Can pushing fluids lead to pulmonary edema?

Lev, MSN, RN, NP · Nov 15, 2015

*I am working on a minor school assignment. It is not due tonight and I have put a lot of thought into it myself, researching concepts and whatnot, before asking for assistance. This is the scenario:
I'm caring for a 75 year old patient after hip replacement surgery
At the beginning of my shift, he rated his pain 2/10
and his vitals were BP 124/84, HR 76, RR 18, O2 98% on RA
On my next rotation, his BP 112/72, HR 98, RR 30, O2 88%
He seems anxious and is sweating, experiencing SOB, coughing up blood-tinged sputum & c/o chest pain when he breathes
I suspect my patient has pulmonary embolism induced respiratory alkalosis.
To address his resp distress, I plan to raise the head of his bed & initiate supplemental O2 therapy, probably via NRB mask@15L/min.
I probably need to call a rapid response team, or at least the doctor. I would inform the provider of my assessment findings and I could suggest the provider order testing of my patient's arterial blood gases to evaluate PaCO2 & HCO3 levels (to evaluate for resp alkalosis & to establish baseline for comparison to evaluate effectiveness of O2 therapy). A D-dimer test could rule out a PE; this might be worth suggesting so we don't end up wasting our time trying to treat something if that isn't really the problem. I could suggest a chest x-ray/CTPA to locate the suspected PE. (An ECG could be helpful in finding the clot if it were in the heart, but I think its in the lungs.) Clearly, antithrombolitic pharmacological intervention(s) would benefit a patient with a PE and I would suggest this if not already addressed by the doctor. Part of monitoring antithrombolitics for effectiveness would be testing the PT-INR prior to and after initiating treatment with Warfarin (or PTT for administration of heparin).
To address the patient's ongoing risk for DVT development, I could educate my patient how to perform exercises appropriate to whatever stage of healing he is in after his hip replacement surgery. According to Hip replacement surgery What you can expect - Mayo Clinic, it is likely it would be appropriate to encourage ambulation with a walker as soon as the same day as the hip replacement surgery or the day following; I could suggest we walk the halls together after my patient completes his meal. If not already ordered, I could suggest to the provider she order sequential compression devices, or prescribe compression stockings.
My question is this: Do I need to address the patient's diaphoresis?
To address the patient's risk for fluid imbalance/dehydration R/T diaphoresis, I want to suggest IV fluid replacement to the provider and/or encourage the patient to push fluids (avoiding coffee & alcohol) but I hesitate because I'm trying to figure out if you have impaired respiratory functioning R/T PE is there any risk pushing fluids could lead to pulmonary edema? Sorry if that's a stupid question, but I'm thinking about how my patient's at risk for pneumonia after anesthesia and he's already coughing up blood-tinged sputum. Do I even need to address the diaphoresis? How much fluid can a person really lose before I can get them stabilized?

Do I need to address the patient's anxiety with anything special? I imagine resp distress is scary and providing my presence in addition to resolving the issue while explaining to the pt what is going on, how my interventions should be addressing things and providing education about how we can prevent reoccurance/complications is probably enough. Should I suggest the doctor order Nitro for the angina or something for the altered B/P? I imagine these symptoms would resolve themselves by treating the PE. Is anything more needed for resp alk?
Thank you so much for your insight. Please let me know if any of my interventions sound off or if I've missed anything major. Thank you again for your time!

Your patient is having textbook signs of pulmonary embolism. Good job figuring this out! The diaphoresis and anxiety are symptoms of pulmonary embolism. They will resolve as the patient is treated. This patient's BP is stable. He/she doesn't need fluids at this time. The chest pain is reproducible and is probably not cardiac in nature. However, whenever your patient is having chest pain or trouble breathing, you should do an EKG to help rule out a cardiac cause. I would also check a temperature to make sure this patient isn't developing post-op pneumonia. That is another possibility for his symptoms. However, nursing school seems to love using scenarios with orthopedic surgery and PE or fat embolism.

The first thing I would do is put the patient on a nonrebreather and elevate the head of the bed as you did and call a rapid response and notify the physician.

I would make sure the patient has a good line in the AC or higher in case a CT to rule out PE is indicated. At the very least, this patient would need a chest x-ray.

I would draw labs. Definitely a PT/INR, D-dimer, and CBC. An ABG may be premature, but check with your doctor. I would also consider blood cultures.

I would NOT ambulate this patient until DVT/PE is ruled out and baseline respiratory function improves.

Good job OP!

Edited to add: Pushing fluids can lead to pulmonary edema in a patient with a weak heart/HF. Without knowing this patient's baseline heart function/ejection fraction, I can't answer this question.

