Fluid volume deficit??

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I'm trying to figure out what my second diagnosis for this patient should be. Based on the information I gathered and assessment data I think that fluid volume deficit should be used. But not sure because of what my ND book says. So this is the same patient from my previous post, the one with pleural effusions. Now I'm trying to address the low BP issue. Her BP's were as low as 92/49 and HR up to 115 at times. She reported lightheadedness, dizziness, but no other symptoms. She actually looked much better than she had the day before and other than having trouble taking a deep breath she was fine. But her H&H was 8.4 & 25. Also RBCs were 2.88. This data is what made me think fluid volume deficit. She had several surgical procedures on 8/28 (gastrectomy-removal of mass, spleenectomy, total abd hysterectomy, partial choly, and hiatal hernia repair). She was admitted on 9/10 due to pain on inspiration, SOB, and worsening cough. This is when they discovered abd fluid collection and the pleural effusion (multiple loculated). The cause of the pleural effusion was unknown, but they did a thoracentesis (exudate). Then on the 16th she had a thoracotomy and afterwards a chest tube was placed for drainage. She had about 300ml of drainage all together, serosanguinous, but it was serous when I left and had slowed way down. Her respiration's were shallow, crackles in LLL, but O2 99 and RR 16-20. ABGs were normal.

She has CKD stage 3, but it is well controlled and she has no complications from that at all. At least not that I witnessed. She also has osteoarthritis, RA, HTN, a history of anemia, and vitamin D deficiency.

She had an order for lotrel, but the amlodipine was held and benazepril given. Other meds that she got while I cared for her were flonase, patanol, and claritin.

Do you guys think that I'm wrong about fluid volume deficit rt blood loss? I'm just trying to figure out why her BP was low and how critical this is. Her RN wasn't too concerned. And the patient was acting like she was fine. She actually looked better than she had the day before. I just thought that it was important to make interventions to ensure that it doesn't drop any more. But I'm not sure if blood loss is even the cause. I know the meds are affecting it, but then there's the decreased H&H and RBC.

Something else I thought of...her Calcium was 7.4. Wouldn't this contribute to blood loss? Is this level not low enough to be treated? She was on electrolyte protocol, but the nurse didn't pull any of her PRN vitamins. She might have been holding them until another time I guess, but not sure. She also had a history of vit. D, B12, and folic acid deficiency.

Specializes in Critical Care, ED, Cath lab, CTPAC,Trauma.

NO...it doesn't contribute to the blood loss. How would having a low Calcium CONTRIBUTE to bleeding?

what are the causes of hypocalcium.....https://www.clinicalkey.com/topics/endocrinology/hypocalcemia.html

Did you look up her surgeries? This is a LOT of surgeries at one time so I am sure she is volume depleted and I m sure she had a significant blood loss. Her blood loss information would be on her old record or her surgical report.

This is a sick patient and I have a ton of questions....but.....

Here is what I think.... this patient has had a massive surgery....for reasons unknown ( her previous symptoms that lead to this decision) there was a significant blood loss that may or may not have been replaced. Renal patients run a low H/H....chronic anemia is common....so is hypocalcemia....amongst other labs.

Surgery was 8/28/13. The patient re-presents to the hospital 9/10/13 (14 days later) with SOB still anemic and CXR showing pleural effusions. The patient complains of SOB but Saturation remain WNL ( but is it accurate in the presence of severe anemia)This patient is tachycardic and complains of dizziness and feeling lightheaded ( a sure sign of hypovolemia)....taking orthostatic vitals at this time would have been appropriate. The patient subsequently had a thoracotomy for a "scraping procedure".

It is important to write down the proper terms of these procedures and look them up. I Google things all the time here when I don't know what someone is talking about...I learn everyday.

