Fluid restrictions vs Patient rights

[HamsterRN, ADN, RN]

I have noticed that I don't share the same view on Physician ordered fluid restrictions as most of the nurses I work with. I agree with educating the patient about why they need to limit their fluid intake as well as addressing issues that might be causing a patient's desire for water such as a dry mouth or chronic cough. I also agree that we shouldn't offer water beyond the fluid restriction when a patient isn't asking for water. I disagree with the idea that a patient who is capable of making their own medical decisions can be denied water even if they have exceeded their fluid restriction when they ask for water.

Some nurses draw the line at getting water for patients, saying that if the patient wants to get their own water then that is out of their control, leaving only ambulatory patients with the ability to obtain water. Other nurses take it even further, putting bed alarms on patients so they can yell at them when they get up to get water.

I agree it is frustrating to be treating a patient for fluid overload when they drink more fluids than they should, and care contracts are often appropriate (if we admit you to the hospital then you have to abide by your fluid restriction or you'll be discharged) but even prisoners of war can't be denied water, this strikes me as potential abuse.

[Quienes]

Wow, how interesting, I can't wait to hear what other people have to say about this.

[dthfytr, ADN, LPN, RN, EMT-B, EMT-I]

There was a similar post in the past few weeks. Overwhelming support for the patient to do what they want even if it's medically wrong. Don't remember touching the subject of the nurses role. What should the patient advocate do? I think I'd put water within the patients reach, reinforce the consequences, and be ready to be fired when the physician throws a temper tantrum. Agree this will be an interesting one.

[steelydanfan]

If a pt. demands water even after I have explained the rationale behind the restriction order, I would simply document the conversation, call the physician to alert him to the patients noncompliance, and provide water in cups when requested.

You cannot force anyone who is in control of their faculties to abide by medical care; and providing food and fluids is a basic human right.

I would also get the "Leaving AMA" forms ready, since you know where THIS is going.

You cannot be fired for " Not following the doctors orders", once the pt. decides it's not going to happen, and the doctor was notified. You don't work for the doctor, you work for the hospital, and the patient.

[Crux1024]

I had a similar post to this where I asked If I shouldve fed an NPO patient who was demanding food..the response was overwhelming, but ultimately they all said the same thing. No.

Youre there in the best interest of the patient. If a doctors order reads "FR 1L"...im giving them ...1Liter. They can live with it or not. I will educate til Im blue in the face, but from me or any other staff member, they are getting no extra water and can put their face under the faucet if they want to and I will reeducate and document appropriately.

As someone else said in my previous thread, you are not there to be their friend. You are their nurse, their advocate for whats best, even when youre advocating against the patient themself.

They can drink as much as they want and drown themselves after theyre discharged. I, however, do not want to deal with the repercussions: whether it be the patients status decline, the crap I'll inevitably get from the doc/NM, or my fellow nurses to whom i give report and let them know that Ive been letting this CHFer drink to his hearts content but now its their problem and im going home.

No thanks.

[Crux1024]

You cannot force anyone who is in control of their faculties to abide by medical care; and providing food and fluids is a basic human right.

I should be in jail then for all the times Ive trampled on the rights of my patients by keeping them NPO for a procedure or sticking to their fluid restriction, or keeping them on a diabetic/renal diet.

[Nurseboy1]

So when you provide water for your patient on the fluid restriction their condition worsens, who do you think will get the blame? If grandma with CHF goes into pulmonary edema and winds up on the vent it's your @$$ that will be in a sling.

There is a part of malpractice where they look at what the reasonable and prudent nurse would do, and if my patient needs the fluid restriction then they can ask for water until they are blue in the face, once past the restriction they will get no more from me. If their families bring it they will be educated and it will be charted. I do not want to be in a court of law explaining why I knew that more fluid would be harmful to the patient and still continued to bring it to them.

Things like fluid restrictions are no fun but when they are necessary they are necessary.

[eriksoln, BSN, RN]

This question, of whether it is a violation of human rights or not, is a good reflection of book nursing vs. RL nursing too.

If I were taking a test or answering an essay question, I'd say they are allowed to have the water unless it is already documented that they are not of "sound mind".

Now, in RL, its not so black/white. Lots of gray areas there. The biggest one being what has been mentioned before. If a pt. is NPO for a procedure, would you give it? Most say no, even (I imagine) a few people who think enforcing the fluid restriction is a violation of pt. rights. Why? Because the detrimental effects are obvious. Pt. goes to the OR having eaten and has poor outcome because of it, extended stay if the procedure is cancelled. When dealing with a pt. with hyponatremia who drinks too much......eh, the lab results won't be back for a long time, will anyone even notice?

