have you used chemical restraint?

[diamondmeadows]

Hello! :flowersfo

I am interested in hearing about your experiences with using chemical restraint in your practice. Have there been times when you have had a PRN order for Ativan, Haldol, or some other drug, and you used it to chemically restrain a patient? Researchers report that nurses state that they do so for many reasons, ranging from preventing patients from interfering with necessary treatments to keeping patients from wandering to quieting demanding patients when the unit is understaffed.

I am working on a presentation about this subject for my nursing ethics class, and I have been reading journal article after journal article. At this point, I feel that it would help to hear from some real nurses with real experience. I am expected to discuss pros and cons of this issue, so I would love to hear your thoughts, opinions, and personal stories about this subject whether you have used chemical restraint or not. With your permission, I would like to use some quotes for my presentation with absolutely no identifying data. I will not even say that it is from allnurses. If you don't want me to quote you, just say so! I still want to hear from you. Please feel free to PM me if you feel more comfortable doing so.

Thank you all!

[namaste_71]

I've often medicated a patient with prn medications like Haldol and Ativan to keep them calm when they are aggitated. Many times they are sick, going through DTs, injured, weak and if they get out of bed they will fall and hurt themselves, or they are so aggitated they are pulling out tubes, so I give the prn and use a bed alarm to keep this safe.

Is this "chemically restraining"?

No. That's protecting the patient.

[BlueEyedRN]

No, I have not used chemical restraints. I have, however, used medications to manage symptoms of the patients' illness. An example of that would be using Ativan to relieve the anxiety and tremors of a person undergoing ETOH withdrawal.

We use sedation and other meds all the time in the ICU, but I don't know if I consider them chemical restraints. We use propofol to allow the vent to do its work, Ativan to calm anxiety, Fentanyl and Morphine for pain. Like NancyNurse says, we're treating symptoms. If we didn't use these meds, blood pressure and heart rates would be through the roof. I think of "chemical restraints" as those scenarios on TV when someone is running naked through the ER and they tackle them and give them a shot of Haldol in the butt. But maybe I'm just wrong about the definition.

And no, you can't quote me (not that I said anything quotable) unless you actually say you got it off allnurses. Otherwise, its plagiarism, which I saw way too much of in nursing school and which infuriated me to no end. I mean, come on, this is an ethics class. You have to identify your sources. Besides, for all you know, I could be making up everything I say and have no actual experience whatsoever. If you are concerned that an online forum isn't credible enough to identify, maybe you shouldn't be using it in your project.

[BlueEyedRN]

No. That's protecting the patient.

So is using physical restraints.

[Flare, ASN, BSN]

I have given a chemical restraint for combative / agitated patients that pose a threat. Giving it for convenience because of understaffing or any other reason along that line is out of the question in my book (though sometimes tempting).

[DaretoDreamRN]

There have beentimes when i have medicated a patient for the safety of the patient and the staff. Pt. is extremely agitated, hostile and swinging. Ativan, Zyprexa, Haldol IM is ordered and administered in the ED!

[MaryPush]

No, I have not used chemical restraints. I have, however, used medications to manage symptoms of the patients' illness. An example of that would be using Ativan to relieve the anxiety and tremors of a person undergoing ETOH withdrawal.

I agree.

In my experience, PRN medications are for treating symptoms of a specific condition.

Anxiety and tremors are symptoms of a condition (in this example, the condition would be active ETOH withdrawal). Paranoia with resultant agitation could be a symptom of a psychotic process.

Chemical restraint is a medication given to control behavior that could foreseeably lead to harm (self or others). Such behavior might not be a symptom of the condition.

[catlynLPN]

I work with developmentally and physically disabled people and it has to be very very bad before we are allowed to get an order for chemical restraint.

They have other methods that are used before it goes chemical.

They put the people on a papoose board until they are calmed down, they can stay there for 55 minutes then have be allowed to get up for a break and if they're still agitated back down they go.

But I remember one person who was so physically out of control he had to be on the papoose board plus some chemical restraint, eventually.