This patient has symptoms consistent with hypovolemia...low B/P lightheartedness, dizziness, and tachycrdia. This need to be addressed. I m NOT so sure that I would have given anti hypertensives ion a hypovolemic patient without calling the MD....especially in leiu of the fact that the patient is symptomatic AND has CKD and therefore requires higher B/P to perfuse the kidneys.

HOwever s the B/P med given is an ACE inhibitor. which means it works by blocking a substance in the body that causes blood vessels to tighten. As a result, benazepril relaxes the blood vessels. This lowers blood pressure and increases the supply of blood and oxygen to the heart....... the patient may have needed the afterload reduction on the heart.....and leave the blood vessel relaxed to keep blood flow constant until volume returns.

This severe anemia can also cause a patient to be SOB...however in the renal patient that is chronically anemic that is probably not the case....however they are exhibiting symptoms of volume depletion with tachycardia, lightheartedness and dizziness.

The patient has a pleural effusion which could be from the trauma during surgery or side effect from the renal failure.

This patient doesn't take deep breaths from the chest tube so pain control is an issue for the lack of deep breathing and coughing will further complicate this patients recovery further with pneumonia/atelectasis.

Now combine these two patient scenario and tell me what you think.

NO...it doesn't contribute to the blood loss. How would having a low Calcium CONTRIBUTE to bleeding?

what are the causes of hypocalcium.....https://www.clinicalkey.com/topics/endocrinology/hypocalcemia.html

Did you look up her surgeries? This is a LOT of surgeries at one time so I am sure she is volume depleted and I m sure she had a significant blood loss. Her blood loss information would be on her old record or her surgical report.

This is a sick patient and I have a ton of questions....but.....

Here is what I think.... this patient has had a massive surgery....for reasons unknown ( her previous symptoms that lead to this decision) there was a significant blood loss that may or may not have been replaced. Renal patients run a low H/H....chronic anemia is common....so is hypocalcemia....amongst other labs.

Surgery was 8/28/13. The patient re-presents to the hospital 9/10/13 (14 days later) with SOB still anemic and CXR showing pleural effusions. The patient complains of SOB but Saturation remain WNL ( but is it accurate in the presence of severe anemia)This patient is tachycardic and complains of dizziness and feeling lightheaded ( a sure sign of hypovolemia)....taking orthostatic vitals at this time would have been appropriate. The patient subsequently had a thoracotomy for a "scraping procedure".

It is important to write down the proper terms of these procedures and look them up. I Google things all the time here when I don't know what someone is talking about...I learn everyday.

This patient has symptoms consistent with hypovolemia...low B/P lightheartedness, dizziness, and tachycrdia. This need to be addressed. I m NOT so sure that I would have given anti hypertensives ion a hypovolemic patient without calling the MD....especially in leiu of the fact that the patient is symptomatic AND has CKD and therefore requires higher B/P to perfuse the kidneys.

HOwever s the B/P med given is an ACE inhibitor. which means it works by blocking a substance in the body that causes blood vessels to tighten. As a result, benazepril relaxes the blood vessels. This lowers blood pressure and increases the supply of blood and oxygen to the heart....... the patient may have needed the afterload reduction on the heart.....and leave the blood vessel relaxed to keep blood flow constant until volume returns.

This severe anemia can also cause a patient to be SOB...however in the renal patient that is chronically anemic that is probably not the case....however they are exhibiting symptoms of volume depletion with tachycardia, lightheartedness and dizziness.

The patient has a pleural effusion which could be from the trauma during surgery or side effect from the renal failure.

This patient doesn't take deep breaths from the chest tube so pain control is an issue for the lack of deep breathing and coughing will further complicate this patients recovery further with pneumonia/atelectasis.

Now combine these two patient scenario and tell me what you think.

