverage, allows doctors to give each other patients' confidential records, and pharmacists to realease information about any medication ordered and/or received by patients, and of course the lawyers representing the insurance companies and collection agencies may get it too.

The scourge of HIPAA will go down in the annals of history as the greatest act of fraud against patients, by misinforming them regarding the meaning of their signature on a form that simply states they were given information about it. Shame on lawmakers who allowed this travesty to pass, becoming law.

As far as a student nurse who finds a patient in need of care, having access to their record, of course is fine, as it allows nursing care to be given, when another nurse may be on his/her break by informing the student nurse of orders that have been given, whether medication has already been given, and the opportunity to record its effect, while specifying what care is possible through the care plan. The student nurse is already obligated to maintain confidentiality, HIPAA or no HIPAA!

It would behoove all healthcare providers to thoroughly read this stupid act, so they will not misrepresent its intention!

[darrell]

I did work in a psych ward - an inpatient crisis unit - and I participated in and initiated restraints, seclusions and medicating over objection. In many cases, it was the only way to keep everyone safe and it was enacted only after less restrictive measures failed.

All that being said, it was also my least favorite part of the job and I was willing to spend a good part of my shift babysitting and catering to avoid having things get to that point. I happen to have some talent for deescalation and not everyone shares the same amount of this, so different nurses may order restraints at different levels of escalation.

(My own thought is that a talented and trained deescalation expert would be a beneficial addition to the chain of events, but this means more money and sometimes in psych the sequence is so fast that the whole thing is done before security even shows up!)

I also have been told by peers that I have an unusual amount of patience. This may help explain why I am willing to go further than many around me to avoid restrictive measures. I just don't get ruffled.

In any case, I am no longer working inpatient and part of the reason is that I would rather spend the rest of my shift sitting down with someone in emotional pain than locking them away and getting on with business. This fits my personal ideology well, but it can be problematic when the patient in question needs constant attention or supervision and the rest of my assignment is feeling neglected because of it. Perhaps something like this affected the decision in your case, too?

Deescalation or managing dementia are skills that don't come easy for many. I don't mind being within arm's reach of violence and I rarely feel much fear from such threats, so that isn't a big factor for me. On the other hand, I'm not much for imposing my will on others and so I'd make a terrible cop or guard. I guess we all have our weaknesses - there isn't a body fluid yet that has had much impact on me, but aggressively setting boundaries just isn't something I've been able to get a good feel for!

The bottom line is that I applaud your compassion and I want you to know that it doesn't necessarily get any easier even when it's a common occurrence.

D

[roshell1963]

:) you were not wrong in trying to help this patient. there are national protocols in place per jcaho that require patients in 2 or 4 point restraints to be monitored very closely. if it is not a psych floor situation (where the intervals are even more frequent) the patient is to be checked every hour at the very least, the restraints are to be removed 1 at a time to allow for circulation to the restrained area and charted accordingly. elderly confused/mentally confused individuals should be placed in the rooms closet to the nurses station where there is the likelihood of someone noticing patient safety issues sooner. elderly individuals do not adapt to new surroundings well, they often need consistent orientation reinforcement to alleviate anxiety. many hospitals have volunteer sitters available through the case management staff, or perhaps someone from the patient's own family or church could come and sit in shared shifts. it is never a bad thing to care enough to go the extra mile for one of your patients. often the staff gets jaded after too large of a workload for too long (years) and personal stress burnout as well. when we no longer can put the patient's welfare first on the job, it is time to find another career. perhaps these are the nurses that need a new work environment, possibly by teaching our new nurses and helping to alleviate the current nursing professor shortage. remember back on the first day of fundamentals when they reminded us we should be treating our patients like they were our own loved ones. just my follow your own conscience, you seem to have a good one.

[klg315]

I wonder what pretending to care would like for you. Just because someone wasn't holding her hand and sitting with her doesn't mean that no one cares! I work in neurosciences where many patients require restraints for a variety of reasons. Some insist on pulling out their IV's, NG's, foley catheters and central lines. Some are aggressive and would punch you in the face as soon as they got their hand free after nicely asking if you could please loosen the restraint. Brain injury or pathology is hard to understand but we have to keep the patients best interest in mind. If she is threat to herself and can't understand why she needs to cooperate, restraints may temporarily be the only viable answer if she has no family to be with her. Ideally it would be nice to have a staff member assigned to her but I know in our facility there is not adequate staffing to do such things.

Chemical restraints are not always a good idea particularly when LOC needs to be regularly assessed.

I hope you are able to come to terms with this experience and I think it is great that you are empathizing with the patient. I'm sure you will be a wonderful nurse for it!

[nursemike, ASN, RN]

I wonder what pretending to care would like for you. Just because someone wasn't holding her hand and sitting with her doesn't mean that no one cares! I work in neurosciences where many patients require restraints for a variety of reasons. Some insist on pulling out their IV's, NG's, foley catheters and central lines. Some are aggressive and would punch you in the face as soon as they got their hand free after nicely asking if you could please loosen the restraint. Brain injury or pathology is hard to understand but we have to keep the patients best interest in mind. If she is threat to herself and can't understand why she needs to cooperate, restraints may temporarily be the only viable answer if she has no family to be with her. Ideally it would be nice to have a staff member assigned to her but I know in our facility there is not adequate staffing to do such things.

