pt was very upset about fluid restrictions

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loriangel14, RN

6,931 Posts

Specializes in Acute Care, Rehab, Palliative.

You have to stand firm. Fluid restrictions are a doctors order and I stick to it.

Zookeeper3

1,361 Posts

Specializes in ICU, ER, EP,.

Ahh, good one.. so here is my disclaimer that you have to weigh with my advice. I'm doing the long story short because your're a student nurse and haven't come across this yet. so you just may think I'm crazy.

I work in an ICU where I pretty much have total control of my patients intake. My unit is locked, has 10 beds and has a camera at the door, so I... I control how much a patient can intake. When the mood hits me and I feel snarky, I stop the KFC fried chicken and the Mc Donald's to my fresh MI, assuming I wish to take on the battle. I work in a right to fire state that has now a ZERO, ZERO tolerance policy for upsetting patients and family.... So now, my hands are tied.. I can no longer be an advocate and teacher if this is ..."one of those families"... or PIA patients... and you are required to let them have their way, because it's no longer about the patient... but everyone's happiness about their experience and they get happy rating cards and if we fall short we get no raise... if anyone complains.. the first offense is suspension, the second termination.... Written in policy, Carried out frequently.

So, knowing that, I happily refill the glass, ignore the infection disease policy and anything goes.. bring it in, yes have it... scarf it all down.

What I will do the entire time they scarf down the deep fried chicken and/or fluids is stand there, family present and tell them, 'my hands are completely tied, I have no ability to stop you, but this is why you need to put the(fork or glass) crap down..... and I'll stand there and lecture until I give up and chart the noncompliance, or they start to get snarky back and I simply say... "you have every right to be non compliant, I need to step out and chart your non compliance, is there anything else I may do for you now?"

With press gainey, all these surveys on "happiness"... plus where I work... you can't say no and risk ticking off anyone to do what is right. So while my situation may be extreme, it really relates to your post.... "teaching on the importance of fluid restriction, pt. fails to comply and demands additional fluids.. fluids given, despite reinforcement on the importance of compliance and risks of negatively impacting health".

Honestly, these people will go home, drink gallons and end back up in the ER next week acting all surprised. I try to teach very hard, but there is a point to give up, chart it, make management happy and know that non compliance will not be fixed this admit... but keep teaching and talking .. one time it may make a difference.

VivaRN

520 Posts

The only thing I would add is that I would notify the provider of the patient's refusal after doing my own CYA. Then I would document that the provider is aware and what action should be taken.

Zookeeper3

1,361 Posts

Specializes in ICU, ER, EP,.
The only thing I would add is that I would notify the provider of the patient's refusal after doing my own CYA. Then I would document that the provider is aware and what action should be taken.

so. Plz, not to pick an argument, but for discussion sake... call at 3am... and the doc says as they have to "maintain a fluid restrict"... the doc won't give you an order at 3am that says... to the CHF patient.. "sure, let them have as much as they want to drink".

I would never call a doc with the patient's crazyness such as this, I'm perfectly capable of letting the patient decide upon their compliance. You refuse to give more fluids and you're suspended for poor patient relations, as the patient has the right to not comply... just don't see it personally, but I've refused many times, with the patient that just needed the "no", can't have it... vrs.. the "give it to me now, or I'll have your job".... patient that is here more frequently.

friend, just discussion, not arguing your point as it is valid....

VivaRN

520 Posts

so. Plz, not to pick an argument, but for discussion sake... call at 3am... and the doc says as they have to "maintain a fluid restrict"... the doc won't give you an order at 3am that says... to the CHF patient.. "sure, let them have as much as they want to drink".

I would never call a doc with the patient's crazyness such as this, I'm perfectly capable of letting the patient decide upon their compliance. You refuse to give more fluids and you're suspended for poor patient relations, as the patient has the right to not comply... just don't see it personally, but I've refused many times, with the patient that just needed the "no", can't have it... vrs.. the "give it to me now, or I'll have your job".... patient that is here more frequently.

friend, just discussion, not arguing your point as it is valid....

No, I agree, I wouldn't call at 3am about that either! I mean if you have tried everything with being firm and such, in my experience the provider likes to know (not an emergency but at some point) so they can address it with the pt, or change the plan of care if needed.

Thanks for your respectful tone!

Specializes in CVICU.
I would never call a doc with the patient's crazyness such as this
Me neither. Not at 3 am, anyway. This issue is something that doesn't warrant waking up the on call doc. It can easily wait until the doctor rounds or until a more reasonable time of day, like 7 or 8 am. But yes, the doctor does need to know if patient is refusing to follow orders.

