pt was very upset about fluid restrictions

Nurses General Nursing

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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.

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!

I hate the threat of "insurance not paying." Most of the time, people who refuse to be compliant, or insist on leaving AMA, they're going to ignore the bills just like they ignore the doctor's advice. So it's the hospital that gets hurt when insurance doesn't pay the bill.

Specializes in CCU, SICU, CVSICU, Precepting & Teaching.
i hate the threat of "insurance not paying." most of the time, people who refuse to be compliant, or insist on leaving ama, they're going to ignore the bills just like they ignore the doctor's advice. so it's the hospital that gets hurt when insurance doesn't pay the bill.

if they even have insurance to begin with. there seems to be a positive correlation between having insurance and taking responsibility for your own health.

Specializes in ICU, ER, EP,.
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!

doesn't work like that, the patient, has to be the one to sign out ama, then if they have insurance it doesn't pay.. and this type of patient doesn't pay anyway.

this non compliant patient frequently sucks off our system, with our with out medicade/medicare and simply does what they want, as they've always done at home.... which led them to this 8th admit for the same reason, that demands blankets and pillows for their family, boxed lunch... full blown fluids to drink, family brings in kfc and they all camp out and demand you wait on them hand over foot and call the supervisor if it takes you more than 5 minutes than blame you for discrimination......

your same skin colored patient crashing on the vent with full blown sepsis delays their fresh coffee.

my raises, annual job reviews or job security is not based upon the crashing vent septic patient with no family to fight for them... but on patient satisfaction for the non compliant frequent flyer that knows how to work the system, and half the time they don't speak english, are illegal and demand 3 people to interpert in a small room to stay the night... so they can "switch off". and hit the call buzzer every 5 fricken minutes.

just did this last night, sorry if i hijacked or took the thread a touch off base. i'll behave.

Specializes in ICU, ER, EP,.

Sorry for the rant all, but you have to actually have a patient that WANTs, WANTS to leave to do AMA, these jokers don't and milk the system.

You can't get compliance with press gainey and survey scores, you can't have both!!!!!!!!!!

It is no longer about the patient.

We will loose tremendous funding because we can't change our outcome scores that are medicade/medicare compliant with press gainey.

YOU CAN'T HAVE IT BOTH WAYS, A DIALYSIS PATIENTi IS REFUSED FULIDS FOR A BETTER OUTCOME WRITES NEGATIVE COMPLAINTS, WE LOOSE FUNDING EITHER WAY.

It is a loose loose scenerio now and I refuse to battle it... drink Up i say, as I tell you otherwise, those that think you have control.... will loose your finding in 6 months. iI'll simply intubate your stupid self when you're in pulmonary edema... only for you not to pay the bill in the end.\

Surprisingly that will ensure I keep my job.... if I argue with you, anger you and you one, call my supervisor I'm suspended, two send in a negative Press Gainey I get no raise and if you name me, I'm suspended.

Here is a picture of water, don't drink it, but call me when you want more. This is what nursing has become.

Specializes in pulm/cardiology pcu, surgical onc.

I had a pt in ltc that was on a fluid restriction for eslf. He called his hospital at 2am trying to get a Dr. to make me give him some water. The operator wouldn't put him thru to an MD and gave me a call to give me a heads up. This pt called the ltc about an hour later asking for me, the charge and pretended to be his physician and giving an 'order' to let Mr. so and so have as much water as he wants. Pretty crafty. This pt stayed up all noc thinking up ways to get more water. I told him he could have as much as he wanted out of his faucet if he wanted to get up. That shut him up til morning. Thank god.

I finally had the chance to talk to my instructor about this. She gave a good suggestion. She said to do a full assessment of the patient and talk about what I was looking for as I was doing it so pt can be aware of it. For example checking for edema, listening for lung crackles, checking the daily weight. If there are signs of fluid overload, tell this to the patient .Have them hear their own breath sounds. If those signs are there, the patient may have a greater understanding and more motivation for wanting to follow the fluid restriction. If they are free of these s/s praise them for keeping their health in check.

If they still insist after all this, give them a small amt of liquids, call the doctor and tell them the findings of the assessment and tell them you are having a hard time keeping them on the restrictions. The doctor may decide to lift it if the pt is doing well. If they are doing poorly the doctor knows that you tried to talk to her, maybe doctor needs to talk to her, but in any case she's choosing to go against AMA on the fluid diet and the doctor knows about it.

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!

