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Fluid Overload questions

  1. 0 hey all,


    have a couple questions regarding fluid overload. i had a patient a few weeks ago who had pancreatitis and earlier she satting 98 and feeling fine with 250cc/hr saline going. this was before my shift. when i assessed her, she had quite a few crackles and she was satting about 92. i wanted to turn down her fluids but the doc wanted to put her on o2. i did the latter and later her sats were 98 again and her crackles were gone.
    my question is, she was young 35 with no cardiac hx. was i silly in worrying about fluid overload? it possibly just could have been atelectasic crackles from her being in bed so long. also, does supplemental 02 create enough pressure to push fluid back into the pulmonary vasculature should there be little fluid?
    from my other experiences, it seems that crackles will be heard sometimes long before sats actually start dropping in cases of fluid overload. your thoughts? thanks again.
  2. 12 Comments so far...

  3. Visit  oramar profile page
    0
    That the O2 helped her heart pump better so the fluid got to her kidneys which then excreted it. It's a pushme pullya situation.
  4. Visit  Janet Barclay profile page
    0
    Not silly to think about fluid overload ever!
    Remember, though, that the crackles of pulmonary edema sound different than retained secretions or atalectasis- they are best heard at the bases, and sound like saran wrap rubbed between your fingers. Also check neck veins for distention and listen for a third heart sound.
    250 an hour sounds like a lot, but with a septic patient, the fluid is largely third spaced into the interstitium.
    Your assessment about the patient's sats was a great one.
    Janet
  5. Visit  Tweety profile page
    0
    Agree that your assessment skills are right on target. A patient with 250 cc/hr, hypoxia and crackles one would think "pulmonary edema". Kudos for calling the doc on that one.

    Another thing besides what Janet mentioned above was what was the BUN and Cr.? Off topic story: I had a coworker of mine a while back get all upset over this "wet" patient. She called the doc and got lasix. As the charge nurse I went to assess the patient and to me it seemed like he had pneumonia, as he coughed up his secretions and was showing signs of dehydration, plus this patient was heplocked and taking poor p.o. (scarey nurse). Sure enough his BUN was in the range of dehyration.
    Last edit by Tweety on May 4, '04
  6. Visit  zacarias profile page
    0
    Quote from Janet Barclay
    Not silly to think about fluid overload ever!
    Remember, though, that the crackles of pulmonary edema sound different than retained secretions or atalectasis- they are best heard at the bases, and sound like saran wrap rubbed between your fingers. Also check neck veins for distention and listen for a third heart sound.
    250 an hour sounds like a lot, but with a septic patient, the fluid is largely third spaced into the interstitium.
    Your assessment about the patient's sats was a great one.
    Janet
    Thanks all for your replies! It's nice to know I did OK int hat situation.

    You know I can imagine edema crackles sound different than atelectasis but unless I can compare them one right after the other, I don't know if I can always distinguish them. I know pulmonary edema crackles are much coarser and wetter sounded though.
  7. Visit  stevierae profile page
    0
    Quote from 3rdShiftGuy
    Agree that your assessment skills are right on target. A patient with 250 cc/hr, hypoxia and crackles one would thing "pulmonary edema". Kudos for calling the doc on that one.

    Another thing besides what Janet mentioned above was what was the BUN and Cr.? Off topic story: I had a coworker of mine a while back get all upset over this "wet" patient. She called the doc and got lasix. As the charge nurse I went to assess the patient and to me it seemed like he had pneumonia, as he coughed up his secretions and was showing signs of dehydration, plus this patient was heplocked and taking poor p.o. (scarey nurse). Sure enough his BUN was in the range of dehyration.
    In these types of patients, would a CVP line have made assessments easier? Just curious--in the OR, anesthesia always puts in a CVP line if there is any possibility of fluid overload or just to more closely monitor their pulmonary status and pick up on or hopefully avoid 3rd spacing--or INADEQUATE volume replacement.


    I agree, though, good old fashioned nursing assessements like Zac did are still required--looking at your patient, listening to his heart & lungs, looking at O2 sat, etc. Good job, Zac!!
  8. Visit  heart queen profile page
    0
    I think you did GREAT! I agree that CVP monitoring is especially helpful, drop a central line and transduce it.. but this patient was most likely on the floor, not even a tele unit... from what I've learned here on the BB, few tele units even are credentialed to transduce. So you're left with basic assessment skills.... shiver... give me a line any day!

    Great job zac. Even at 35, fluid overload, with a healthy EF is a possibility. Your patient was getting 6 liters in a 24hr. period.... the vasculature, cardiac output is roughly 5-8 liters, so at 250 per hour, all that fluid is going to start shifting somewhere. Even with severe ICU type sepsis, where we pump in even 8 liters in 24 hrs. it starts to shift. Now you know to add the o2, keep watching the sats and listen to the lungs more frequent, then call again. But, I'm wrong.. you already knew that!