The superintendent got him transferred the very next day to a unit more equipped to handle him.

At this facility we're not even allowed to give people sleeping aides.

EVERYthing that might even have the hint of a chemical restraint has to go thru human rights, so we just don't have anything to give. I think one person is now on a sleeping aid just because he does NOT sleep at night.

And even anything like Excedrin PM or Tylenol PM won't be ordered just because they think we'll use it too much. Some of them actually could use it, but we're not allowed to have it.

We do give some Xanax and Ativan on a routine basis, to a few people. But PRN....no. It takes an act of congress to get a PRN...it is possible, but you better make sure the person really needs it and other methods are tried before you get it.

At the nursing home where I do a little part time work I have given some patients Ativan at night because they wake up, get restless, noisy and disturb their roommates and other people down the hall.

If you don't give some of them something NObody gets any rest.

So yes, I've used it in the nursing home, but not on the other {state} job.

[kmoonshine, RN]

"Chemical Restraint: a psychopharmacologic drug that is used for discipline, to control behavior, or for convenience and is not required to treat medical symptoms."

I am in emergency nursing, so I don't have PRN orders. I am all for using medications for patients whose actions stem from an illness. For example, I had a 28 year old paranoid schizophrenic off his medications - he appeared very scared, and after I tried to minimize external stimuli (quiet environment, using soft tone of voice), I had to resort to using ativan/haldol/benadryl + 4-pt leather restraints because he started punching himself and his father (he was very strong, needed 10+ people plus 3 police officers to restrain him). After the medications started to work the 4-pt leathers went off; he was more aware of what was going on and was able to control his behaviors.

I would never use medications to prevent someone from wandering or getting out of bed, or for my own benefit (ie "break time!"). I think the viewpoint today is "its better to have someone fall than be chemically/physically restrained" since it takes away the person's dignity. Isn't that why they have extra-low beds nowadays?

I would also be extremely reserved to use these meds on older adults, unless the cause of their aggitation/anxiety/behavior was identified. When I was still a student (on an ortho/med surg floor), I had an elderly lady who had been addmitted for occult hip fx. I was reading her admission chart, and it said A/O x 3 when she had first arrived to the ED. Well, its now 3 days later and she is confused, trying to eat her blanket that was "toast" to her, and kept on talking about "sitting on the couch over there", begging me to "let her go lay down". I will never forget this lady. I was very upset about the situation because the nurses kept her medicated with ativan and morphine (and eventually had to give her reversals due to slow, shallow resp's). It is my belief that she had developed pneumonia during her hospital stay (crackles, sputum production) but as a student, no one listened to me. I believe it was the pneumonia that was the source of her aggitation and confusion, and the nurses were medicating her for their convenience. Even their charting was incorrect, stating lungs "WNL" (um, yeah right!). They discharged this patient that very day (even though I protested - I was caring for her and saw her rapid decliine). I watched the obituaries over the next few days and I saw she died the day after being discharged. I guess my point is that even if someone is rambling incoherantly, LISTEN to them, don't just jump on the PRN medication bandwagon. Make sure to do extra-thorough assessments on all patients that are confused/disoriented, and dont assume anything. Use medications if you have reasons to do so to help the patient, and use restraints if warranted (my safety comes first).

[Gr8Dane]

Sorry but once these new medicare laws come into affect, the ones that push costs ontop hospitals for patient falls (Broken hips, fractured bones, -Cdif infections, etc), every single MD will be ordering IV Ativan and Haldol, and every single confused/elderly patient that is at risk will be snowed in order to prevent falls and excess losses to the Hospitals.

At my hospital we have no psych unit or anything of the sort, they get stuck on the Medsurg floors (Unless a need is found for tele) and we get stuck dealing with them.

We deal with them by chemically restraining them. We are not trained in any other way.

[diamondmeadows, BSN, RN]

I have never seen sedation given because the unit was busy/understaffed. Wouldn't that be assault?