This is unfortunately a common misconception and is simply not true. The truth of the matter is that Medicare and virtually all private insurance companies will pay for any care up to the point of discharge. What may not be covered, depending on the specific insurance, is subsequent readmission for the same condition within a specific time period, i.e. 15 or 30 days, if the patient left on their own AMA.

IMHO, any doctor or nurse that would make this type of statement to a patient is a fool. Regardless of how well intentioned you may be, attempting to compel a person to do something against their will by direct or implied threat is called coercion. It is a criminal act in all 50 states. Speaking of criminal acts, taking any possession of the patient (this would include food and beverages) without their permission is theft, and using force to do so if they resist may be either assault or strong-armed robbery.

As others have correctly pointed out, the patient has the absolute right to refuse any treatment or procedure, including complying with any dietary or fluid restrictions, and they can do so without leaving AMA. You can't physically force them to comply.

Teaching and documenting is about the best you can do - never threaten, deceive or outright lie to a patient to try to persuade them to comply.

I think the suggestion by the OP's instructor is a good one, but after all is said and done, the bottom line is that the patient still has the final say.

I am 'justavolunteer' & I have even gotten grief from pts. and families about fluid restriction, restricted diets, etc. Often the patient is 300 lbs.+, diabetic, on a restricted diet along with the FR. They seem to think the nurses should just wave a magic wand or something. Then they can be instantly cured & go back to wolfing cheeseburgers & whatever else got them to the hospital in the first place.

I love being a volunteer and I am willing to do whatever I can to make people more comfortable. Most of the patients & families are extremely helpful & appreciative of my efforts. However, it amazes me that a few individuals seem to take absolutely no responsibility for themselves or their actions. If I tried a tenth of the shenanigans some so called grownups pull when I was a child, my parents would have skinned me!

Specializes in Critical Care Nursing AKA ICU.

let them DROWN themselves just document that you informed pt/family and of course the MD b/c those little bastards will try to pin it on you, saying "the nurse never informed me". make the family get their love one the water or whatever he or she want to eat/drink.

This is unfortunately a common misconception and is simply not true. The truth of the matter is that Medicare and virtually all private insurance companies will pay for any care up to the point of discharge. What may not be covered, depending on the specific insurance, is subsequent readmission for the same condition within a specific time period, i.e. 15 or 30 days, if the patient left on their own AMA.

IMHO, any doctor or nurse that would make this type of statement to a patient is a fool. Regardless of how well intentioned you may be, attempting to compel a person to do something against their will by direct or implied threat is called coercion. It is a criminal act in all 50 states. Speaking of criminal acts, taking any possession of the patient (this would include food and beverages) without their permission is theft, and using force to do so if they resist may be either assault or strong-armed robbery.

As others have correctly pointed out, the patient has the absolute right to refuse any treatment or procedure, including complying with any dietary or fluid restrictions, and they can do so without leaving AMA. You can't physically force them to comply.

Teaching and documenting is about the best you can do - never threaten, deceive or outright lie to a patient to try to persuade them to comply.

I think the suggestion by the OP's instructor is a good one, but after all is said and done, the bottom line is that the patient still has the final say.

good post, shark.

i need to point out that my insurance co has called me, verifying that i indeed, received said services...

obviously they do not want to pay for services i never received.

i have to wonder if insurance would cover services if pt is non compliant?

it's actually not a bad idea, when you think about it:

that ins co's need to enforce actual compliance in the hosp or they won't be covered.

it would seemingly reduce the amt of litigation out there, for those notorious, pita pts/families.

leslie

Specializes in ICU.

anon456,

I find it helps to write a "countdown" of fluids and put it on the bulletin board where the pt can see it. So, you start out by writing "1200 mls - June 8th 0700" at the beginning of the shift, discuss the goal/limit with the pt, and then subtract as you go. The pt always knows how much they have left, and they feel they have some control over how much and when they choose to use that 1200 ml.

Specializes in CCU, SICU, CVSICU, Precepting & Teaching.
anon456,

i find it helps to write a "countdown" of fluids and put it on the bulletin board where the pt can see it. so, you start out by writing "1200 mls - june 8th 0700" at the beginning of the shift, discuss the goal/limit with the pt, and then subtract as you go. the pt always knows how much they have left, and they feel they have some control over how much and when they choose to use that 1200 ml.

and when it's gone, it's gone. i can't force them to be compliant, but i'm not going to aid and abet their noncompliance, either.

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