[MBA2BRN]

Hi. I just finished a case study on an elderly woman living outside of an assisted living situation. However, next semester I will be working with real elderly people living in an assisted living situation. My case study covered dehydration and issues concerning problems with the GI tract.

Anyway it dawned on me that although I understand the concepts presented to me in my assignment, I do not know how to deal with a real clinical situation, where my patient will REFUSE to intake fluids to prevent dehydration.

As a social worker in my former life, if people refused treatment we documented it and moved on or the law stepped in to enforce treatment. How does a Student Nurse convince his/her patient to take in fluids and/or follow treatment plans? Assume that said student is new to the patient so no real relationship is established AND the Student Nurse does not want to fail clinical that day. Thanks.

[qaqueen]

As a student, you need to see your instructor. In a healthcare facility, you will have a preceptor. They will guide you through this and many other sticky situations.

Best of luck on your new adventure.

[blackberry4eva]

I agree with the last post, but know that patients have the right to refuse any treatment. Try to talk with the patient about the consequences, and if they still refuse do not give it to them and of course document everything.

[qaqueen]

Blackberry4eva is absolutely correct. I work at a hospice. Many of my patients refuse water, food, even meds. Documentation is KEY!

[MBA2BRN]

THANK YOU! I was scared nursing was extremely different then social work!!!

I assumed nurses (well Student Nurses) would be accountable for everything even things that is out of our control such as, a patient refusing treatment. I am very happy to know that this is not the case. Education and documentation I can do! Being made accountable for the actions of others; no can do. Thanks again!

[Angie O'Plasty, RN]

You might also find out why the patient is refusing. Some refuse to drink because they're afraid they'll be up all night to pee. Some refuse to drink because they can't taste anything anymore, and they've become somewhat anorexic. Medications can cause this problem.

Some folks just don't want plain water, and don't like milk or juice. You might offer jello, ice cream, Italian ice, broth, or the like. With that type of patient, you want to make every calorie count--so often, they will have nutritional supplements like Boost milkshakes or Magic Cup ice cream ordered.

In other words, if a patient refuses to eat or drink, unless they're a DNR, terminal, and on Hospice, I consider it part of good nursing care to find out why and coax them to try a little.

Also, in the acute care setting you should find there is usually some policy on how long a patient can realistically go without eating/drinking without some form of medical intervention such as TPN, PPN, or placement of an NG tube or G-Tube.

Checking the patient's labs will also clue you in as to their actual nutritional status. Someone who's dehydrated for instance, will usually come up with a high BUN, normal creatinine, and other electrolytes will be out of whack. To check someone's actual nutritional status protein-wise, an albumin and prealbumin level will be drawn.

As a person refuses to eat or drink, you will see decubs and poor wound healing, and that is why vitamins and nutritional supplements are part of the wound healing regimen.

[llg]

Don't forget to explore WHY the patient is refusting fluids or nutrition or whatever. ASSESS before you make a decision what to do (or not do) about it.

For example, a person might limit intake to minimize trips to the bathroom -- because it is too difficult to do on their own and they are embarrassed with the assistance needed. If you can solve their toileting problems, they might be extremely grateful and be happy to quench their thirst. (My mother limited her intake for that reason.)

Remember: Always assess the situation thoroughly before you choose an intervention! Establish a relationship and get to know the patient. Explore the situation from the patient's point of view and understand why they make the decisions they make. Don't just educate and document. That might not be meeting the patient's need at all.

Edit: I see Angie and I had the same thought at the same time. :-)

[Daytonite]

Yes, always assess. When a patient is refusing to do something, you try to give them a logical explanation why they should do it. They do have the right to refuse, so you can't force them to do anything. Then, investigate to see if there's something to explain why they are refusing. However, your duty to the patient doesn't stop there. Basic survival requires food and water. So, if a patient is refusing fluids you need to also make a determination if this is life-threatening or not. If it is, a call needs to made to the patient's doctor and he/she needs to be informed that the patient is refusing fluids. If the doctor has specifically ordered the patient to be taking a certain amount of fluids daily and the patient is refusing to do this the doctor also needs to be notified of this.

[Angie O'Plasty, RN]

Oh, almost forgot. In order to really assess what the patient is eating, we have a procedure called a Calorie Count. Every teaspoonful of food or drink is measured and we work with the Dietary Dept's Nutritionist to calculate needs and assess whether those dietary needs are being met.

So, to sum up:

Your patient doesn't want to eat or drink. You know that the patient is not a terminal, DNR or Hospice patient. Investigate why. Investigate possible medication causes or mechanical causes. Maybe it's something as simple as that the patient needs help to eat or drink and doesn't want to admit it.

Report to your colleagues and see if Patient is eating/drinking at some other point during the day. Report to the doc. Suggest labs and a dietary consult or a calorie count. Put the patient on strict i/o's and daily weights. Check skin daily.

Keep in mind that the nurse is key to following through with most of these interventions.

[iceyspots]

yes some patients need a little coaxing, especially with the elderly population. I've learned how to influence them a little more to get them to drink and eat.