Sophie, a 25 year old, was admitted under your care to the High Dependency Unit from the Emergency Department

Sophie, a 25 year old, was admitted under your care to the High Dependency Unit from the Emergency Department for ongoing observation following diagnosis of grade one sub-arachnoid haemorrhage (SAH).

Sophie, a 25 year old, was admitted under your care to the High Dependency Unit from the Emergency Department for ongoing observation following diagnosis of grade one sub-arachnoid haemorrhage (SAH). A short time after admission you notice that Sophie has become less responsive and does not appear to be moving her right arm. You notify the medical officer and an urgent CT scan is ordered. Whilst awaiting her CT scan Sophie’s GCS continues to drop requiring her to be intubated for the purposes of the scan. Sophie’s scan reveals a ruptured posterior inferior cerebellar artery (PICA) aneurysm. She is promptly taken to theatre and an emergency surgical clipping is performed.
Sophie was later transferred to the Intensive Care Unit post operatively for recovery. She is intubated, sedated and ventilated with aim to wake her and assess her neurological status prior to extubation. After her condition stabilised, her sedation is ceased to allow her to waken for neurological assessment. As her registered nurse, you perform a full neurological assessment and note decreased movement in her right arm and leg, her eyes are opening spontaneously but she is not obeying commands and is attempting to pull out her endotracheal tube. To protect Sophie from self-accidental harm you request permission from the doctor to apply hand restraints.
Later, when Sophie’s husband and mother attend her bedside they expressed their concern over the use of the restraint’s and demand that they be removed. When you try to explain the need for the restraint, the husband becomes increasingly distressed and insists you remove the restraints immediately. Although you try to explain the temporary need of restraints, the husband refuses to listen and begins to remove the restraints stating “you do not have the right to do this to my wife”. You then ask the husband and mother to leave the room as their behaviour was upsetting Sophie.