Double Fluid mess ups

[anon456]

I just wanted to post this for all the newer nurses, but also to remind people who don't run into this on a daily basis on your units.

I work peds and we have a lot of patients who are tube-fed either through an NG or a g-tube depending on their conditions/syndromes, etc. Of course when they come in they are often NPO and have IV fluids running. I have had two cases where I took over the care of patients who had both IV fluids and tube-feedings running at the same time. One patient has come back from OR much earlier that day before I got on shift and because there was not an order to d/c IV fluids when restarting tube-feedings, the patient got both. I took over care of the patient at 7 PM but didn't notice the double fluids until about 8:30 PM when I finally had a chance to do a full assessment. The patient was a cardiac baby who also had a trach and some pulmonary disease. I saw that the patient was having increased work of breathing and wet lungs. We had to give several doses of Lasix before the baby finally was able to pee off enough fluid to recover. The MD sat by bedside for about 2 hours and we came close to transferring the patient to ICU.

The lesson is that you have to ask yourself-- why does this patient need both IV and tube-feeds?? It is common when a patient is starting feeds back up to increase feeds slowly and subsequently decrease IV fluids. Last night I had a patient we were doing this on. I had to increase the feeds by 5mL/hr every 6 hours, but the MD did not write the order to decrease IV fluids at the same time. I did it anyway and then called the MD later when I had time and they confirmed that I was supposed to do that, and they apologized for not putting in in the order. I try to look for a TOTAL FLUID ORDER, such as for a baby, 37mL/hr total fluids between IV and tube feeds.

The website www.mdcalc.com has an excellent tool for peds nurses to calculate maintenance fluids, appropriate bolus amounts, and mg/kg/hr urine output. I use it all the time to double check the doctors.

THanks for listening. :-) Nursing humbles me daily.

[umcRN, BSN, RN]

I work in a pedi cardiac icu so double running fluids is a big no no and we always go down on fluids as we advance feeds whether its ordered or not. Now on the other side of that the thing that irks me is when a NEWBORN is made npo and the nurse doesn't think to hang fluids or remind the MD to order them. These are newborns we're talking about and they drop their blood sugars fast and that's more deadly than fluid overload or dehydration.

[anon456, BSN, RN]

Agree wholeheartedly. "Nursing judgment" has to be more than, "I just don't like it/feel comfortable with it/understand it."

I don't know about any studies on sleep deprivation in small infants-- considering how many hours a normal baby sleeps, there should be-- but I can tell you that a 13-year-old and a 42-year-old get really, really cranky when they can't complete even one 90-minute sleep cycle in 48 hour (after that she got heplocked). Even setting that volutrol to three hours would have been better.

In my facility we are limited to setting it for 2 hours at a time, and we have to visibly check the PIV site ever hour. I feel horrible for sometimes needing to dig in the blankets for the IV site that's hidden, but I have also caught the beginnings of bad IV's quickly this way. There's nothing we can do about it, either, it's policy. I agree about sleep deprivation, which is why we finally changed the policy to not bathe kids under 2 on night shift unless it was before bedtime. We used to do 4 AM baths on the babies whose parents were not there.