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.
Specializes in Psych/CD/Medical/Emp Hlth/Staff ED.
I don't consider arguing to be a bad thing. There is nothing wrong with airing opposing viewpoints about what is best for patients and trying to figure out where the other side is coming from and how they formed their decisions. Yes, sometimes an explanation just leads to another question. If you're looking for a discussion about something where everyone agrees and repeats the same thing over and over then there are plenty of those to be found on this site.
Specializes in Critical Care, ED, Cath lab, CTPAC,Trauma.
To HamsterRN.............WELL said!!!!!!!!!!!! This is the actual clinical data that backs up your rationale!!!!!! Angiotensin II is the reason fluid restriction is falling out of favor.........treat the physiological cause to treat the patient...........novel idea:rolleyes: I also think you like a good lively discussion and playing devils advocate!!!!!! Making decisions with good sound clinical knowledge will keep you out of court and goes a long way to making you the best clinician you can be as well as make sound decisions. I was waiting for someone to bring the clinical eveidence to back up the rationale of giving or not giving fliuds!!!! Well done!
I don't consider arguing to be a bad thing. There is nothing wrong with airing opposing viewpoints about what is best for patients and trying to figure out where the other side is coming from and how they formed their decisions. Yes, sometimes an explanation just leads to another question. If you're looking for a discussion about something where everyone agrees and repeats the same thing over and over then there are plenty of those to be found on this site.
Just about everyone on this site knows by now that that isn't what I look for.
What I am not looking for is a "discussion" where someone twists everything I post in order to fit their agenda.
To me, the rational for the F.R. holds great sway as to how far i would go toward leniency. On my TBI unit, where we often treat pt's that are NOT competant or ambulatory, it is easier to restrict fluids than a "walky-talky",who's potentially beligerent, confused and will drink from the faucet. That's extenuating,...and my realty. But to my point. MOST often we have the fr in place because of hyponatremia. Often borderline low. We only recently added nacl tabs to the sole intervention of fr to increase, obtain and maintain na wnl. Naturally, when i float to a tele unit and the restriction is in place because of a cardiac condition, i don't want to throw someone into chf because of education and/or compliance issues. With the hyponatremia, the body is not going to steer like a race-car(fast), more like an ocean-liner(slow). So, i take it on a case-by-case basis and use my best judgement. Holding fluids on a competant pt who understands the risks is unethical and probably illegal. Doctors can be overly cautious and often do not respond rapidly enough to lift or ease a F.R., imo.
Specializes in Gerontology, Case Management, Pediatrics.
]This is a subject dear to my heart. As nurses, we witness the results of patients' non adherence to the POC. Through the years, we have seen the development of the Patient Bill of Rights which all patients receive upon admission to a facility. So we struggle with what we have learned in nursing school and reality. First and foremost, we are not responsible for the actions of another. We do advocate for our patients. We do follow physician orders when those orders are correct. The key IMHO, is education and documentation and when all else fails having the patient sign a statement indicating they have been educated and are aware of the effects of non adherence to a POC. Many of us can relate stories of loved ones who ask our help and then choose to do whatever they want. Even our significant others ignore what we think is the right choice. The bottom line: autonomy is a patient right, but we also have an obligation to do no harm. If they are competent, then by all means let them have the water. I would not provide it personally but I would explain as tactfully as possible, trying to avoid any hint of judgement, why I can not in good conscience do so by reinforcing the reasons for a fluid restriction and what the consequences are. And document the conversation. It may seem that we say the same thing over and over, but that is the reality of health care.
]Maybe we can address how frequently the fluid is being provided; can we change the schedule to be less more often? If the patient is thirsty, could it be a side effect of a medication? What are the lytes? Brainstorming with the team may help.
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]An area of interest for anyone in health care today is motivational interviewing. This is a proven, patient centered counseling method for addressing patient ambivalence and resistance to change. It has been shown to improve treatment adherence and outcomes, promote health behavior change, and improve patient satisfaction with care. Maybe your facility can arrange a seminar for the staff to augment your tool boxes.
I agree that the patients have the right to disregard the physicians orders, however I am not a maid they hired to do their bidding either. I have the right not to bring in additional fluids if it will cause the patient harm. This is part of being a nurse also. I can't stop them if they don't want to listen, but I don't have to participate in it either.
Patients' rights must not be trampled upon. Nurses' duties to their patients must not be trampled upon. The patient has a right to eat or drink whatever he/she wants. The nurse has a right to follow doctors' orders. A nurse must not physically prevent a patient from being non-compliant with food or drink. A nurse must not go against doctors' orders and give food or drink which violates doctors' orders. An alert and oriented patient has the legal right to obtain and consume food or drink but the medical staff must not obtain food or drink for the patient against doctors' orders. Education, documentation, and notifying the MD is all that nurses can do.
If patients set the agenda for nurses then they, the patients, become doctors from whom nurses take orders. We must be professionals which entails not breaking the law regarding patients' rights and not acting contrary to doctors' orders. To do any of these may land a nurse in serious trouble.
We as nurses', regardless of our convictions or sympathies, must follow simple guidelines for the benefit of the patient and OUR PROTECTION.. And please, do not place water within reach of a patient if you know that the patient will be non-compliant with doctors' orders. You will be held responsible in the same way as if you had given the patient the water.
The patient has the right to leave the hospital and get water, just like te have the right to leave if they don't agree with anoter aspect of their care. It is not part of their rights to have water provided against physician orders. A fluid restriction is a treatment, failing to provide that treatment is a failure to provide proper care. They are not prisoners, thy may leave at any time. If say they state that they are refusing to follow that part of treatment then the physician still must be notified before you should give them water and try should be informed thy they can be discharged whether ready to leave or not for failing follow treatment.
one of the most important things I learned in nursing school was how quick we are to label a pt. noncompliant. noncompliance comes with a stigma. let's try to find the root of why a patient is not complying with medical advice and see if there is another solution.
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.
Ummmmm, You do realize that rather it is in solid or liquid form the end result is the same. ie there is a certain # of mL's of fluid ingested. It seems kind of pointless to make sure they dont wait for it to melt and then drink it.
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.
I skipped the 500 pages of this thread... but since this was a response to my post...
When I am a patient I AM NOT A CHILD!!! If a woman goes in to labor and goes into the hospital, the doc wants an epidural, pitocin, NPO. So would you say that if I chose not to go NPO or to refuse the epidural and/or pitocin I should go have my baby in the alley? Thats pretty much what you're saying. Drink water and go have your heart attack elsewhere. The reason people hate hospitals so much is because they feel like they loose all control of themselves and their lives when they walk in there. How is a patient taking responsibility for themselves when you treat them like a CHILD??? It is a proven fact that bringing patients into the process of taking care of themselves improves compliance. Wetting their lips, bringing them a sip of water, talking to them about the reason for the restriction (and I dont mean quoting 'education' I am really listening to them) goes a lot further. It doesnt take all day to make a patient feel like a person, but treating them like a child with no control over the decisions of their care and their life can bring a feeling of hospital-phobia and helplessness that will last for a LIFETIME.
Making decisions with good sound clinical knowledge will keep you out of court and goes a long way to making you the best clinician you can be as well as make sound decisions. I was waiting for someone to bring the clinical eveidence to back up the rationale of giving or not giving fliuds!!!! Well done!
cherrybreeze, ADN, RN
1,405 Posts
This is tiring now. All you want to do is argue, and I've already indulged it farther than I want to. I'm done here.