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One of the biggest challenges in nursing profession is to decide whether applying restraints or using alternate intervention on agitated dementia elderly patients. Because, on one hand, nurses do not have time to intervene with these patients using therapeutic communication, due to understaffed; on the other hand, using restraint measure on these patients would conflict with legal, ethical and professional nursing system. Especially among nursing experts, the appropriateness of using restraints on distressed dementia elderly patients becomes their sensitive discussion topic. Similarly, this paper will discuss use of restraints related to the professional aspect of nursing with a real life scenario where a dementia elderly patient is being physically and chemically restrained in the surgical unit 4 North-West (4NW) of Jewish General Hospital during the clinical internship of 180.AO 60N.
Summary of incident
On February 8th, 2013, the nursing student provided care for Ms A.C., a 96 year old female patient. She was brought into attention to nurses because Ms. A.C. refused to take her medication and moved herself on the edge of bed while all four bedrails were still raised. Ms. A.C. was restricted to be in bed because she was hospitalized in 4NW for a left hip replacement surgery due to a recent fall injury. Moreover, she has the relevant medical history of right hip hemiarthroplasty, dementia and Alzheimer's disease. The nursing clinical instructor prevented Ms. A.C. from falling by standing opposite to the patient with the left arm holding around patient's back and left shoulder and with the leg blocking patient's knee. Meanwhile, the nursing instructor calmly explained to Ms. A.C that it was unsafe for her to ambulate which could further deteriorate her left hip injury by keeping it flexed 90 degrees. After a lengthy session of therapeutic communication by the nursing instructor, Ms. A.C. still exhibited agitated behavior. Subsequently after initial assessment by the nursing instructor, the patient was determined that she had impaired cognition to understand the reason of her hospitalization, to recognize where she was and to be cooperative. Without successfully calming the patient, the nurse in-charge then attempted to administer Haloperidol, as prescribed, orally to the Ms. A.C. However, the patient resisted to take the medication. Ms. A.C. was brought back to supine position on bed with collaboration of the nursing staff. As the patient was having an intravenous access, Dimenhydrinate, which could be found in patient's PRN medication list, was administered intravenously by the Nurse in-charge to Ms. A.C. After five minutes, the patient slept quietly on bed. The student nurse then closely monitored Ms. A.C.'s vital signs every hour after Dimenhydrinate administration.
In this real life situation, both physical and chemical restraints are being applied on patient. The four siderails of bed and the physical presence of the nursing instructor held around the patient both serve as the physical restraints. Meanwhile, the chemical restraint is the administration of Dimenhydrinate. The professional nursing issue to be discussed in this paper is to determine whether the use of chemical restraint is necessary and appropriate in this particular situation.
Criteria indicating credibility of nursing resources
Before getting into discussion on the professional aspect of nursing in using restraints on dementia elderly patients, the credible nursing resources, such as nursing journals and articles, are necessary to be included as reference during discussion. The purpose of the nursing articles is aimed to continuously improve nursing care and to provide credible evidence-based knowledge for the general public and for nurses. The credibility of a nursing article can be determined by the following criteria: written by recognized expert, peer reviewed, current and connected to recognized organization.
In the nursing academic article, "Use of physical restraint in institutional elderly care in Finland", as one of the references of this paper, can be found in the "Cumulative Index to Nursing and Allied Health Literature" (CINAHL) database. The overview snapshot of this article as shown in the CINAHL database indicates that the article was selected to publish in the "Research in Gerontological Nursing" journal, in 2009; therefore, the content of this journal is considered to be current as it was published within these recent five years. Moreover, this article was reviewed by expert peer and especially by the editorial board. Thus, this academic article is a credible nursing resource.
Acknowledgement of using restraints on dementia elderly patient
The nurse in-charge administered Dimenhydrinate intravenously to Ms. A.C. to prevent the patient from further deteriorating the left hip and from falling. With regard solely to the professional aspect of nursing, I am in favor with this nursing intervention in this particular circumstance, because we are all in consensus that the patient's safety is the first priority. Moreover, since the patient demonstrates agitated behavior and impaired cognition, nurses are at risk of physical injury during the de-escalation of patient agitation. Furthermore, Ms. A.C. is at risk of further injured her left hip while sitting at the edge of the bed, who is also at risk of developing other complication, such as fracture and hip dislocation. Therefore, I believe that applying both physical and chemical restraints for the sake of the patient's safety is the appropriate nursing intervention for this exceptional circumstance.
In A.C.'s case, I believe that the disease process of dementia affects the patient's cognition and prevents her from being cooperative with the nursing staff. As evidence by the analysis in (Zampieron, Galeazzo, Turra, & Buja, 2010), "aggressors often have impaired cognitive processing and data suggested that many patients may not have been fully aware of their situation and might have experienced some difficulty in comprehending the staff member's actions, which triggered the episode of violence" (p. 2338).
According to Orientations ministérielles relatives à l'utilisation exceptionnelle des mesures de contrôle nommées dans l'article 118.1 de la Loi sur les services de santé et les services sociaux (Ministère de la Santé et des Services sociaux, 2002),