I would advise the patient of the risks of engaging in such behavior, exactly why they are on the restriction, and then leave the room. If they continue to ask for fluids I'd confirm, "Knowing the risks I've told you, and the fact that this could easily keep you in the hospital for days longer than you would have been otherwise, you still want me to exceed your restriction?" I'd give them as minimal as I could get away with (a cup, not a pitcher) and document "Patient advised of risk and understands risks inherent in not complying with fluid restrictions. Chooses to exceed restrictions."Also, I'd try offering a few ice chips if they have dry mouth or some swabs. Maybe what they really want is a little relief that doesn't actually take all that much fluid to fix.

Now, sometimes you really truly do have to put your foot down. If you have a post surgical patient who hasn't had a return of bowel sounds and is begging for ice chips - no way. They get a swab around the mouth and that's it!

Zookeeper3

1,361 Posts

Specializes in ICU, ER, EP,.
No, I agree, I wouldn't call at 3am about that either! I mean if you have tried everything with being firm and such, in my experience the provider likes to know (not an emergency but at some point) so they can address it with the pt, or change the plan of care if needed.

Thanks for your respectful tone!

I see your point, but bear with me working nights, I lack the interaction that happens with the doc on day ****. The patient, I will "assume" will promise come hell or high water that they are of the compliant bunch, only to show their orifice as soon as the doc leaves. While I respect your post from a "cya point of view, these stinkers leave us all in the lurch as how to deal with them and put one of us against the other frequently".. which is what I was tryiing to say, but NOT , NOT disagreeing with you in your point. Make sense or am I too tired?

HiHoCherry-O

123 Posts

Specializes in CVICU, ED.

So many good responses on here!!

I am sick of hearing about customer service. Not that I don't support providing good customer service, but I don't think that someone should be afraid of losing a job because food/drink, warm blanket etc wasn't provided within a satisfactory time.

I agree. Fluid restrictions and diet are doctor's orders. It becomes a suggestion for the patient to follow upon discharge home. While in the hospital, it is an order. I love, love, love it when patients pull the "I have rights. . ." line because, yes, "you do have rights, and along with those rights come responsibilities." If you have not read the Patient Bill of Rights, you should because right under it is the list of patient responsibilities including following the doctors orders, and if unable to do so, making this known to your physician so that a decision can be made as to manage care.

With regard to hospital grades and customer service, I thought hospitals were also graded on readmission status. If a patient is readmitted, with the same diagnosis soon after being discharged, this does not look favorable for the hospital.

I also agree with another post that questioned the patient's manipulation of the situation. She probably had not seen you before and thought she would try to pull a fast one on you, then test the waters by getting angry when you would not comply. Good Job!!

I had a patient scream at me and kick me out of his room because I would not let him have caffeinated coffee (I work in a CVICU). He was tachycardic before I even had this discussion with him so I know it wasn't as a result of the exchange. I just politely said "no problem." Its amazing how nice he was when he wanted pain medication of which I happily gave, still holding fast to the "no caffeine" rule.

Katie5

1,459 Posts

The patient has the option of signing AMA.

Ruthiegal

280 Posts

Specializes in LTC, Disease Management, smoking Cessati.

It's hard to be on fluid restrictions, step into that patient's shoes, you go without and see how you feel, did anyone offer her a hard candy to keep her mouth moist? If you make your own spit it helps. Look for answers and ways to help. When my ex was on fluid restrictions after surgery for a brain tumor, life savers were his life savior! If she can't have sugar, get some sugar free ones... chewing gum with xylitol will help.... help her find ways to get through it. Everyone will be more relaxed and happy.

caliotter3

38,333 Posts

I go along with the first post. You are required to explain the why for the ordered care. You are not expected to twist the person's arm, do anything against their will, or sneak something past their knowledge. If they want to refuse, just document the refusal along with what you said to explain the ordered procedure, medication, or in this case, restrictions.

Ruby Vee, BSN

17 Articles; 14,030 Posts

Specializes in CCU, SICU, CVSICU, Precepting & Teaching.
it's hard to be on fluid restrictions, step into that patient's shoes, you go without and see how you feel, did anyone offer her a hard candy to keep her mouth moist? if you make your own spit it helps. look for answers and ways to help. when my ex was on fluid restrictions after surgery for a brain tumor, life savers were his life savior! if she can't have sugar, get some sugar free ones... chewing gum with xylitol will help.... help her find ways to get through it. everyone will be more relaxed and happy.

that's a nice idea for people who are able to control their own secretions and the only issue is fluid restriction. that won't work for a lot of our icu patients who might aspirate the hard candy. we have a policy against given patients gum or hard candy.

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