Well I have included interventions for ineffective breathing pattern, ineffective airway clearance, acute pain, fluid volume deficit, ineffective renal perfusion, an decreased cardiac output. When I first started researching about ckd I was thinking anemia was part of it, but couldn't be the whole problem. I did look up the surgeries and my initial thinking is that yes, she had to have lost a lot of blood. But I always doubt myself when I see how the nurses are approaching it. They always seem so calm about things that I think are really important. So I kind of thought maybe she was just anemic and BP was low because of the meds. Now I'm thinking differently. To be completely honest my interventions for fluid volume deficit are very generic because i really am not sure what all I should do other than assess, monitor, and report it to the physician. I would think she needs fluids running and blood though.

Thank you for explaining the benazepril. That was throwing me off.

Specializes in Critical Care, ED, Cath lab, CTPAC,Trauma.

Well they need to be treating her gingerly because of the renal disease...fluid overload could overwhelm this patient. Without seeing the chart.....the decision to transfuse is difficult. New recommendations are showing a much lower HCT, around 7 before transfusion is ordered. It also depends on co-morbidities, symptoms presented, and the patients age. National Guideline Clearinghouse | Blood transfusion: indications, administration and adverse reactions.

The nurses may seem calm about things because they know the nuances of this patient and have spoken to the doctor and know the plan. I would as a nurse have concerns for this patient as she is exhibiting symptoms of hypovolemia and orthosttic hypotension. I would probably remind the MD at every opportunity....if this patient was far from her baseline.

Interventions this is where a good care plan book comes in handy...I use Ackley: Nursing Diagnosis Handbook, 10th Edition

....here are a few.

Nursing Interventions and Rationales

  • Watch for early signs of hypovolemia, including thirst, restlessness, headaches, and inability to concentrate. Thirst is often the first sign of dehydration
  • Recognize symptoms of cyanosis, cold clammy skin, weak thready pulse, confusion, and oliguria as late signs of hypovolemia. These symptoms occur after the body has compensated for fluid loss by moving fluid from the interstitial space into the vascular compartment; several liters of fluid may be lost from the body
  • Monitor pulse, respiration, and blood pressure of clients with deficient fluid volume every 15 minutes to 1 hour for the unstable client, every 4 hours for the stable client. Vital sign changes seen with fluid volume deficit include tachycardia, tachypnea, decreased pulse pressure first, then hypotension, decreased pulse volume, and increased or decreased body temperature
  • Check orthostatic blood pressures with the client lying, sitting, and standing. A decrease in systolic blood pressure of 20 mm Hg or a decrease in diastolic blood pressure of 10 mm Hg within 3 minutes of standing when compared with blood pressure from the sitting position is considered orthostatic hypotension. This can occur with dehydration or cardiovascular disorders
  • Note skin turgor over bony prominences such as the hand or shin.
  • Monitor for the existence of factors causing deficient fluid volume (e.g., vomiting, diarrhea, difficulty maintaining oral intake, fever, uncontrolled type 2 diabetes, diuretic therapy). Early identification of risk factors and early intervention can decrease the occurrence and severity of complications from deficient fluid volume and acute kidney injury
  • Observe for dry tongue and mucous membranes, and longitudinal tongue furrows. These are symptoms of decreased body fluids
  • Recognize that checking capillary refill may not be helpful in identifying fluid volume deficit. Capillary refill can be normal in clients with sepsis, increased body temperature dilates peripheral blood vessels, and capillary return may be immediate
  • Monitor total fluid intake and output every 4 hours (or every hour for the unstable client). Recognize that urine output is not always an accurate indicator of fluid balance. A urine output of less than 0.5 mL/kg/hour is insufficient for normal renal function and indicates hypovolemia or onset of renal injury A commonly accepted definition of oliguria is a urine output less than 0.5 mL/kg for each of 6 or more consecutive hours, which is thought to confer “risk” of renal injury; when urine output less than 0.5 mL/kg persists for 12 or more consecutive hours, the kidneys are designated as “in injury”
  • Note the color of urine and specific gravity. Normal urine is straw-colored or amber. Dark-colored urine with increasing specific gravity reflects increased urine concentration and fluid deficit. Increasing specific gravity of urine also reflects fluid deficit
  • Hydrate the client with ordered isotonic IV solutions if prescribed. Isotonic intravenous fluids such as 0.9% normal saline or lactated Ringer’s allow replacement of intravascular volume
  • Assist with ambulation if the client has postural hypotension. Hypovolemia causes postural hypotension, which can result in syncope and increased risk for injury

I'm betting this unfortunate woman had mets in her pleura, and that's where the pleural effusion comes from, and in her peritoneal space, and that's where the ascites comes from. Too many bricks falling off this wagon...

