pt was very upset about fluid restrictions

Nurses General Nursing

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I'm a student nurse-- not sure how to handle this

I had a pt on a fluid restricted diet. This pt had been in hospital for at least a couple of weeks and the fluid restriction was nothing new. The tray came without liquids on it as usual and she asked me if I would get her some coffee and milk. I told her I needed to ask the nurse in charge because of her fluid restrictions. She got really mad at me when I told her that. I asked the pt what was her understanding of why the restriction was in place and she told me why, and how it related to her health problem but was unhappy about it and said why doesn't anyone just listen to me and get me what I want?

The CNA then wrote out her totals of fluids at the meals she'd had on the board to help her understand that she'd had too much fluid already, and she still got mad about it. I told the nurse and the nurse said do not give her fluids, she's had enough today. I was then asked to remove the water pitcher because the pt's family had filled it for her. I encouraged the pt to talk to the doctor about her concerns and she said she had already that morning, but the orders were the same.

At what point does the pt have the right to refuse the diet and get the fluids she wanted, vs. the nurse's duty to follow doctor orders about the diet or fluid restrictions? I felt caught in the middle and was unsure what to do.

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Specializes in ER, Trauma.

IMHO, when you come down to it, the patient can do whatever they want. The doctor recomends what he feels is best for the patient. You follow the doctor's instructions, try to walk the line between being the patient advocate while following the doctor's orders, and document, document, document. Don't get hung up feeling in the middle. If the patient doesn't want to follow the doctors instructions, you document. You're a nurse, not a police officer. Let the doc fight it out with the patient.

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Specializes in Hospice, LTC, Rehab, Home Health.

The patient has the right to have whatever diet and fluids she wants. The nurse should document the teaching she has done and then in a concise and nonjudgmental statement using the patients own words indicate that the patient understands the benefits and risks to following the orders but chooses to have x fluids and y foods. A mentally competent person has the right to refuse ANY treatment. It is then up to the MD whether or not he wants to continue to treat a non-compliant patient.

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Keep in mind that while the patient has the right to follow or not follow her physician's treatment plan YOU are under no obligation to facilitate it.

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I wouldn't go and get it for them, but if their family brings it in or they get it themselves out of the sink or whatever, then just document their refusal and your education. Just like if someone is on a cardiac diet and their family brings them in a bucket of fried chicken. Just document your education and the patient's refusal. They aren't in jail and they have a right to refuse this stuff. If the family or friends bring in some narcotics for the patient or something like that then that is different. Then you'd have to get the supervisor, security and all of that involved.

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Specializes in Med/Surg, ICU, ER, Peds ER-CPEN.

Being a stickler for CYA, I'd grab a refusal of treatment and document pt refuses prescribed diet and have the pt sign, so when they throw themselves in CHF and are drowning in all that extra fluid, it's not on me.

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Specializes in Acute Care Cardiac, Education, Prof Practice.

I am wondering if the patient was just testing someone they didn't know. It sounds like she was attempting to bully/intimidate you, or capitalize on a possible lack of knowledge/procedure.

Tait

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Specializes in CCU, SICU, CVSICU, Precepting & Teaching.

patients will test each newcomer -- maybe they can get something from this new person before they figure out the fluid restriction. they'll play staff off against each other ("the day nurse let me have all the fluid i wanted; why can't you?"). they'll attempt to bully you into filling the pitcher with ice water -- which you cannot do, since you're following doctor's orders. they'll sneak in food, they'll steal food or drink off the roommate's tray. i had one patient on a fluid restriction for heart failure -- someone told him watermelon was ok to eat and got him a refrigerator so he could eat as much as he wanted. he was eating two melons a day and i had to ultrafiltrate him every day just to keep his fluid balance even. (4-5 kg of watermelon!) patients will drink out of the sink, out of the toilet, out of the mop bucket and out of their roommate's ventilator circuit. (pardon me while i gag over that one!)

i had a patient who got good at getting drinks from engineering, housekeeping, bio-med, her roommate's family -- anyone who passed by, she'd try to get them to sneak her a drink. we could not get her heart failure under control and tune her up enough for transplant, and she missed two hearts. finally the whole transplant team got together and confronted her telling her that she had one week to comply with her fluid restriction (and diet) or they'd remove her from the heart transplant list and she'd die. then we had a meeting with housekeeping, support associates, biomed, the plumber and anyone else who had ever given her liquids and explained the same scenerio. "give her something to drink and she'll die." we put the fear of god into biomed and the plumber but probably didn't make much of a dent on housekeeping. (not where i work now -- housekeeping won't even do their own work, much less fetch for the patients which is someone else's job.) she did get transplanted eventually, and last i heard she was doing well.

there's only so much you can do about a noncompliant patient. do your best, do what you can but don't let it make you crazy. it is their life, after all.

unless, of course, they're incompetent and then you have another issue.

