So I am on a hospice unit, my preceptor boasts that they are a zero restraint unit.
We go into a pt room and the pt is restless and half way out of bed and very disoriented.
We help him back in to bed.
Preceptor says, "Hey take those pads that are on the floor and stand them up on each side of the bed, then unlock those two high back recliners and use them to push the pads against the bed and be sure to lock the brakes on each chair."
The term zero-restraint can be a little tricky. In most facilities, in my state at least, there are levels of restraint, going from chemical restraints, to physical restraints along the lines of side rails, body pillows, mittens, lap belts, and then going up to a more extreme level, such as four points.
Most of the "zero-restraint" facilities in my area, maintatin a strict policy not to use the latter, but can resort to the chemical and some less invasive forms of physical restraint with proper documentation that it is a last resort in a long chain of attempts with other types of restraints. I don't know the ins and outs of official policy so am not sure how acceptable that is officially. But it is what facilities do.
The more extreme the restraint the more difficult it is to justify so facilities that say they are zero, usually are very careful about exhausting all efforts, and may even transfer a patient out before relying on any kind of restraint.
With hospice patients, however, chemical restraints can become necessary. I have had hospice patients become so agitated that I was worried they would kill themselves before they were ready to die peacefully.
What you are describing sounds horrible and unconscionable, though.
At any rate, I remember one SNF I worked in, we had this patient who was extremely complex, lots of tubes, co-morbitities, highly acute issues, and completely out to lunch. Was incredibly agitated and kept trying to find a way to fall out of bed.
Staff ended up putting him on a low bed with side rail, and alarm, which was a restraint, but there was plenty of documentation about how dangerous the patient was to himself. He really shouldn't have been there, but this was one of those facilities that will take anyone and then just jerry rig a safety policy.
I had never worked with the patient, but one day I picked up a night shift and he was on my watch. I had sat down to take report and heard him yelling from his room. I went in there and saw that someone had parked a locked wheelchair by his bed to prevent him from crawling over the side rail and onto the floor.
What had happened is that he had attempted to crawl out of the bed, was completely tangled in his feeding tube, and his head was lodged between the side rail and the wheel of the wheelchair. His neck was lying on top of the side rail and he was in the process of strangling himself and could not unlodge himself, fortunately he was able to shout because otherwise by the time I got back there he would have been dead.
I never forgot that incident. Still sends chills up my spine.
You said you're a student, so let me go over a few things your instructors won't bring up (there's enough they have to cover!)
1. You're hospice and palliative, or you're not. Medicare/medicaid/most insurance will not cover Hospice AND curative treatments. When we have a patient that wants palliative radiation tx to shrink a mass, we discharge them from hospice, let them seek treatment under their insurance/medicare/medicaid, and then readmit to hospice after the treatment. Most hospices are non-profit and can't afford to pay for palliative radiation/chemo/etc., so we discharge you so your insurance covers it. In our state, there's no gray area, you are Hospice or you aren't. In your state, it could be different.
2. Many Hospice patients go thru a period at the end of their lives where they can't eat -- days, weeks, sometimes a month. When we get those, the first thing we do is give them mag citrate via NGT to clear out the bowels, follow with a couple of bisacoyl, sorta like a colonoscopy prep. The patient will be passing gas, but there's nothing in there to turn in to concrete from the morphine pump or Roxinol. If the patient hasn't had their bowel emptied, it could cause pain. If they have a substantial tumor burden in the abdomen or GI tract, it can cause pain, but trying to give them MOM or any laxative would probably make it worse. That would be a "look and see" situation at the patient's history, chart, med list, last known BM, last meal, etc.
