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.
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.
If a patient doesn't want to adhere to the medical orders, they can leave. It IS their lives. . .and that is why some of them end up in the hospital. Not taking their meds, not eating their diabetic diet, not monitoring their BP. We live in a society that wants to assume no responsibility for our own behavior and then these people come to the hospital wanting to be cured but wanting absolutely NO DISCOMFORT whatsoever. UGH. Drinking a liter of water a day is tough. . .but it ain't abuse and it ain't going to kill you. Being in the hospital is not fun and easy! For some reason people seem to think it should be the equivalent of staying at a 4 star hotel, all demands met regardless. Then, if they don't get their way. . .they sue. But yeah, if I give them water and they end up on a vent, they also sue. Because the responsibility for their health is never their own.
I became a nurse to help people who want to be helped. . .not to coddle irresponsible people. They may dislike me for it, but I have received many letters of "thank you" from patients and their families for pushing them to get better and take control over their own lives. Nurses have to be tough sometimes - it's not all about fluffing pillows. It's like being a parent - the kids is going to scream "I hate you" sometimes but ultimately they need the direction, the discipline and the tough love.
It doesn't mean I won't help alleviate the need for thirst. Lola77 is right. We can give the patient ice chips (as long as it is approved to do so, as i've encountered some cases where even ice chips are not allowed) or try to get the mouth wet. It really depends on the dx and progression of illness or recovery, as some doctors will allow sips.
Doctors have a reason for withholding fluids. Until there are significant scientific studies that say that putting an NPO is useless and fluids can be taken upon the discretion of the nurse or patient, then i'll keep the patient on NPO as ordered.
This is interesting--and I've never really thought about it from this angle, I've had patients before drinking out of the toilet, etc. to get to water...it's really sad when you think about it. But when you think about the things that we do, to get them away from the fluids...in order to enforce a doctors order for meds, we rarely go through the same hoops...if a patient refuses a medication, even if it's for something important, blood pressure, diabetes, a diuretic, etc...we document, and move on...sure, we may go back and ask the patient again if they want to take the med...but I've never gone and gotten AMA paperwork or a bed alarm over a Metoprolol...just interesting
If its an A+O patient and amb, I would tell them FS/NPO is a physicain order that I must abide by, if they choose not to follow the orer once I am out of the room, that their problem. If they cannot walk to get their own water, they will probably talk the visitor into helping them get water/food.The point is I would not sway from the order, thereby you have done no wrong or harm to the patient. If the patient goes into chf exacerbation or had difficulty from a test, they will have to explain to the physician that they drank water or ate food on their own. DOCUMENTAION is key to your not being called in to a court of law explaining that you allowed them to have a water/food. Its like any other nursing education, you cannot demand anyone to follow the rules, but you do not help them to not follow them.
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.
Sometimes fluid restrictions are necessary and helpful in some instances. Cardiac surgery patients are another example. They can have 10 to 20lbs of fluid on board after their surgery and are put on a fluid restriction in addition to being on diuretics until they get back to their pre-op weight. Diuretics alone aren't enough.
I've seen a patient -- frequent flyer, diabetes induced renal failure, HTN, CHF, dialysis pt -- who begged ice chips from everyone who hit their door. Doesn't sound that bad, does it? Well, being a bookish sort of nurse, we started talking and realized this pt had gotten 12 cups of "ice chips" in the course of our shift. So I trot into the kitchen, fill up 12 cups of ice chips, and wait for the melt. Turned out the pt got almost 350cc of fluid. Now, that was roughly 7 p to about 5 am, when we put 2 and 2 together. So, let's say the guy gets 350ccs of "ice chips" on each of the three shifts. He's blown his 1000cc fluid restriction on ice chips. We give him his 1000ccs as liquid, and he sneaks another liter or two from family (who were the king of the "Big Gulps"). God only knew how much fluid he was actually getting, he'd gain wait every time we weighed him. Drove dialysis crazy. When we told him he wasn't getting ice anymore, he told us he'd be on the call bell every 5 minutes all night to "show us." And he did. Luckily, his behavior didn't get any other patient killed because we were all running into his room 100 times a night.
This was the same guy who would leave dialysis and go to his vehicle and pull out a 2 liter soda and drink it in the parking lot, visible to the dialysis center staff. And then he'd be back in with crazy BPs, CHF exacerbation, pulmonary edema, pneumonia...
And yes, I was working the night his free will killed him. So, I give swabs and glycerine, I don't give ice chips anymore. You don't want help, don't come to the ER, or go home if you don't want us to help you.