    You da bomb!
  9. Visit  stevierae profile page
    0
    Quote from heart queen
    I think you did GREAT! I agree that CVP monitoring is especially helpful, drop a central line and transduce it.. but this patient was most likely on the floor, not even a tele unit... from what I've learned here on the BB, few tele units even are credentialed to transduce.

    WHAT? You mean they don't have the CVP water manometers anymore?

    I was going to say the "old-fashioned" CVP manometers, but I thought then I would REALLY be showing my age (50, LOL!) We used them routinely right through the '80s.

    Yeah, nowadays we transduce CVP lines and look at the tracing on the datascope, but we still keep the water manometers around for the "older" anesthesiologists who prefer them...they really ARE older, like in their 60s...

    Personal note to Zac--do you by chance work at Harbor View? Awesome, awesome, awesome trauma center--A "trauma center's" trauma center.

    Or Virginia Mason?

    Please don't say you work at Swedish...... :uhoh21:
    Last edit by stevierae on May 3, '04
  10. Visit  heart queen profile page
    0
    stevierae, yup, No manual transducing unless your in an older facility, yes, sorry to say, back with 80's technology. For some ungodly reason, this is considered a higher level of care, fewer and fewer med surg. floors do it. I'm pretty sure that few step down's do that type of H20 manometer reading. Go figure, so simple and accurate.


    Quote from stevierae
    WHAT? You mean they don't have the CVP water manometers anymore?

    I was going to say the "old-fashioned" CVP manometers, but I thought then I would REALLY be showing my age (50, LOL!) We used them routinely right through the '80s.

    Yeah, nowadays we transduce CVP lines and look at the tracing on the datascope, but we still keep the water manometers around for the "older" anesthesiologists who prefer them...they really ARE older, like in their 60s...

    Personal note to Zac--do you by chance work at Harbor View? Awesome, awesome, awesome trauma center--A "trauma center's" trauma center.

    Please don't say you work at Swedish...... :uhoh21:
  11. Visit  zacarias profile page
    0
    Quote from stevierae
    Personal note to Zac--do you by chance work at Harbor View? Awesome, awesome, awesome trauma center--A "trauma center's" trauma center.

    Or Virginia Mason?

    Please don't say you work at Swedish......

    No I don't work at Harborview but I LOVE that place! It is awesome and have worked there in the past and did clinicals there. I would consider it in the future. I work it's sister hospital, the UW! I actually don't mind Swedish.......
    Ok, so I work on gen Med floor with telemetry but we don't ever monitor CVP on our floors. Some of our patients do have TLCs though I wonder how hard it would be to set it up? It sounds like it wouldn't be cost efficient, especially since not everyone is really at risk for fluid overload on the med floor.
    Stevie, are you from Seattle? You seem to know it.
  12. Visit  Tweety profile page
    0
    Quote from stevierae
    WHAT? You mean they don't have the CVP water manometers anymore?

    I was going to say the "old-fashioned" CVP manometers, but I thought then I would REALLY be showing my age (50, LOL!) We used them routinely right through the '80s.

    Yeah, nowadays we transduce CVP lines and look at the tracing on the datascope, but we still keep the water manometers around for the "older" anesthesiologists who prefer them...they really ARE older, like in their 60s...

    Personal note to Zac--do you by chance work at Harbor View? Awesome, awesome, awesome trauma center--A "trauma center's" trauma center.

    Or Virginia Mason?

    Please don't say you work at Swedish...... :uhoh21:

    Oh no, most floor nurses don't even know what they are and how to use them. But they can be useful if used properly.

    In most cases on med-surg units, it's assessment and xrays and labs than can diagnose pulmonary edema.
  13. Visit  critcarenurse16 profile page
    0
    Quote from stevierae
    WHAT? You mean they don't have the CVP water manometers anymore?

    I was going to say the "old-fashioned" CVP manometers, but I thought then I would REALLY be showing my age (50, LOL!) We used them routinely right through the '80s.

    Yeah, nowadays we transduce CVP lines and look at the tracing on the datascope, but we still keep the water manometers around for the "older" anesthesiologists who prefer them...they really ARE older, like in their 60s...

    Personal note to Zac--do you by chance work at Harbor View? Awesome, awesome, awesome trauma center--A "trauma center's" trauma center.

    Or Virginia Mason?

    Please don't say you work at Swedish...... :uhoh21:
    OMG-- we still use the "old fashioned" water manometers.
    It's not me showing my age, but the docs who woun't let go of the past... LOL:chuckle
  14. Visit  amethyst221 profile page
    0
    Was this patient in an ICU? How severe was the pancreatitis? The physician should have a very good idea of what the patient's fluid status is so you were right to call. Severe pancreatitis can cause systemic inflamatory response syndrome which can cause third spacing. You would not want to slow down the fluids on a patient with that condition. They can go into hypovolemic shock and brady down to cardiac arrest. There is a condition known as noncardiogenic pulmonary edema and that is a hallmark of ARDS (Adult Respiratory Distress Syndrome) which is treated with higher concentrations of oxygen.

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