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.[/quote
This thinking is a little out of whack... Let me elaborate. Patients do have the right to make their own decisions regarding their care, but if they aren't going to do anything the doctor/nurses suggest then they are better off at home... We are not miracle workers and there is no magic wand that we can wave and make everybody better. People get prescribed certain treatment because that is what is going to help them get better/keep them from getting worse. If they don't agree with this treatment and don't/won't follow it, then I say let the bed they're taking up go to someone who will do what they need to do to get better. There is a problem these days with people thinking that when they come to the hospital we should make them feel all warm and fuzzy and say everything's going to be ok... People don't seem to get that your health is not a right, it's something that you have to work at.
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.
Have you dealt with pt like this before?
I don't see it as a hard choice in any case whether NPO or fluid restriction. I will find a way of distraction and education. Why would I want someone to put themselves in an even worse situation. These are serious conditions and even a dixie cup of water can do damage. I would also look through the chart or talk to the pt about spacing their alloted water out during the shirt and try food that wont leave the mouth all achy and dry. I had a real sad case, elderly lady who was way past her fluid restriction limit when I got her. So there was no way I could in any right mind give her move. I swabbed her mouth a zillion times that night and did other things to keep her from feeling the thirst. Do I feel her rights were trampled on? NO I felt the other nurses. the doctors. and I were trying to SAVE her life!
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.
i understand what you are saying. i'm interested though in finding out what you would do with a patient that keeps asking for water...do you keep giving them "a dixie cup full" of water? it can add up and even this small amount could lead to undesirable results for some patients. there are patients that will continue to ask every few minutes, even if you keep giving them a little each time. if their health were to be negatively impacted, then what would be your defense?
i think it's a tough issue, that has to be dealt with on a case by case basis. depends on the severity of the patient's condition, if they are ok after just a couple of sips of water, or just continually ask for it...have other measures been taken, such as oral care, maybe an ice chip or two....i would consider these, then teach, document the teaching as well as compliance, or lack thereof
When I worked on a Heart Transplant Unit several years ago, we would give the patient frozen grapes to help with their thirst, or those oral care sponges dipped in a few ice chips (but we were careful even of these as to not give them too much.)
As for allowing the patient to go over their MD ordered fluid restrictions, I am not an enabler, and will not bring patient more water/fluids than is ordered, just as I will never wheel a patient outside to smoke a cigarette. I cannot keep their family from smuggling in fluids from outside, nor can I prevent the ambulatory pt from drinking from the sink, but I will be sure not to leave any cups lying around.
I don't see how one MD order is different from another. If the MD orders Lortab 10, 1 tablet q6h prn, I surely do not give my patient 2 tables q4h. I personally do not see the difference.
Specializes in Psych/CD/Medical/Emp Hlth/Staff ED.
....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.
That's an interesting way to view patient advocacy: simultaneously advocating for and "against" them.
Specializes in Psych/CD/Medical/Emp Hlth/Staff ED.
....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...
I'm having a hard time following this logic. To me, the reason why defending giving coumadin to a pt with INR of 6 with the fact that you had an order doesn't hold up to scrutiny is that you can't justify a questionable action with an MD order. The same logic would mean that we can't defend the denial of water to a lucid patient based on an MD order, which seems to be one of the most common justifications given so far.
The logic with eriks' argument has to do with the actions of "a reasonable and prudent nurse". If you are ever in a legal situation this is the standard that you will be judged by. If you gave the coumadin to the patient with the INR of 6.0 and they developed a head bleed and stroked and died or suffered permanent disability you would be liable. It's not simply a matter of giving a pill simply because it is ordered, but having the knowledge of the disease process and how the medication will interact with it in addition to potential effects of the medication. The "reasonable and prudent nurse" would hold the dose and contact the physician for further orders.
I view a fluid restriciton in the same light. I'm not sure what area you work in, but in my area I have taken care of patients with horrible CHF. On lasix drips and dopamine/dobutamine and still fluid overloaded. Sometimes diurectics are not enough and if the patient has a very low EF then letting them exceed the fluid restriction can be very harmful. I realize that the patient has autonomy, however part of my state's nurse practice act says that I plan and participate in the plan of care as ordered by the provider. To me this means that I follow the orders (as appropriate) and I will not willingly circumvent the plan of care.
Allowing the patient to violate their fluid restriction by willingly bringing them water, to me is not a legally defensible position. I feel it is also wrong to willingly help a patient harm themselves, they may not know how their actions can harm them but I've seen the end result too many times.
Specializes in Psych/CD/Medical/Emp Hlth/Staff ED.
I realize that the patient has autonomy, however part of my state's nurse practice act says that I plan and participate in the plan of care as ordered by the provider. To me this means that I follow the orders (as appropriate) and I will not willingly circumvent the plan of care.
Whose plan of care is it? It should be the Patient's plan of care, not the Physician's or anyone else's and as patient advocate, it's the Nurses job to make sure that is the case.
I seem to be in the minority, but I believe a patient has the right to refuse treatment and not be forced into a treatment against their will, and a fluid restriction is part of our treatment.
Specializes in Psych/CD/Medical/Emp Hlth/Staff ED.
I'm not sure what area you work in, but in my area I have taken care of patients with horrible CHF. On lasix drips and dopamine/dobutamine and still fluid overloaded. Sometimes diurectics are not enough and if the patient has a very low EF then letting them exceed the fluid restriction can be very harmful.
Allowing the patient to violate their fluid restriction by willingly bringing them water, to me is not a legally defensible position. I feel it is also wrong to willingly help a patient harm themselves, they may not know how their actions can harm them but I've seen the end result too many times.
I deal with the same patients and certainly won't argue that a patient deciding to exceed their fluid limit is not making the smartest decision, but it's their decision to make, not mine.
Whose plan of care is it? It should be the Patient's plan of care, not the Physician's or anyone else's and as patient advocate, it's the Nurses job to make sure that is the case.
while the pt should ideally have input re poc, the poc is essentially a treatment plan, and the dr. is the treater.
and so, it's the doc who primarily calls the shots, and as stated, the pt can either comply or not.
i agree that ultimately the pt has the final say.
but as a nurse, and depending on the severity of the situation, i am going to try and uphold the poc to extent possible...
Yes the patient has the right to refuse treatment. The AMA forms will back us up in case they absolutely refuse. Sometimes it is way convenient for us to just say sign it and in our minds we say 'good luck with that' or 'let's see how well you can do without following treatment' *evil laugh*
What are we there for if not to give them the best treatment? NPO might seem to trivial especially for the lay person. If they get up and get a drink themselves, it's out of our control, esp when it's from a toilet eyw. But no way should we help them out and give them that drink. Again it's a case to case basis.
Specializes in Psych/CD/Medical/Emp Hlth/Staff ED.
while the pt should ideally have input re poc, the poc is essentially a treatment plan, and the dr. is the treater.
and so, it's the doc who primarily calls the shots, and as stated, the pt can either comply or not.
i agree that ultimately the pt has the final say.
but as a nurse, and depending on the severity of the situation, i am going to try and uphold the poc to extent possible...
respectfully, sensitively, and competently.
i thought that's what we were supposed to do.
leslie
That's my concern, it doesn't sound like we believe the patient has the choice to comply or not and that we believe A&O patients can be forced into compliance, often without the ability to leave the hospital or fend for themselves in the hospital.
KyPinkRN
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