pt was very upset about fluid restrictions

[anon456]

I'm a student nurse-- not sure how to handle this

I had a pt on a fluid restricted diet. This pt had been in hospital for at least a couple of weeks and the fluid restriction was nothing new. The tray came without liquids on it as usual and she asked me if I would get her some coffee and milk. I told her I needed to ask the nurse in charge because of her fluid restrictions. She got really mad at me when I told her that. I asked the pt what was her understanding of why the restriction was in place and she told me why, and how it related to her health problem but was unhappy about it and said why doesn't anyone just listen to me and get me what I want?

The CNA then wrote out her totals of fluids at the meals she'd had on the board to help her understand that she'd had too much fluid already, and she still got mad about it. I told the nurse and the nurse said do not give her fluids, she's had enough today. I was then asked to remove the water pitcher because the pt's family had filled it for her. I encouraged the pt to talk to the doctor about her concerns and she said she had already that morning, but the orders were the same.

At what point does the pt have the right to refuse the diet and get the fluids she wanted, vs. the nurse's duty to follow doctor orders about the diet or fluid restrictions? I felt caught in the middle and was unsure what to do.

[leslie :-D]

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.

while i appreciate your frustration, there is no way i'd refill their glass or do anything to enable the inevitable, recurrent mi.

also zoo, be careful.

it is these types of families who will turn around and sue the pants off of you...

insisting that the nurse "even filled the glass for me".

these types of families, you just can't win.

and it sucks big time, that pg would rather us contribute to the pt's downfall, than to advocate and protect their health.

i honestly think i would risk getting a black demerit, than playing their dangerous game.

leslie

[Mulan]

[quote=Zookeeper3;4344239 if anyone complains.. the first offense is suspension, the second termination.... Written in policy, Carried out frequently.

It's surreal that this should be happening anywhere.

[anon456, BSN, RN]

Thanks for the insight! I love this forum because I get many points of view. This nurse I was working with was a stickler for following procedure, which was probably to save her in a case of liability. In the case of the fluid restriction she was seeing it as an ORDER and probably the same as a med order or other kind of order. So it would make her liable to provide the pt with the fluids. I do agree that an AMA could be signed that would protect her, and a talk to the doctor when he/she did rounds. That makes the most sense and saves the nurse from getting a bad review or not following orders.

This same nurse also did not d/c a person's continuous fluids for a shower. The pt said that the other nurse let her d/c it, but this nurse said the order was for continuous fluids and that meant continuous. The pt was able to take a shower just fine with the IV running although she was mad about it. (This was a different pt than the one on fluid restriction)

[Sonjailana]

I try to offer more mouth care when people are on FR or are STRICT NPO. I find that many people really just don't like the sensation of dry mouth, and are happy to rinse and spit or brush their teeth. It also looks like I care a little.

[canoehead, BSN, RN]

If you look at it from a business perspective-ie how much money will we make? It makes sense to inform the patient of the MD's advice and then do whatever they request. The PG scores go up, family loves the kind nursing staff, the patient has repeated admissions, or longer admissions, and becomes a gold mine for the company. The more times we can admit them and "save "them before they finally croak, the more procedures and monitoring we can justify, the more money we get. That is where the suits are at, and they've finally figured out a way to justify it.

[Zookeeper3]

while i appreciate your frustration, there is no way i'd refill their glass or do anything to enable the inevitable, recurrent mi.

also zoo, be careful.

it is these types of families who will turn around and sue the pants off of you...

insisting that the nurse "even filled the glass for me".

these types of families, you just can't win.

and it sucks big time, that pg would rather us contribute to the pt's downfall, than to advocate and protect their health.

i honestly think i would risk getting a black demerit, than playing their dangerous game.

leslie

Thanks for the understanding, balancing what is right for them, is becoming more difficult here, it's simply nuts! Never before would I even imagined giving a pitcher of water to a CHF patient. Now I teach, refill, teach, preach sometimes I feel like I beg compliance and then walk out of the room and chart the lack of it.

If I hear once more about the patients right to refuse..... (what is good for them) I'm going to puke. They wouldn't be in my care if they made good decisions, ya know;). My hospital is a touch jacked up with the customer service crap, no black demerit for me.. .one or two strikes and we're out. I say, drink up if you want it even though I've taught you different... I need to work. Crazyness these days. I do hear what your saying, just not in my environment now.

[leslie :-D]

I try to offer more mouth care when people are on FR or are STRICT NPO. I find that many people really just don't like the sensation of dry mouth, and are happy to rinse and spit or brush their teeth. It also looks like I care a little.

i agree.

i've actually gotten these folks a cold, wet washcloth and let them suck on it.

leslie

[invernessfl]

This comes down to patient autonomy. Basically it means that the patient is in control of their body. When it comes down to it, just document the heck out of it(remember the chart is a legal document), and then do what the patient wants and hand it over to the doctor. One thing you might do is tell the doctor beforehand about the patient's noncompliance so that they are prepared when they see the patient.

[wooh, BSN, RN]

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.

That one doesn't affect my raise though.

Doctors can write "orders" all they want. And patients can refuse to comply with those orders. If the patient refuses their medication, they refuse. I educate, I chart, I notify the doc when they're next on the floor. If the patient refuses their diet order, same thing. I educate, I chart, I notify the doc when they're next on the floor. If the doc thinks that he/she can do a better job of convincing the patient to comply, they are more than welcome to try.

I refuse to care more about the patient's health than they do. If they want to comply, I'll help them get better. If they don't want to comply, I'll try to help them get better, but I tell them things would go better and faster if they decided to comply with their plan of care.

[PostOpPrincess, BSN, RN]

Patient has the right to refuse.

I have the obligation to educate, and provide the rules.

Patient doesn't have to comply.

I chart well and offer alternatives. He/She can still refuse.

I just move forward.....

Like Wooh said, if the patient doesn't worry for himself/herself (the adult patient in particular)...it's not my place to be worried--that's way too much energy to waste.

[BookwormRN]

"The CNA then wrote out her totals of fluids at the meals she'd had on the board to help her understand that she'd had too much fluid already, and she still got mad about it. I told the nurse and the nurse said do not give her fluids, she's had enough today. I was then asked to remove the water pitcher because the pt's family had filled it for her. I encouraged the pt to talk to the doctor about her concerns and she said she had already that morning, but the orders were the same."

I've been reading the replies and didn't see this issue addressed. (If I missed it, please forgive me!)

At our facility, we assign fluid distribution according to the number of mls ordered per day. For example: with an 1800 ml fluid restriction, we delegate 900 ml to the kitchen (300 per meal, or so much per meal and per snack during the day), and 300 mls per day/eve/NOC shift. That way, the patient should not "meet" their restriction by evenings and have nothing left for NOCs.

[platon20]

When patients pull this BS, the best way to handle it is to get the doctor to write a letter to their insurance company and notify them that the pt is refusing doctor's orders and will be discharged AMA. That way, the insurance will refuse to pay for the hospitalization and the patient will be charged the full bill. Lets see how they like disobeying orders when they have to pay $100,000 up front for their hospitalization!