I understand what you are saying. However, nurses in research have reported doing this, and nurses in real life that my group members and I have spoken to have also reported doing this, so I felt the need to throw it out there. I just want honest responses. Thanks for your input! :)

[Virgo_RN, BSN, RN]

Sorry but once these new medicare laws come into affect, the ones that push costs ontop hospitals for patient falls (Broken hips, fractured bones, -Cdif infections, etc), every single MD will be ordering IV Ativan and Haldol, and every single confused/elderly patient that is at risk will be snowed in order to prevent falls and excess losses to the Hospitals.

At my hospital we have no psych unit or anything of the sort, they get stuck on the Medsurg floors (Unless a need is found for tele) and we get stuck dealing with them.

We deal with them by chemically restraining them. We are not trained in any other way.

At my facility, MDs do not routinely order IV lorazepam or haloperidol for confused and/or elderly patients, because sometimes these drugs can worsen the confusion/agitated behavior. Getting an order for physical restraints is equally difficult. We manage patients by using bed alarms, sitters, and enlisting the help of family members. If the situation is especially difficult, then anxiolytics may be prescribed by the physician, but again, this is not a chemical restraint. It is to manage the patient's symptoms.

[diamondmeadows, BSN, RN]

Thank you all so much for responding to me. I truly appreciate your thoughts and experiences.

And no, you can't quote me (not that I said anything quotable) unless you actually say you got it off allnurses. Otherwise, its plagiarism, which I saw way too much of in nursing school and which infuriated me to no end. I mean, come on, this is an ethics class. You have to identify your sources. Besides, for all you know, I could be making up everything I say and have no actual experience whatsoever. If you are concerned that an online forum isn't credible enough to identify, maybe you shouldn't be using it in your project.

Maybe I didn't make my intentions clear enough in my original post. This project is a scholarly endeavor, so I'm not planning to use anything here as part of the informational content of the presentation; that will come from journal articles. I thought I might use quotes from nurses, which I would indicate that I got from an online or real life discussion, and would use names like "Nancy" instead of real life names to avoid identifying the person (as is done in qualitative studies, not that I am suggesting that I am doing one!) I thought this might add relevance to the presentation. By all means, if someone wants me to identify him or her, I can do that, but in order to encourage people to be candid, I want to offer as much confidentiality as I can.

You are absolutely right that I have no idea if you are actually a nurse or not. However, my group members and I have not been asking to see the licenses of the supposed nurses we have been speaking with in real life, so I am ok with it in this situation. Again, I am hoping to use this to try to bring the content home from the realm of journal articles to the realm of real nursing, not as informational content.

Thank you for your perspective!

"Chemical Restraint: a psychopharmacologic drug that is used for discipline, to control behavior, or for convenience and is not required to treat medical symptoms."

Thanks for sharing this. The definition I have encountered in literature is very similar:

“Chemical restraint describes both deliberate and incidental use of pharmaceutical products to control behavior and/or restrict freedom of movement, but which is not required to treat a medically identified condition”

Hughes, R. (2008). Chemical restraint in nursing older people.

Nursing Older People, 20

(3), 33-39.

The only key difference is that researchers include incidental as well as intentional use.

It sounds like a pretty negative term, but most nurses report using chemical restraint out of a desire to keep their patients safe. As far as agitation goes, my understanding from what I have read (which should most definitely be taken with a grain of salt since I am a student) is that if using an anxiolytic or something is part of the treatment plan for a patient with agitation that is expected as a result of his or her condition, it would not necessarily be considered chemical restraint. Some of you mentioned DTs, and I would think (correct me if I'm wrong) that agitation would be expected for a patient with DTs, and a benzo or something would be needed. From what I understand, this would not be considered chemical restraint.

I think what would be considered chemical restraint would be a scenario I have not yet seen anyone here report. That would be something more along these lines: an elderly patient becomes agitated and an anxiolytic is used to contain the situtation even though the cause of the agitation has not been determined. My highly non-expert opinion would be that in this situation, the drug is being used as a chemical restraint.

Thanks again for all the responses! Hearing stories from practice is my favorite thing about this forum.