3. You said the patient was holding their belly moaning in pain. What was their diagnosis? Liver CA with mets? It's to be expected they'd have belly pain if they weren't getting enough pain medication often enough. There's a great page on morphine and the Hospice patient http://www.hospiceworld.org/book/morphine.htm that's worth you looking at. Explains how morphine's good for somethings, not for others. Liver mets, it's great. If the patient was curling around their stomach because the pain was in bone CA in the pelvis, spine, etc., the morphine's not always the best drug for that. You said the patient was getting a ton of morphine. If they were still talking with you, they weren't snowed, so they really weren't getting a ton. My guess is they think there's been progression of existing disease or a new site for mets (the x-ray); if there's a new tumor in the rectum from prostate CA, you don't want to go sticking fingers up there.
3) Hospice is not about cure, it's about comfort, and my concern is the patient is not being kept comfortable. If the radiology shows the patient's GI tract is clear, up the pain meds (terminal agitation can sometimes mean "nurse is afraid of giving morphine"), give ABHR (Ativan-Benedryl-Haldol-Reglan) + narcotic, keep them comfortable, and be a listening presence with them.
4)Restraints -- if I'm in agony from terminal cancer or have terminal agitation from end stage COPD, and my nurse is afraid to medicate me, I'll be crawling out of the bed, too. Once we get a person's meds straight and get the nurses to actually give them (if in patient), we usually don't have issues with needing restraints.
That was the big red flag for me, if the person's in so much pain they're agitated, why aren't the getting everything in the MAR to make them comfortable, or a quick call to the MD to get more?
anything can be a restraint if it prevents free movement. We had a patient who could only push his wheelchair backwards. Someone backed it up to a wall to keep him in place and that was a restraint. You have good instincts. Better to get a sitter than worry about a fall. Also, assess first. The patient may need to go to bathroom, get a drink, be in pain, etc. Don't forget confusion that comes with some meds and low glucose levels.
Don't mean to hijack the thread, but I've got to ask how you managed to keep your patient who could only wheel backwards from running over the other patients?
4 side rails= restraint; 3= mobility enabler (or if full length, 2 up= restraint, 1 up=enabler)
W/C seatbelt= restraint; foam lap buddy= enabler (if they didn't have it and tried to scoot in the w/c they land on their head....and if they have the wherewithal, they can undo it).
Sleeping pills- with documented dx of insommia= not a restraint
Benzodiazepines - not covered by Medicare, so seen less frequently when patient has no other payor source (sad but true). Klonopin's original labelled use is as an anticonvulsant... if they have to have it for seizures, it's still not covered, but not a med for restraint use.
Benadryl= lousy side effects w/elderly...may end up worse than if left alone.
Sometimes I feel like I am the only one that considers siderails up x4 as a restraint. If the patient requests all up, then I document that. Otherwise, the patient needs a sitter.
I found this one out myself in the hospital i woke up and wanted to get up my bed had 3 rails up with pillows going down both sides my table in the spot where 4 rail would have been and the legs where up on the bed just anuff that I was not able to get up no mader how I tried . So it seems that there are many things you can do to replace the rails but I am not shore they are better .
When I was 8 I was in the hospital and I can remember climbing off the foot of the bed because I wanted to go the play room
You said you're a student, so let me go over a few things your instructors won't bring up (there's enough they have to cover!)
1. You're hospice and palliative, or you're not. Medicare/medicaid/most insurance will not cover Hospice AND curative treatments. When we have a patient that wants palliative radiation tx to shrink a mass, we discharge them from hospice, let them seek treatment under their insurance/medicare/medicaid, and then readmit to hospice after the treatment. Most hospices are non-profit and can't afford to pay for palliative radiation/chemo/etc., so we discharge you so your insurance covers it. In our state, there's no gray area, you are Hospice or you aren't. In your state, it could be different.
2. Many Hospice patients go thru a period at the end of their lives where they can't eat -- days, weeks, sometimes a month. When we get those, the first thing we do is give them mag citrate via NGT to clear out the bowels, follow with a couple of bisacoyl, sorta like a colonoscopy prep. The patient will be passing gas, but there's nothing in there to turn in to concrete from the morphine pump or Roxinol. If the patient hasn't had their bowel emptied, it could cause pain. If they have a substantial tumor burden in the abdomen or GI tract, it can cause pain, but trying to give them MOM or any laxative would probably make it worse. That would be a "look and see" situation at the patient's history, chart, med list, last known BM, last meal, etc.