Well they need to be treating her gingerly because of the renal disease...fluid overload could overwhelm this patient. Without seeing the chart.....the decision to transfuse is difficult. New recommendations are showing a much lower HCT around 7 before transfusion is ordered. It also depends on co-morbidities, symptoms presented, and the patients age. National Guideline Clearinghouse | Blood transfusion: indications, administration and adverse reactions.

The nurses may seem calm about things because they know the nuances of this patient and have spoken to the doctor and know the plan. I would as a nurse have concerns for this patient as she is exhibiting symptoms of hypovolemia and orthosttic hypotension. I would probably remind the MD at every opportunity....if this patient was far from her baseline.

Interventions this is where a good care plan book comes in handy...I use Ackley: Nursing Diagnosis Handbook, 10th Edition

....here are a few.

Ok so I had all of these and some others, but didn't know about the cap refill not being good indicator with this. Also didn't have orthostatic hypotension. Thanks for sharing what u know about transfusions. I also had to monitor for fluid overload if fluids were infused, because of her condition.

Specializes in Critical Care, ED, Cath lab, CTPAC,Trauma.

What do you need to know about infusions.....

What do you need to know about infusions.....

Like when a transfusion would be ordered.

Specializes in Nephrology.
She doubtless loss a lot of blood from that massive surgery. She's probably short of breath and easily dizzy because she has such a low oxygen-carrying capacity (hct of 25, hgb 8.4) so she uses up what oxygen she has in her blood with really minimal muscle activity; she has little reserve. This low hct may be related to blood loss, but may also be related to the renal failure (where does erythropoietin come from? what do ESRD people on dialysis normally run for H/H? Why?) and a good slug of anemia of chronic illness (she must have had some sort of malignancy). "loculated" is an adjective that means "pus," so she had/has an infection in that pleural space. Vit D deficiency is a renal disease side effect, high blood pressure also points to renal disease. RA, rheumatoid arthritis? Is she taking immunosuppressants for that? What will that do to her hematocrit, WBC, and risk for infection?

Also, think about what hematocrit is. It's the percentage of blood volume that is red blood cells-- this is measured by spinning down a tube and measuring how much of the tube is RBCs. Now imagine that someone with a Hct of, oh, 40 suffers a sudden loss of 50% of his blood volume in the field. He staggers into the ER (well, to do much staggering, he must have bled in the parking lot, or maybe even the ambulance bay :) ) and they stick him for a Hct before anything else happens. What is his hematocrit then? If you said, "40," you're right. He doesn't have a lot of blood left, but there has been nothing to dilute/decrease the %age of it that's red cells, so there is no change in his Hct.

After they tank him up with a lot of normal saline, his circulating volume is restored to where it was before he bled. What is his hct now? Right, somewhere around 20, because his blood is now diluted with NS and there has been no restoration of red cells.

Next: Think about oxygen carrying capacity. Compare, for example, the amount of oxygen delivered to the cells of two people. Both have normal PaO2 on ABG and both have SpO2 of 99% (this is percent of RBCs saturated by oxygen). They both have roughly equivalent BP and HR. However, one has a hematocrit of 40, and one has a hematocrit of 20. The one with the Hct of 20 will feel short of breath more easily, because she just isn't carrying much oxygen to his cells, and may have other signs of low oxygenation, like tachycardia, tachypnea, or even ischemic pain if his arteries are a little hinky (think angina, claudication).

