Can anyone explain to me the rationale behind this order? | allnurses

Can anyone explain to me the rationale behind this order?

  1. 0 Just some background on the patient-elderly man, severe abdominal pain, dehydrated. He was NPO, had NG tube to constant suction with a large amount of drainage coming out. CT of abd was negative. He hadn't had a bm in a few days so the GI doctor ordered a retention enema which was given with good results. Labs were pretty stable, but did have a potassium of 3.3, which we gave him po potassium based on the protocol in place. He was already getting normal saline at 125 ml/hr. That's the background.

    So the resident doctor came and wrote an order for Lactated Ringers at 100ml/hr and D5NS at 100 ml/hr to run at the same time. I have never seen an order like that and just did not understand the rationale behind it, neither did any of the other nurses I work with, another doctor, nor the pharmacist. I called and clarified this with the doctor and he came back to the floor to talk to me. He said he asked his attending and superiors and they all agreed to the order, when I asked him the rationale behind why LR and D5NS, he said he didn't really know and that he would be researching that. I've tried to find some information on it, but can't. Anybody have anything?
  2. Visit  MyUserName,RN profile page

    About MyUserName,RN

    Joined May '11; Posts: 161; Likes: 223.

    23 Comments so far...

  3. Visit  TheCommuter profile page
    6
    So you're telling me that the resident did not know the rationale behind something he ordered? This is one of those things that makes me go, "Hmmm?"
  4. Visit  MyUserName,RN profile page
    0
    Quote from TheCommuter
    So you're telling me that the resident did not know the rationale behind something he ordered? This is one of those things that makes me go, "Hmmm?"
    Yes, those were his exact words!
  5. Visit  leslie :-D profile page
    3
    Quote from MyUserName,RN
    Just some background on the patient-elderly man, severe abdominal pain, dehydrated. He was NPO, had NG tube to constant suction with a large amount of drainage coming out. CT of abd was negative. He hadn't had a bm in a few days so the GI doctor ordered a retention enema which was given with good results. Labs were pretty stable, but did have a potassium of 3.3, which we gave him po potassium based on the protocol in place. He was already getting normal saline at 125 ml/hr. That's the background.

    So the resident doctor came and wrote an order for Lactated Ringers at 100ml/hr and D5NS at 100 ml/hr to run at the same time. I have never seen an order like that and just did not understand the rationale behind it, neither did any of the other nurses I work with, another doctor, nor the pharmacist. I called and clarified this with the doctor and he came back to the floor to talk to me. He said he asked his attending and superiors and they all agreed to the order, when I asked him the rationale behind why LR and D5NS, he said he didn't really know and that he would be researching that. I've tried to find some information on it, but can't. Anybody have anything?
    it *sounds* like they could be used as a volume expander (r/t dehydration), in addition to raising his k+ level by bringing it back into cells.
    it should only used short term.

    leslie
  6. Visit  Anna Flaxis profile page
    1
    I can only think that maybe it had something to do with the patient's acid/base balance, and wanting to keep him from tipping into the acidotic side with the NS. Did you have a pH on him?
    MyUserName,RN likes this.
  7. Visit  GrnTea profile page
    4
    ns doesn't cause acidosis.
    if he didn't develop the k+=3.3 (which is only a little bit lower than normal) acutely and isn't having pvcs, he doesn't need it fixed acutely; if the enema made him all better, advance diet as tolerated would have taken care of all of this.
    i'd be really careful about giving an old person 200cc/hour-- watch very carefully for chf, like check his chest q2hourly.
    new resident in july doesn't know what he's doing? check. or why his 2nd or 3rd year told him to do something? check. all is normal in the hospital for this time of year.

    and you did pull the ng before you gave him po kcl, right? else you could have just put it directly into the suction cannister, :d .
  8. Visit  #1ME profile page
    1
    I'm guessing the PO KCL was administered via the NGT.
    313RN likes this.
  9. Visit  tokmom profile page
    5
    Quote from #1ME
    I'm guessing the PO KCL was administered via the NGT.
    Doesn't matter if it was placed in his NG or he swallowed it. If the NGT is at continous suction the KCL is just going to be sucked back up into the cannister. You would need to clamp the NG tube.

    Why didn't they just put it in his IV?
    diva rn, sauconyrunner, barbyann, and 2 others like this.
  10. Visit  metal_m0nk profile page
    1
    Quote from grntea
    ns doesn't cause acidosis.
    ns can cause non-gap acidosis if given in large amounts, but i don't think that's the issue here. severe dehydration is linked to acidosis and ns doesn't prevent or treat it. i too would be looking for a ph.
    Last edit by metal_m0nk on Jul 20, '12 : Reason: neeeeeed mooooooar coffeeeee!
    MyUserName,RN likes this.
  11. Visit  #1ME profile page
    2
    Doesn't matter if it was placed in his NG or he swallowed it. If the NGT is at continous suction the KCL is just going to be sucked back up into the cannister. You would need to clamp the NG tube.
    ^^
    That is a given to me.
    gummi bear and MyUserName,RN like this.
  12. Visit  metal_m0nk profile page
    0
    Aaaaaaaaaaaand then there's the renal NH3 production which is heightened in hypokalemia which can cause acidosis...
  13. Visit  K+MgSO4 profile page
    1
    An enema will NOT fix a bowel obstruction. Unless it was a very low partial obstruction.
    The K is usless given PO as it is not absorbed. That is the rationale for the NG. What goes in must come out if the usual exit route is blocked it will reverse up the entrance. So no matter how long you clamp the NG it will still be there.
    Because the GIT has lost the absorption function electrolytes are not being absorbed causing K+ derangement.
    I don't understand the,rationale in the choice of fluid resus.
    From a colorectal nurse who has just spent a night shift explaining this very thing to a grad.
    MyUserName,RN likes this.
  14. Visit  MyUserName,RN profile page
    1
    Quote from grntea


    and you did pull the ng before you gave him po kcl, right? else you could have just put it directly into the suction cannister, :d .
    didn't have to pull the ng before giving. the ng tube was clamped during and for about an hour after med administration. the patient was able to swallow pills with the ng tube in place. i didn't give kcl iv because there was not an order for iv, only po. yes i could have obtained an order, but since the patient was already taking po meds while the ng tube was clamped, i didn't see the need to do so.
    Last edit by MyUserName,RN on Jul 20, '12
    #1ME likes this.


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