Chemical restraints are not always a good idea particularly when LOC needs to be regularly assessed.

I hope you are able to come to terms with this experience and I think it is great that you are empathizing with the patient. I'm sure you will be a wonderful nurse for it!

I also work in neurosciences. It often seems like a cross between LTC and psych. So many patients needing total care. So many with mental status changes. More than a few with both. Not long ago, someone on our unit was looking for logos for t-shirts and hoodies for our unit. I favored one about "Rodeo Nursing" which had a stick-figure patient in 4 point restraints and a stick-figure nurse with a big syringe (more of that dark humor discussed earlier in the thread). Needless to say, it was not the one chosen, but some nights it sure fits.

I guess I have nothing else to add, at this point. Just wanted to say hi to another head case.

[Cobweb]

Cops and nurses have a lot of the same issues. Long, long ago, this episode was on Hill Street Blues. I had an episode somewhat like this young student and this episode was like an epiphany to me about the "uncaring nurses". What happened is that a guy was in a car wreck and lost his arm. There was soooo much garbage in the streets, and the cops frantically searched through the garbage looking for his arm. One cop finally finds the arm, after crawling through the garbage looking for the arm, and says something like, "Hey his watch is still on here. Takes a licking and keeps on ticking!" The citizens who stood and watched them forever digging through garbage in the gutters filed a complaint on them for their "disrespectful and uncaring" behavior.

[survivor08]

Having just come out of ICU as a pt, a restrained one at that. Chemical restraints not good choice if q hr neuro checks are needed and remember how many "regular meds" adversly effect elderly population. I am only 49 and between my pain/nausea meds I saw bugs and tried ripping off bandages and pulling out my PICC. Restraints were not fun but I was safe. Today it is hard for family to be caretaker in hospital and ICU has strict hours. Even though I was an RN in this hospital and had probably 50 people that would have sat with me this is not protocol. Perhaps you did not have entire story and "When you finish school and walk the walk for a while you will see the other side. Please do not judge. Your new co workers will surely not like you and then you will be one of those newbies, complaining how mean everyone is to "new grads". Just trying to give bigger picture. Just graduated last May and had been there and done that. Best of luck to you.

[WalkieTalkie, RN]

Having just come out of ICU as a pt, a restrained one at that.

Thanks for sharing your personal experience with restraints. It makes me feel a little better about having to use restraints in certain situations.

[Karen05]

I work in an MICU unit where we frequently have to use restraints for various reasons, including protecting the patient from removing his/her IV; and most, if not all patients are not happy about this (who can blame them?)

In your situation, given the woman's age, chemical restraint may not have been the most optimal choice, as the elderly are no longer as efficient in metabolizing drugs in their system. She was NPO, so obviously you could not give in to her request for water, although you might have swabbed her mouth or asked the MD about providing a small amount of ice chips. Further, the patient may have indeed been given an explanation as to where she was and why she was being restrained but either forgot or was not able to comprehend the situation due dementia. As to the attitude of the nurse, unfortunately I see that a lot; frustration, excessive work load, stress, exhaustion or lack of empathy can cause one to be so callus and careless in one's attitude and behavior.

My advice (if I may) would be to learn from the short-comings of others, remembering to provide care to your patients as you would have provided to your loved ones and go into your shift each day being the best nurse YOU can be, regardless of those around you.

[ctconn35]

how sad is that. we are talking about a 80 year old woman. Are you telling me that the chemical restraint wouldn't of helped her settle down. Ridiculous!! It was a easy way out for lazy nurses so they don't have to be bothered. That is against the law. I hope and pray to God I never become a nurse like that or I am done. Unacceptable. I feel bad you had to deal with something like that. Nurses let's not forget they are human beings. Treat them with respect. I would of turned them in.... sad and angry.

[nursemike, ASN, RN]

how sad is that. we are talking about a 80 year old woman. Are you telling me that the chemical restraint wouldn't of helped her settle down. Ridiculous!! It was a easy way out for lazy nurses so they don't have to be bothered. That is against the law. I hope and pray to God I never become a nurse like that or I am done. Unacceptable. I feel bad you had to deal with something like that. Nurses let's not forget they are human beings. Treat them with respect. I would of turned them in.... sad and angry.

We are, in fact, telling you that a "chemical restraint," may have made her much, much worse. Haldol, benzodiazapines, and even diphenhydramine can have paradoxical reactions, especially in the elderly. Even if they're effective, they can mask mental status changes from other causes. Are they lethargic due to the meds, or are they having a stroke? And is it safe to assume that keeping a patient snowed is more compassionate than mechanical restraints?

The OP has shown a commendable willingness to learn from the views of more experienced nurses. Some of the nurses' actions and words in the situation described may have been wrong, or wrongish, or at least not very right. But I, for one, saw nothing to indicate the nurses were lazy, and I hesitate to assume they were as uncaring as they may have appeared to the OP.

My hope and prayer for every student nurse is that they will gather facts and make reasoned assessments instead of leaping to conclusions, that they will be open to learning, and that they will show proper respect for other nurses, who may just know what they are talking about.