Pseudonym · Nov 16, 2015

Levhttps://labtestsonline.org, I learned my patient exhibiting Rapid breathing & rapid heartbeat are both indicative of an infection and I can see the value in running these labs. Did you have something different in mind when recommending these tests?I don't want to suggest things prematurely. I've read a couple threads where nurses expressed that its our job to advocate for our patients by suggesting things we feel our patient would benefit from (as residents may not always know and are often open to our suggestions). I thought an ABG would be necessary to determine if the patient was experiencing resp alkalosis. Am I overcomplicating things? Should I just focus on the textbook PE s/sx & not worry about tests to diagnose resp alkalosis R/T PE? Thanks again!

akulahawkRN, ADN, RN, EMT-P · Nov 16, 2015

I've just a few thoughts on this as well. First, the scenario supports the Pulmonary Embolism picture. What it doesn't show me is the alkalosis. This patient is having an obstructive problem with gas exchange in the lungs. O2 can't get in, CO2 can't get out. Since the body's retaining CO2, the RR is going to elevate in an attempt to get rid of it, and the same response is true for the oxygenation issue. Chances are good that even if you put the patient's HOB up and provide a high concentration of oxygenation, the resp rate will still remain elevated, just perhaps not as high as 30/min. You might also notice very prominent external jugular veins.

Second, while an ABG would tell you how bad things are, it's but a single piece of the puzzle. I'd draw a D-Dimer, CBC, CMP, Lactate, PT/INR, blood cultures, and perhaps an ABG after MD consult. An EKG may show signs of a PE if you know what to look for. The CXR is a good idea, making sure that the patient has good IV access is paramount in the even that a CT scan w/ contrast is needed, though if your facility has the capability to do angiograms, that could also be used to show the PE.

Third, this patient is on the way to having a very bad day, so calling an RRT and immediately notifying the MD about this patient is very, very important. Also, start monitoring the patient's vital signs fairly frequently. With one of those patients, I'm going to greatly consider adding EtCO2 to the mix of vitals.

Fourth, while this patient may have a PE, there's also a chance that there's an infection brewing, drawing blood cultures is a good idea. The clinical picture does say "Pulmonary Embolism" but don't forget the differential diagnoses.

Lev, MSN, RN, NP · Nov 16, 2015

CBC would be to rule out infection such as pneumonia. If WBCs were high and there were signs of pneumonia on the chest xray the doctor may order blood cultures. Surgery itself (stress on the body, trauma, intra op use of steroids) can also elevate WBCs. This is why I would also check a temp. However, a surgical patient can also have an elevated temp from atelectasis. A PE itself can cause a lower grade fever. CBC is not necessary for antithrombotics but a PT/INR would be. This patient at a minimum will get a chest x-ray. If the d-dimer is high they will get a CT. I wouldn't worry about respiratory alkalosis for this patient yet. However, I was reading up a little on ABGs for pulmonary embolism diagnosis and in general they are not necessary for your typical population. However, it says that in high risk situations such as with a post-op patient an ABG can be of value if other causes are ruled out. You are not looking for alkalosis (probably wouldn't develop so quickly anyway, since the body is still compensating). You are looking for a low PO2 level.

"Conversely, in a patient population with a very high incidence of pulmonary embolism and a lower incidence of other respiratory ailments (eg, postoperative orthopedic patients with sudden onset of shortness of breath), a low PO2 has a strongly positive predictive value for pulmonary embolism."

Medscape: Medscape Access

needlesmcgeeRN, ASN, RN · Nov 16, 2015

Is this the same "patient" from the other day...?

Keith.RN · Nov 16, 2015

To develop the thinking that a nurse requires for clinical practice, there is something that the nurse must ask themselves when faced with any change in clinical status and the symptoms that are presenting and in this scenario the patient who has diaphoresis. The nurse must ask why. WHY is the patient diaphoretic?

What is driving this physiologic response? It is there for a reason and it is always a clinical red flag. Diaphoresis most often is present when the sympathetic nervous system (fight or flight) is activated. This patient is in distress and based on the symptoms you've identified, a pulmonary emboli is the most obvious reason. Fluid volume deficit and treating this as the way to resolve this problem is missing the bigger picture that the WHY answers. Deal with the WHY and the priorities of this clinical scenario become more obvious.

Don't forget that with any problem seen in practice clinical data collected is often related and must not be seen in separate "silos". Knowing that diaphoresis is a sign of fight or flight because there is a sensed imminent threat to this patient's life, the anxiety that is present is likely related to the reason for the diaphoresis, and the PE. Make it a priority to use and apply your knowledge to make these connections of clinical data. This will come with clinical experience so give it time!

