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.

[kanzi monkey]

I absolutely did make an assumption, and have definitely regretted it, and with the advice of the people here, gotten a better sense of perspective regarding restraints. I'm only saying that it bothers me that even after I have admitted to over reacting, that I'm still being talked down to (by some, not all), as though I need to be coddled or something like that. I've even said i'm not looking for sweet-talking, just professional courtesy and compassion.

You have a great capacity to acknowledge and respect the many facets of a very complex situation. Once you've been a nurse for a while, I recommend revisiting this discussion because I imagine it will only foster your growth. You are fair-minded and considerate. My personal feeling is that, in general, the tone of this discussion has also been fair--the 'coddling' you feel may just be a glimpse at the many personalities you will work with as a nurse. You may not understand where another person is coming from when they speak to you in a certain way, but after a while their intention will dominate their tone. I've noticed that sometimes people "sweet-talk" as a way of showing courtesy and compassion. I think it's a cultural thing. It's not my way, but if the intention is pure, I get it.

I came to nursing from a completely different field. And I truly feel like an anomaly sometimes--I tend to communicate very differently than the majority of my co-workers, and I have definitely felt condescended to, coddled, or outright disrespected. I am sensitive to those things, but that's just the way I roll.

Oh, and I don't think you over-reacted at all. What you saw, from a student perspective, was horrifying--or at least not what you envisioned when you set out to be a nurse. It seems perfectly natural that it upset you. This discussion has given you--and all of us--more to think about.

[elthia]

I absolutely did make an assumption, and have definitely regretted it, and with the advice of the people here, gotten a better sense of perspective regarding restraints. I'm only saying that it bothers me that even after I have admitted to over reacting, that I'm still being talked down to (by some, not all), as though I need to be coddled or something like that. I've even said i'm not looking for sweet-talking, just professional courtesy and compassion.

I'm a little late to the thread but...can I mention something.

I think the students should remember that nurses are there to take care of the patients. Not all nurses find having a student assigned to their pt helpful, and not all nurses enjoy teaching students, some nurses find it frustrating. Frankly, I wish the nursing students who came to my hospital were half as courteous as the med students. The clinical instructer from a certain school is just as bad.

Also, if a nurse has spent the last 5 or more hours redirecting a pt, replacing IV's, jumping up every 15 minutes because the bed alarms going off, calmly talking a paranoid pt down, calling family who refuses to come in, calling admin who refuses to pay for a sitter, while trying to care for 5 more patients, and she needs to get out on time due to family commitments. She might be a little cranky, and may vent a little and say something like "the patient's just crazy". If the walls of my med room could talk, you would think I was certifiable.

[Tweety, BSN, RN]

I absolutely did make an assumption, and have definitely regretted it, and with the advice of the people here, gotten a better sense of perspective regarding restraints. I'm only saying that it bothers me that even after I have admitted to over reacting, that I'm still being talked down to (by some, not all), as though I need to be coddled or something like that. I've even said i'm not looking for sweet-talking, just professional courtesy and compassion.

Well, the first line of your post was that you were expecting some flack. Why flip flop and expect professional courtesy and compassion? LOL

I thought there was more than the one assumption, but no need to belabor it and I'm glad you learned something and didn't let it deteriorate to a student vs. experienced nurse thread.

[cherrybreeze, ADN, RN]

I have not read all the responses, so if I repeat anything, or address what's already been resolved, I apologize.

I understand being a student, but the tone in several of the OP's post upset me despite that.

I wish you wouldn't continue to call these nurses "uncaring." I'm not saying it's not possible that they weren't. I'm not them. But I do work in med/surg, and have had plenty of patients over the years that I've had to restrain. I hate to do it. But, you do it when you have to. As far as telling her she's NPO? For all you realize, she's been told this 400 times. You can look someone in the eye, explain it all to them, to have them look back at you and go, "I'm so thirsty, I need water!" Explaining, in advanced dementia patients, is an exercise in futility. It doesn't mean you don't care.

Chemical restraints would indeed be worse. You can give someone a dose of Ativan or Haldol and instead of watching them then settle down, you get to watch them freak out. Happens more often than you'd think. Then they also aren't moving themselves in bed, increasing their falls risk, or ARE moving around in bed.......increasing their falls risk. Medicare no longer pays for ANY costs associated with pressure sores or injuries from falls. Hate to bring money in to it, but we know that's the reality today.

Sitters? Right. We have had them, and used them.....until our admin decided we were spending too much on them, so now, if we need one, it comes out of our staffing allowance. We simply cannot take a nurse off the floor so that we can have a sitter. It's not possible.

Lastly, IMO, low census is even WORSE, especially in cases like these. You don't have more staff on, you just have less patients and less staff. You might have 2 or 3 RN's on rather than 4 or 5. That's less bodies able to run in to a room when an alarm goes off, or what have you. Their assignments are just as big as when the floor is packed.

[elthia]

Chemical restraints would indeed be worse. You can give someone a dose of Ativan or Haldol and instead of watching them then settle down, you get to watch them freak out. Happens more often than you'd think. Then they also aren't moving themselves in bed, increasing their falls risk, or ARE moving around in bed.......increasing their falls risk.

Also, Haldol can prolong the QT segment and cause arrythmias. Ativan can cause respiratory depression. Ambien can cause delusions and hallucinations in the elderly. Even benadryl is prone to cause delusions and hallucinations in the elderly. These are not medications you want to give lightly to the medically fragile.