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Specializes in Med-Surg Nursing.

I had a patient report me to her doctor because I would not give her any MORE water in the middle of the night after I already gave her the 100cc she was allowed to have during my 8 hr night shift. She was ordered a 1500cc fluid restriction for CHF. I tried to explain to her that I can only give her so much water during the night and I had already given her that allotment when I gave her a sleeping pill at midnight.

If pt's don't want to follow their doctors orders then they ought to sign out AMA and save us BOTH the grief because they obviously know SO much more than their doctor does.

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Specializes in Med-Surg Nursing.
The patient has the right to have whatever diet and fluids she wants. The nurse should document the teaching she has done and then in a concise and nonjudgmental statement using the patients own words indicate that the patient understands the benefits and risks to following the orders but chooses to have x fluids and y foods. A mentally competent person has the right to refuse ANY treatment. It is then up to the MD whether or not he wants to continue to treat a non-compliant patient.

While that may be true, if a dr has ordered a pt to be on fluid restrictions and I knowingly give them MORE fluids beyond that order(1500 or 2000cc in 24 hrs) then I am putting MY license on the line and risk getting fired for not following Dr's orders.

If a patients wants more to drink and are on a fluid restriction, I am NOT going to be the one to give them the extra fluids.

If a family member is smuggling in food that are not a part of the patients prescribed diet, I have the right to bar the visitor from the room. I've had to do that before.

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Specializes in CCU, SICU, CVSICU, Precepting & Teaching.
i had a patient report me to her doctor because i would not give her any more water in the middle of the night after i already gave her the 100cc she was allowed to have during my 8 hr night shift. she was ordered a 1500cc fluid restriction for chf. i tried to explain to her that i can only give her so much water during the night and i had already given her that allotment when i gave her a sleeping pill at midnight.

if pt's don't want to follow their doctors orders then they ought to sign out ama and save us both the grief because they obviously know so much more than their doctor does.

what did the doctor do?

i took care of an obnoxious attorney years ago, who threatened to sue me if i didn't bring him a big fat glass of ice water immediately. he was also on a 1500cc fluid restriction. i explained the fluid restriction, the rationale, etc., but it didn't make any difference. he wrote down my name for the law suit he was going to start. about that time, his doctor (a world famous surgeon) wandered by, and the lawyer whined to the doctor that "this (bad word for female dog) won't give me any water and you said i could have anything i wanted. tell her to give me my water right now."

by then i was pretty frazzled from dealing with his obnoxiousness all day. "it's not up to him," i snapped to the patient about the surgeon. the patient's jaw dropped and i think the surgeon was a bit taken aback as well. but he backed me up, saying "she's right, it's her call." and he walked right out. the rest of the day, every time the patient whined about suing me or calling his doctor to "report me," his wife would say "the doctor says it's her call. be nice to her."

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Specializes in Med-Surg Nursing.
IMHO, when you come down to it, the patient can do whatever they want. The doctor recomends what he feels is best for the patient. You follow the doctor's instructions, try to walk the line between being the patient advocate while following the doctor's orders, and document, document, document. Don't get hung up feeling in the middle. If the patient doesn't want to follow the doctors instructions, you document. You're a nurse, not a police officer. Let the doc fight it out with the patient.

Again, the doctor does not RECOMMEND diets and fluid restrictions....they are ORDERS! BIG difference! As nurses, we are obligated to follow doctor orders which means that if Mr Smith wants more water/pop/soda beyond his ordered fluid restrictions, he cannot have it! So no Mr Smith, you can't have another can of Coke! I will not give it to you. Doing so would put my job on the line! Now I can't stop Mr Smith from going over to the sink and sucking water out of the faucet. But I will not give him another glass of water no matter how nicely he asks. I also can not stop Mr Smith's daughter from bringing him in a 2 liter of Coke but if I see her doing so, I can confiscate the item or ask the daughter to take it home with her.

The Dr is not there to fight it out with the patient hour after hour. I am. I am simply doing my job, which is to follow the Dr orders.

If the patient does not wish to follow the orders of his doctor, they can sign out AMA since they obviously know so much more about their medical condition and how to treat it than their doctor.

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