How I deal with it is simple. They get the water unless I see A DOCUMENTABLE threat to the pt's safety. If their sodium is critical low instead of just......low......I may refuse it. If they are in active CHF and showing severe complications already.........no water. For those who do get the water, I call the doctor (yes, early in the AM) to let them know the pt. is being non-compliant and document heavily on why I assessed giving the water was a danger to the pt's safety. Now, if the doctor yells and hoot and hollers, I invite them to give me a phone/verbal order to do something about the non-compliance. Most back down and decide to deal with it in the AM, and sometimes that "deal with it" is simply talking to the pt. about the dangers of taking water they should not (something they should have done in the first place). I've seen "deal with it" lead to an early D/C too.

Why the difference between "book nursing" and RL? Well, others have pointed it out. "Withholding water is a violation of pt. rights" won't stand up in court. Thats in the same league as "I gave the coumadin to the pt. with an INR of 6.0 your honor because the doctor ordered it and I have to follow doctor's orders." People rant and rave about the thirsty pt. who is "oh, so abused" becasue you won't give them water, but none of those people will stand up in court and say "I made that nurse give the water your honor." when something goes wrong.

Mind you, this is all after I've done every imaginable nursing measure. Offer swabs and educate on only "swabbing" and not drinking the water. Make sure oxygen is humidified. Make the pt. as comfortable in every other way so that the thirst does not seem so bad.

[al7139, ASN, RN]

Hi,

Heres my two cents:

I work on a tele unit where we see lots of patients with CHF and abnormal labs that would benefit from fluid restriction to correct the problem.

If the patient is A&O, I discuss with them the MD order, educate them on why it is important and how it can help them, and explain how we measure and ration their fluid intake.

Most of the time (as far as I can tell) this works to keep patients and family compliant (I have never caught anyone drinking from the sink).

However, there are those few, who, no matter how much you educate and explain will do it their way and will not listen to us or the MD's. In these cases, I document my education, the patients response to the teaching, and I note every time they exceed the FR in spite of teaching.

I also let the Dr. know that the patient is non compliant and note that I have informed the MD.

Most of the time, the doctors understand, and these patients usually are discharged sooner since they are uninterested in helping themselves.

If the patient is confused, I have to say it is easier to restrict them, unless a "well meaning" family member decides to "help."

I don't know if it is abuse or not. IMHO, I do my best to follow the order, but I can't stop a patient or their family from making the wrong decision, so I just document everything.

Amy

[missjennmb]

"not interested in helping themselves"

Nice way to think about patients. sigh This is why I don't work in a hospital, and am terrified of being there. Patient rights are trampled, and to not agree with or abide by one choice means you are "not interested in helping yourself". I'm sorry but patients have a right to make their own choices in life, even if its to their detriment. It is THEIR lives, and when they are unable to walk to the sink, they are completely at our mercy for every thing. We may not like it, or agree with them, but throwing the baby out with the bath water and assuming they dont care about themselves and should just go home has a lot to do with the total non-compliance of patients. Think of it this way: if you have a patient with a fluid restriction that is insisting on a drink regardless, and they get their own, they are probably going to get a tanker full of water. If you get it for them, you can give them a dixie cup full, and that might be enough to get them through.

The idea of being the patient in this situation practically has me breaking out in hives.

[subee, MSN, CRNA]

Is there good evidence that fluid restrictions are even helpful? A cup of water is not a cup of salt. Unless the patient is in ESRD, fluid restrictions seem a draconian and primitive regimen when we have diuretics available.

[Lola77]

new nurse here. . .but when I have run into this situation I have stuck to my guns, got them a few ice chips to wet their mouths, repeated education and documented. So far even my most cranky patients have ultimately thanked me.

Fluid restrictions would SUCK - imagine laying there in bed, thirsty, nothing to do but think about it, watching your roommate suck down a gatorade. I think even I, a nurse, would be tempting to cheat. Putting water in their reach is just cruel.

Also, in the one case where a person was threatening to leave, to sue, to "call their son who is a doctor in New Jersey" i simply gave her about 30 CC of water and that satisfied her. No sense in filling a water pitcher and leaving it there when she was satisfied with a small amount.

It is grey area - differs with each scenario/person/case. This is why we have nursing judgment and critical thinking skills - to know when to bend a little and when to stick to the order and just say NO.