Medicare no longer pays for ANY costs associated with pressure sores or injuries from falls. Hate to bring money in to it, but we know that's the reality today.

During our last staff meeting our manager was proud to report we had no falls last month, of course our use of restraints has gone up significantly.

On my floor we use A LOT OF ANTICOAGULANTS. There was a time, when if a family said no restraints, we would not restrain the pt, no matter what. We once had a little old confused lady on a heparin drip, who got out of bed. Her bed alarm was set, and she was around the corner from the nurses station. I was sitting at the nurses station, and heard the alarm go "beep beep" then BOOM, CRASH!!!. We were in her room in seconds. I held c-spine, while her nurse called the rapid team, and someone else ran to get a c-collar. She died the next day in the ICU, massive intracranial bleed. Thankfully, it was carefully documentted that restraints were not utilized due to family's protest. I am not thankful that the pt died. I am thankful that my coworker has documentation to prove that she was not willfully negligent in the pt's care, and that she need not have to worry for her job, nor her license.

Lastly, IMO, low census is even WORSE, especially in cases like these. You don't have more staff on, you just have less patients and less staff. You might have 2 or 3 RN's on rather than 4 or 5. That's less bodies able to run in to a room when an alarm goes off, or what have you. Their assignments are just as big as when the floor is packed.

I agree, sometimes low census is worse because if you work on a large unit then your patient assignment is spread out. 38 bed floor, all private rooms, it makes for a large unit...if you're at low census, that's a lot of walking.

[cherrybreeze, ADN, RN]

One last comment on the "crazy old lady" thing.........I think there are a lot of ways to interpret this. I hear comments similar to this come out of the mouths of a WIDE variety of nurses. I think it leans towards the concept of *gallow's humor*.......I know it's not the same thing exactly, but do you all KWIM?

[Rascal1]

I agree, sometimes low census is worse because if you work on a large unit then your patient assignment is spread out. 38 bed floor, all private rooms, it makes for a large unit...if you're at low census, that's a lot of walking.

Would it not be prudent to relocate the highest fall risk and medically challenged closer to the central nurses' station ?

[stustressed]

I share the same response from the above comments.....

chemical may have been contraindicated..

maybe needed a sitter, etc

Kudos to you for trying to spend time with her to relax. I am getting ready to graduate and I can relate to your situation..seen it happen alot.

One of the greatest gifts a student nurse can give is TIME. NO matter what the situation is or the order is, nurses (esp on a busy Med surg floor) don't have the time to spend 1:1 with patients.

Could she have mouth swabs and chap stick to relieve her oral discomfort?

Just remember that whatever you see as a student that you don't like (even with a good explaination or order) you have the power to make it different when you are a nurse.

You also have the power to keep questioning as a student..bring it up with your instructor, classmates, etc.

You obviously have great compassion for patients..hold on to it, it will drive you through!!

[meluhn]

One last comment on the "crazy old lady" thing.........I think there are a lot of ways to interpret this. I hear comments similar to this come out of the mouths of a WIDE variety of nurses. I think it leans towards the concept of *gallow's humor*.......I know it's not the same thing exactly, but do you all KWIM?

I know exactly what you mean. If anyone could hear the way we talk at work and the language we use amongst ourselves, they would think we were all a bunch of uncaring foul-mouthed degenerates. We do it for each others benefit and to make each other laugh. Also, it is a great stress reliever to go behind closed medroom doors and quietly tell a friend/co worker what you really think of your rude/demanding/whiny/neurotic (or whatever) patient/manager/family member. In front of the pt we are nothing less than absolutely professional and compassionate. If it weren't for this little bit of private stress relief, I don't know if we would hold up as well. I am fortunate to work with a great team that supports each other and this is one little way we do it, by venting in the manor I have described. I think that is what you mean by gallows humor, though I have never heard that expression.

[HeartsOpenWide, RN]

Chemical restraints are used last. Maybe they did try to explain to her that she was NPO but if she is senile it would not matter. Sure what the nurse said was in appropriate. Pt. are not restrained on a wim or for the convince of the nursing staff, the nurse told you she was restrained because she was trying to pull out her I.V. I am far from experienced (graduate in a few weeks) but I understand that restraints are sometimes necessary, sometimes particularly in confused elderly. I would question if she has a UTI since it can often be mask as a cognitive dysfunction. Any elderly that presents with delirium should have infection r/o.

[Koyaanisqatsi-RN]

In front of the pt we are nothing less than absolutely professional and compassionate. If it weren't for this little bit of private stress relief, I don't know if we would hold up as well. I am fortunate to work with a great team that supports each other and this is one little way we do it, by venting in the manor I have described. I think that is what you mean by gallows humor, though I have never heard that expression.

How do you manage to keep it from leaking over into your patient interactions? I am honestly curious. I have vented more than my fair share in my day, of course. I know what you mean, but I guess I'm not sure the best way to keep it from affecting my patients. In the past when it was a job where I needed to vent all the time, it was increasingly difficult to hide it from others. How do nurses manage this?

[meluhn]

We dont always necessarily just make fun of our pts. We joke about all sorts of things. A laugh here and there throughout the day makes a big difference. Its not like we are a bunch of drunken sailors or anything, we just do alot of laughing. We are not malicious in any way and I personally usually like most of my pts and co workers. I kid around with my patients too. As long as you don't cross the line and get personal or off color, I think its therapeutic. You have to have a sense of humor in nursing, if you cant laugh, you will end up crying.