3. You said the patient was holding their belly moaning in pain. What was their diagnosis? Liver CA with mets? It's to be expected they'd have belly pain if they weren't getting enough pain medication often enough. There's a great page on morphine and the Hospice patient http://www.hospiceworld.org/book/morphine.htm that's worth you looking at. Explains how morphine's good for somethings, not for others. Liver mets, it's great. If the patient was curling around their stomach because the pain was in bone CA in the pelvis, spine, etc., the morphine's not always the best drug for that. You said the patient was getting a ton of morphine. If they were still talking with you, they weren't snowed, so they really weren't getting a ton. My guess is they think there's been progression of existing disease or a new site for mets (the x-ray); if there's a new tumor in the rectum from prostate CA, you don't want to go sticking fingers up there.
3) Hospice is not about cure, it's about comfort, and my concern is the patient is not being kept comfortable. If the radiology shows the patient's GI tract is clear, up the pain meds (terminal agitation can sometimes mean "nurse is afraid of giving morphine"), give ABHR (Ativan-Benedryl-Haldol-Reglan) + narcotic, keep them comfortable, and be a listening presence with them.
4)Restraints -- if I'm in agony from terminal cancer or have terminal agitation from end stage COPD, and my nurse is afraid to medicate me, I'll be crawling out of the bed, too. Once we get a person's meds straight and get the nurses to actually give them (if in patient), we usually don't have issues with needing restraints.
That was the big red flag for me, if the person's in so much pain they're agitated, why aren't the getting everything in the MAR to make them comfortable, or a quick call to the MD to get more?
I had to copy this because once was not enough....I worked hospice (and I loved it)...Nerd, this was TERRIFIC!!! 1,000 KUDOS to you...:yeah:I have nothing to add.
mazy
932 Posts
The term zero-restraint can be a little tricky. In most facilities, in my state at least, there are levels of restraint, going from chemical restraints, to physical restraints along the lines of side rails, body pillows, mittens, lap belts, and then going up to a more extreme level, such as four points.
Most of the "zero-restraint" facilities in my area, maintatin a strict policy not to use the latter, but can resort to the chemical and some less invasive forms of physical restraint with proper documentation that it is a last resort in a long chain of attempts with other types of restraints. I don't know the ins and outs of official policy so am not sure how acceptable that is officially. But it is what facilities do.
The more extreme the restraint the more difficult it is to justify so facilities that say they are zero, usually are very careful about exhausting all efforts, and may even transfer a patient out before relying on any kind of restraint.
With hospice patients, however, chemical restraints can become necessary. I have had hospice patients become so agitated that I was worried they would kill themselves before they were ready to die peacefully.
What you are describing sounds horrible and unconscionable, though.
At any rate, I remember one SNF I worked in, we had this patient who was extremely complex, lots of tubes, co-morbitities, highly acute issues, and completely out to lunch. Was incredibly agitated and kept trying to find a way to fall out of bed.
Staff ended up putting him on a low bed with side rail, and alarm, which was a restraint, but there was plenty of documentation about how dangerous the patient was to himself. He really shouldn't have been there, but this was one of those facilities that will take anyone and then just jerry rig a safety policy.
I had never worked with the patient, but one day I picked up a night shift and he was on my watch. I had sat down to take report and heard him yelling from his room. I went in there and saw that someone had parked a locked wheelchair by his bed to prevent him from crawling over the side rail and onto the floor.
What had happened is that he had attempted to crawl out of the bed, was completely tangled in his feeding tube, and his head was lodged between the side rail and the wheel of the wheelchair. His neck was lying on top of the side rail and he was in the process of strangling himself and could not unlodge himself, fortunately he was able to shout because otherwise by the time I got back there he would have been dead.
I never forgot that incident. Still sends chills up my spine.