Fluid Overload?

  1. Hypothetical question: (no reason given for the bolus)

    Pt just had 1000cc IV fluid bolus and has not passed urine in one hour and HR is tachy in the low teens and is slightly cool, clammy & diaphoretic also SOB(resps 20)...

    what would you do?....

    this is Fluid Overload I am looking at here right?

    APart form checking blood pressure & checking lungs sounds and getting pt on oxygen if not already on, checking for edema ...and calling the Doc anything else I should or could be doing?






    Thanks - this is some question I have been given in work to answer amongst others and this one I feel I am missing something - am I?
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  2. 7 Comments

  3. by   jmgrn65
    if they aren't putting any urine out, It's possible they are dehydrated. tachycardia is one of the symptoms of dehydration.
  4. by   Antikigirl
    Hey...awesome! You are thinking worse case scenero and going on to the next step in either proving or disproving! This is a good thing!

    In this case I would call the MD with the news and get a bladder scan (before hand) to see if it is retention. Do exactly like you said..check lungs and such...if you don't have a bladder scan then ask the MD for orders for straight cath to rule out retention, so the focus is on the worse case if needed to go there!

    You are doing your critical thinking...good job!
  5. by   suehp
    Quote from TriageRN_34
    Hey...awesome! You are thinking worse case scenero and going on to the next step in either proving or disproving! This is a good thing!

    In this case I would call the MD with the news and get a bladder scan (before hand) to see if it is retention. Do exactly like you said..check lungs and such...if you don't have a bladder scan then ask the MD for orders for straight cath to rule out retention, so the focus is on the worse case if needed to go there!

    You are doing your critical thinking...good job!
    Thanks...I forgot about bladderscanning....

    funnily enough it is one of those things I keep forgetting in work too until the last minute...and then I remember we have a bladder scanner!

    Thanks again
  6. by   AnnieOaklyRN
    Also should be r/o renal failure as the cause for low urine output. Also important to assess lung sounds to r/o pulmonary edema as the cause for shortness of breath. Fever can also cause all those symptoms as well... Also would base it on BP.

    Sweetooth
  7. by   javanurse2000
    I agree with everything that's been posted...when I read stuff like this, I am so glad I found this site! You didn't mention if you were positioning pt to facilitate resp. (HOB up) -- A mixed blessing sometimes, b/c I've noticed if pt's are big or are weak, they tend to slouch even with some bolstering, so might want to check on him/her more often. Also, may want to get a K+ and Na+ levels...not sure what you had hanging, but if he/she may be way off - would account for the symptoms you described. Good luck and let us know!
  8. by   TiffyRN
    Another thought. When I worked with adults; most were "medical" vs. "surgical". So when a patient didn't void it was assumed it was a heart or kidney problem; i.e. they needed lasix, dialysis, something like that. And I had seen too many patients overloaded with fluids after surgical procedures by surgeons who just didn't get that these patients with touchy kidneys and hearts couldn't handle lots of fluids.

    But I did see the other side one night with a lady who was later confirmed to have a retroperitoneal bleed from coagulopathy. We kept bolusing and she kept not peeing; with a foley. HR little tachy, pale, diaphoretic. So her lack of response to the boluses was due to hypovolemia due to blood loss. But she was losing so much blood that the crystalloid boluses we were giving just didn't cut it. When the surgeon ordered a CBC and coags and we saw the drop in H&H and off the chart PT's (severe liver disease); She earned herself a transfer to Surgical ICU and multiple transfusions before they confirmed the bleed. I heard she went through 50 units of PRBC's within a couple of days.

    So I learned my lesson; consider hypovolemia when you have lack of urine output.
  9. by   RazorbackRN
    If the pt has a foley, you could also go ahead and do a foley flush just to make sure the foley is draining as it should.

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