Specializes in M/S, MICU, CVICU, SICU, ER, Trauma, NICU.
Fluid restrictions means no extra fluids beyond what is ordered.
I won't enable the behavior. No cups, no nothing, including yelling or belittling. I'll educate, but the consequences on an ADULT with appropriate faculties has to be taken on by the ADULT patient, and chart like there is no tomorrow.
I'm not going to cause someone to go into heart, liver, kidney, etc., failure.
I'm not the patient's friend; I'm their advocate. I can understand their desire for the fluids. They can sign themselves out AMA if they don't like it--their not liking it? That's not my problem. Trust me, I sleep well at night with this philosophy.
fluid restrictions seem a draconian and primitive regimen when we have diuretics available.
right... allowing a px to drink because someone created diuretics:uhoh3: IMO I would not recommend adding on to a px medications, which every pharma company would reply to with why not. Giving extra drugs just so he can drink will not help his recovery.
My dad continues to eat whatever he wants because he has his wonder drugs for his cholesterol and hypertension.
this pt had gotten 12 cups of "ice chips" in the course of our shift. So I trot into the kitchen, fill up 12 cups of ice chips, and wait for the melt. Turned out the pt got almost 350cc of fluid.
This was the same guy who would leave dialysis and go to his vehicle and pull out a 2 liter soda and drink it in the parking lot, visible to the dialysis center staff. And then he'd be back in with crazy BPs, CHF exacerbation, pulmonary edema, pneumonia...
I will not kill you to make you happy.
That's right. Even ice chips have to be monitored. I've never given a cup of ice chips, only a spoonful to be sure they don't wait for it to melt and rink it.
I've rotated briefly in dialysis units and pxs I had told me openly that they eat whatever they want pre-dialysis because their blood will be "cleaned and good as cured" after.
Specializes in Critical Care, ED, Cath lab, CTPAC,Trauma.
I have had patients drink out of the toilet too! If they are alert.....I will educate and educate and educate. I will call the MD and inform them of the patients non-compliance. I will document the patients non-compliance as many times as necessary. I won't provide them with a drinking cup and I tell the patient I won't and why I won't give them a cup. If there is not an ice chip order I will try to get one sometimes if you get them a popsicle order it helps. If they are confused I will not leave water, they cannot make the decision of what is right.......I have frozen mouth swabs in juice or in melted popsicle liquid. But I won't give them water. If they get that hostile......I too would explain to the patient why this was being done and let the family know.......but that they can opt to not be in the hospital. Before I was a sup. I would get the charge nurse,the manager, the sup and the hospitalist all involved.....CYA Patient rights yes but as the nurse we must follow the MD orders........so NO I would not give water. CYA and document.
To me, it is the line between what a patient wants and what is ordered. An obese patient may want fatty foods, an alcoholic a bottle, or a smoker a cigarette. I can't/won't restrain them from going to get it, but I also won't provide it. If they don't want to comply, there is education, documentation, and if needed the AMA form and a discharge from services.
The nurses I worked with used to do the same thing with diabetic patients. If they were fully aware of their diabetes, mentally sound, and capable of making their own decision, we'd give them graham crackers all night as long as they asked for it even though it goes against their diabetic diet. We just always strongly reinforced the negative consequences of doing so and ensured they were fully aware of the decision being made.
If patients really want it, they'll get it. I had a guy who was NPO because of surgery in the morning and I caught him drinking water out of the sink in his bathroom :) Needless to say, his surgery was postponed.
Lola77
102 Posts
If a patient doesn't want to adhere to the medical orders, they can leave. It IS their lives. . .and that is why some of them end up in the hospital. Not taking their meds, not eating their diabetic diet, not monitoring their BP. We live in a society that wants to assume no responsibility for our own behavior and then these people come to the hospital wanting to be cured but wanting absolutely NO DISCOMFORT whatsoever. UGH. Drinking a liter of water a day is tough. . .but it ain't abuse and it ain't going to kill you. Being in the hospital is not fun and easy! For some reason people seem to think it should be the equivalent of staying at a 4 star hotel, all demands met regardless. Then, if they don't get their way. . .they sue. But yeah, if I give them water and they end up on a vent, they also sue. Because the responsibility for their health is never their own.
I became a nurse to help people who want to be helped. . .not to coddle irresponsible people. They may dislike me for it, but I have received many letters of "thank you" from patients and their families for pushing them to get better and take control over their own lives. Nurses have to be tough sometimes - it's not all about fluffing pillows. It's like being a parent - the kids is going to scream "I hate you" sometimes but ultimately they need the direction, the discipline and the tough love.