Nurse Eric -Bedside Skills - Implementing A Fluid Restriction

Nurse Eric - Bedside Skills

Implementing A Fluid Restriction 

Introduction

"How can you allow me to become dehydrated like this? I feel like you are trying to kill me. I need water."

Have you ever been a patient and felt like this? Have you ever had a patient who's said something like this? Has a family member ever accused you of being a criminal for withholding water from their loved one? Do your patients often complain when they've run out of PO fluids by 1600?

Are you looking for a better way to manage a fluid restriction? Let's do this!

Often Nurses have a patient with a fluid restriction (FR). With the fast pace of nursing care, and hearing out many unhappy, thirsty patients, I've noticed an opportunity for improvement. Let's get into it.

SBAR Summary

Situation - Patients often feel frustrated when a doctor orders a fluid restriction, especially later in the day when they have already consumed all or most of their daily limitations. In a situation of poor planning or implementation, patients can become frustrated and nurses are faced with either finding a way to help the patient cope with their feelings or begin to make exceptions to the FR by allowing fluid and charting patient non-compliance.

Background - Fluid restrictions are often a very important part of the plan of care for patients with different conditions. Fluid overload can lead to life-threatening complications with regard to Airway and Breathing, the first two elements of the ABC's of nursing and medical critical thinking with respect to patient care. Electrolyte imbalances can also be a problem that requires close monitoring that could lead to cardiac or CNS events.

Assessment - In the past, the nurse played the role of the boss and taskmaster. The nurse was in control and nurses were good at somewhat forcing the patient to comply. These days, nurses create partnerships with their patients. Since "my way or the highway" is fading into the past, a new model for partnership in all aspects of patient care should be considered.

Recommendation - I've developed a fluid restriction daily planner that has been very useful to me and could be useful to nurses everywhere. I'm recommending developing a worksheet that can be used by any nurse and the education to implement the partnership model of FR implementation. Elements of the worksheet include photos of the most commonly used fluid containers in the care area, a section for communicating the reason for the fluid restriction and how much fluid is allowed in a 24 hour period, a section to plan fluid consumption for each major part of the day when fluids would be consumed and a section to record the actual fluids consumed.

Fluid Restriction Daily Planner

Education

I believe that the best way to educate healthcare workers is by modeling the method that I've found works best. Since this is uploaded on the web, I'll include a video of how to use the daily planner for those who are auditory and visual learners along with a video example of me partnering with a patient (actor) and working through the implementation of the intervention. 

Key Points

• The nurse should confirm the order and develop a plan to implement the order and educate the patient. 

• The daily planner can be updated with photos relevant to any institution or care area. Requests for the spreadsheet can be made at nurseericyeah@gmail.com

• The care area should decide whether daily I&O's are calculated from midnight to midnight or from shift change to shift change. 

• The nurse should implement the FR planner and educate any other staff about how it is to be used. Nurses' assistants, dietary personnel, dietitians, food delivery staff and others should be made aware of the patient being on an FR in the EMR and through signage in the room. 

• The nurse should initiate the FR planner and educate appropriate staff on how and if they should be involved in implementing the plan. Personally, I like to call the cafeteria and let them know that no fluids should be delivered to the patient. Rather, any fluids should be delivered to the nurse or appropriate nursing staff. 

• This is a partnership where the nurse should encourage the patient to take ownership of the physician order. Allowing the patient to plan and document will also help the nurse assess if the patient will need reinforcement of how to follow an FR before discharge. 

• After assessing if the patient is competent and willing to participate in the partnership, the date, reason for the FR and total fluids allowed should be reviewed with pt and documented on the sheet. (This is not official documentation, but rather for the patient's purposes only. All official documentation should be transferred to the EMR.)

• After orienting the patient to the worksheet, the patient should decide how to spend their daily allowance during the timeframes of breakfast, lunch, dinner and night shift. 

• Leaving fluids for the night shift is very important as this is the time when patients tend to become frustrated and agitated. 

• Before the first fluids are given the nurse and patient should agree to follow the plan. This allows the nurse to later remind the patient that this is the plan they developed for the FR ordered by their doctor. Any requests to deviate from the plan should be approached as a potential need to speak with the ordering provider to have the FR reviewed. The nurse should not take on the burden of taskmaster or boss, rather, they should be merely holding the patient accountable for the plan they devised based on their providers' orders. This takes the crosshairs off of the nurse and encourages patient responsibility, compliance, and models the importance of not deviating from providers' orders, rather, working with the provider for a satisfactory outcome. 

I hope you've found the concept in this article helpful. Feel free to consider implementing this patient partnership fluid restriction daily planner in the unit where you work. This could make a great ACT idea or quality improvement project. Please keep me updated if you decide to work on this and feel free to connect with me on FB or IG @nurseericyeah