Remember also that fluid volume loss from the vascular space may not be visible and measurable as chest tube drainage or blood loss from surgery. Where did all that ascites and pleural effusion come from? It oozed out of capillary beds, that's where. People can lose a tremendous amount of intravascular volume by losing proteinaceous fluid into a pleural or peritoneal space. Alcoholic or other cirrhosis can cause liters of ascites per day; malignancy in the peritoneal, pericardial, or pleural space can "weep" fluid in huge amounts, too.

There are a lot of things going on with this lady. She has a lot of reasons for hypovolemia (what's her serum protein look like? Is she edematous?) and poor internal BP maintenance. I'm not sure I'd blame it all on bleeding.

:yes: I was going to write a response, no need.

Specializes in Critical Care, ED, Cath lab, CTPAC,Trauma.
Like when a transfusion would be ordered.

Well...this is NOT a simple answer for giving blood has it's own inherent risks. Each patient is evaluated individually. Uaually the current recommendation is for a HCT 7 and under .....here is a transfusion guide line PDF from the red cross and it is 112 pages long.

http://www.redcrossblood.org/sites/arc/files/h21208_37600_compendium_brochure.pdf

It is important to know baselines when dealing with pts with so many comorbidities. With CKD, pts will have baseline H/H around 8/24 , blood transfusion protocol at my hospital is to transfuse at 7/21 and under. Pts with chronically low H/H have bodies that are accustomed to living with this and they will not be symptomatic. There is a problem when they are symptomatic- lightheaded, dizzy. The blood pressure 92/49 is not low-look at the MAP. If it deviates from the baseline, then yes it is low. With BP meds, Drs set parameters for when to give and not give. HR, SBP. I have seen orders that say do not give if SBP is less than 90. Ok, well if its not under 90, give it, their body can handle it and if you dont give it, their BP will not be maintained. There were times Ive given beta blockers to pts with bradycardia HR in the 40's, I had to ask the Dr about his rationale and also read the cardiologist note- giving the beta blocker in that case was intended to increase the contractility of the heart and to also convert his heart rhythm. As for blood loss-they will always report Estimated blood loss in the report after surgery, you will also get it in report from the RN in the OR before the pt returns to the floor. They knew how much blood loss there was and if it was a concern and there was a need to replace it, it was already addressed right after her surgeries. 300 ml blood loss from a chest tube is also not that concerning of a number over a shift especially if it is a new chest tube. I would say 500 ml is concerning. Hopefully the pulmonary specialist is coming in shortly after the pt returns to the floor to assess the chest tube and output himself, or comes in at least before shift change. If output was trending downward each shift, changing to serous color then all of a sudden the output is more and its sanguineous, then that is a problem. If her BP is lower than baseline and she is symptomatic, call the MD, they may order IVFs, they may order orthostatic VS, they may adjust doses of her BP meds-who knows maybe the night before she was very hypertensive and the Dr. increased her daily dose of a BP med and it just wasnt right for her. Also, the kidneys regulate BP, so with pts with CKD, you can see a wide variety of BPs in a shift from the same pt, high to low-I've seen 210's/150s to 70/30's in the same shift in in the same pt with CKD. She had a gastrectomy-how much of her stomach was removed? How much is her PO intake? That could play a factor in her fluid volume as well. Ca of 7.4 is not WNL, but for CKD, this is often a number you will see and they do not aggressively treat a Ca like this, they give daily medications to balance phosphorus and ca, usually around mealtimes-renvela is one that lowers phosphorus, ca/phos have inverse relationship in the body.

Well...this is NOT a simple answer for giving blood has it's own inherent risks. Each patient is evaluated individually. Uaually the current recommendation is for a HCT 7 and under .....here is a transfusion guide line PDF from the red cross and it is 112 pages long. http://www.redcrossblood.org/sites/arc/files/h21208_37600_compendium_brochure.pdf

Thanks for the post

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