Fluid volume deficit??

THELIVINGWORST, ASN, RN · Sep 19, 2013

Shouldn't your priority be resolving the SOB and ineffective airway clearance? That sounds like relative hypovolemia to me. Idk. Jmo

nurseprnRN, BSN, RN · Sep 19, 2013

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.

mlauren · Sep 19, 2013

Wow overflow of information here, but thank you. I need to read this slowly and think about each and every little thing you have mentioned. I don't fully understand ckd, because we haven't studied it yet so I was unaware of some of the complications you mentioned.

Esme12, ASN, BSN, RN · Sep 19, 2013

moved to nursing student assistant for best response.

nurseprnRN, BSN, RN · Sep 19, 2013

Ah, didn't mean to blow you away. This will all make more sense the more you learn. Hit the index of your med-surg text for more info on chronic renal disease.

Part of your learning in school is not waiting for the lecture :) When you have a patient with an unfamiliar condition, that's when you look it up and start learning stuff. Just think how easier the renal lectures will be by the time they occur!

mlauren · Sep 19, 2013

Oh and she was not a dialysis patient. And I thought loculated meant the fluid had divided into compartments.

nurseprnRN, BSN, RN · Sep 19, 2013

Not on dialysis yet, but chronic renal disease nevertheless. Loculated does mean divided, but it is almost always because it's clumpy pus (sorry for the visual, but I can't think of a less unappealing way to describe it). If they called it "exudate," that's just basically serum; is there info in the op report as to what they got when they looked in there?

Esme12, ASN, BSN, RN · Sep 19, 2013

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.(What??) 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.

I have highlighted what I think is important. I brings several things to mind.

This is a HUGE bloody surgery...

8/28 (gastrectomy-removal of mass, spleenectomy, total abd hysterectomy, partial choly, and hiatal hernia repair

Have you looked up what a Loculated effusion is ? What did they do during the thoracotomy? Did this patient have a resection of a lung? Have you looked up all of these surgical procedures to see what they mean and why were they performed?

What symptoms does this patient have that make you concerned about volume? Did you take orthostatic vitals? Has she received blood? Does she have fluids? Is she on antibiotics? Should a CKD Stge 3 have hypotension? Are her kidneys at further risk? They still gave the B/P meds with her pressure so low? What would be your concern about this?

mlauren · Sep 19, 2013

Not on dialysis yet but chronic renal disease nevertheless. Loculated does mean divided, but it is almost always because it's clumpy pus (sorry for the visual, but I can't think of a less unappealing way to describe it). If they called it "exudate," that's just basically serum; is there info in the op report as to what they got when they looked in there? [/quote']
Oh ok. No there wasn't anything in her chart that explained tht. My instructor reviewed it with me and said that they were not sure what caused it, but possibly another mass.

mlauren · Sep 20, 2013

I did look loculated pleural effusion up and found that it was fluid build up in pleura divided into compartments. In the chart I read something about the thoracotomy involving scraping of something, but couldn't understand exactly what it was saying. I have looked up some info about all of the procedures.

Her H&H and RBCs make me think low volume and I figured it was due to blood loss from the surgeries, but wasn't sure how much she lost and if it would still be a problem weeks later. I couldn't find anything about blood loss during/after surgery in the chart or anything about blood transfusions. That would be helpful to know. She wasn't receiving any fluids or transfusion while I was there with her. No antibiotics were ordered that I seen unless I missed it on the list.

Stage 3 CKD...I'm just learning about this, but I know that they usually have high blood pressure as a complication. So no, usually hypotension isn't the issue. Since it is for this patient though, it could lead to more kidney damage, because they aren't getting the blood supply they need.

I don't understand why benazepril was still given. But the RN pulled it and my instructor agreed that we should give it. ???

Shouldn't this patient be getting fluids? Do you think she wasn't getting any b/c of CKD and fluid restrictions? What about blood transfusions? At what point is the BP so critical that there needs to be something done about it??? I wish I could go back and see what is going on with this patient today. I really would like to know if her BP went back up and if so, what was done to correct it.

mlauren · Sep 20, 2013

I did look loculated pleural effusion up and found that it was fluid build up in pleura divided into compartments. In the chart I read something about the thoracotomy involving scraping of something, but couldn't understand exactly what it was saying. I have looked up some info about all of the procedures.

Her H&H and RBCs make me think low volume and I figured it was due to blood loss from the surgeries, but wasn't sure how much she lost and if it would still be a problem weeks later. I couldn't find anything about blood loss during/after surgery in the chart or anything about blood transfusions. That would be helpful to know. She wasn't receiving any fluids or transfusion while I was there with her. No antibiotics were ordered that I seen unless I missed it on the list.

Stage 3 CKD...I'm just learning about this, but I know that they usually have high blood pressure as a complication. So no, usually hypotension isn't the issue. Since it is for this patient though, it could lead to more kidney damage, because they aren't getting the blood supply they need.

I don't understand why benazepril was still given. But the RN pulled it and my instructor agreed that we should give it. ???

Shouldn't this patient be getting fluids? Do you think she wasn't getting any b/c of CKD and fluid restrictions? What about blood transfusions? At what point is the BP so critical that there needs to be something done about it??? I wish I could go back and see what is going on with this patient today. I really would like to know if her BP went back up and if so, what was done to correct it.