Keith Rischer, RN, MA, CEN, CCRN

Larry3373 · Nov 16, 2015

Don't forget to assess for changes in LOC (level of consciousness) frequently. If the patient becomes nonresponsive, or they go from being oriented to disoriented, then they are likely declining quickly and probably need to be intubated. The rapid response the op suggested should help evaluate if this is necessary also.

Horseshoe, BSN, RN · Nov 17, 2015

Isn't this the exact scenario you presented the other day? Doesn't seem like a minor assignment if you are still working on it. You have my sympathies.

To address the patient's ongoing risk for DVT development, I could educate my patient how to perform exercises appropriate to whatever stage of healing he is in after his hip replacement surgery. According to Hip replacement surgery What you can expect - Mayo Clinic, it is likely it would be appropriate to encourage ambulation with a walker as soon as the same day as the hip replacement surgery or the day following; I could suggest we walk the halls together after my patient completes his meal. If not already ordered, I could suggest to the provider she order sequential compression devices, or prescribe compression stockings.

This is not even on the short list of your current priorities. This patient is in distress and in danger of going south in a big way. Ambulation or other exercises should not be your concern at this time.

My question is this: Do I need to address the patient's diaphoresis?
To address the patient's risk for fluid imbalance/dehydration R/T diaphoresis, I want to suggest IV fluid replacement to the provider and/or encourage the patient to push fluids (avoiding coffee & alcohol) but I hesitate because I'm trying to figure out if you have impaired respiratory functioning R/T PE is there any risk pushing fluids could lead to pulmonary edema? Sorry if that's a stupid question, but I'm thinking about how my patient's at risk for pneumonia after anesthesia and he's already coughing up blood-tinged sputum. Do I even need to address the diaphoresis? How much fluid can a person really lose before I can get them stabilized?

Hypovolemia secondary to diaphoresis is not a concern in this scenario. The diaphoresis is, as already stated, a symptom of his primary problem and will no longer be an issue once the primary problem has been resolved.

This sounds like a textbook case of a PE. Yes, it could be an infection (you don't say how many days post op he is, which is important if we are thinking he developed one after surgery), but an infection isn't probably going to be as immediately life threatening as a PE. The PE needs to be ruled in/out first IMO before you start thinking infection. Obviously if you are already drawing labs, it's no biggie to consider that when the labs are ordered. But yes, RRT for sure, call to the physician for sure, and prioritize the PE first. The problem with the PE is that he effectively cannot breathe because there is a mechanical impediment to oxygenation. Everything follows from that. CP is most likely due to the PE, as is his anxiety, high RR, and diaphoresis. You can also think cardiac, but it seems that your instructor is trying to get you think PE in a post op ortho patient.

Pseudonym · Nov 20, 2015

I read all your comments a couple nights ago and was going to respond then but lost access to the internet due to storm conditions where I live.

Lev

Horseshoe & NeedlesMcGee, yes this is the same patient scenario I posted on previously. I'm still learning from this scenario. Yesterday, when my instructor opened discussion for this scenario, we spent less than 2 minutes discussing it and not even everyone in my group participated in the conversation! I was so disappointed after I'd spent so much time really analyzing this case, but in the end, my goal in school is to really build up my knowledge base so I can become a competent nurse. Thanks for your patience with me while I maximize my learning!

Keith, I appreciate your reminder not to view clinical data as separate silos but to identify the WHY behind it all. What I hear you saying is if I focus on the PE [the why] the treatment priorities become clear. Thank you for the encouragement re: giving myself time to gain clinical experience and to make these connections.

Larry, thank you for sharing that intubation might be warranted should the patient become disoriented. The only intubation we've covered so far in school has been of the digestive tract so I genuinely hadn't been thinking down that line at all until you brought it up. I had hoped to look more into it before my teacher opened this scenario for discussion, but I will follow up by researching this more independently as soon as I get a chance.

KelRN215, BSN, RN · Nov 21, 2015

Pushing fluids CAN lead to pulmonary edema, but pushing fluids is not warranted in this case. Your patient has a normal BP and heart rate. Telling the patient to avoid alcohol and caffeine is not a conversation for this point in time, he is about to start circling the drain.

As an aside, many years ago during a simulation class (I think the fake patient was septic from bacterial meningitis), a Resident was talking about how one of her Attendings always used to say "you can recover from pulmonary edema" when the Residents would question aggressive fluid resuscitation for patients in septic shock. Treat the hypovolemia/shock then give diuretics if needed.