I'm a nursing student in a high acuity setting this quarter, and I cared for a pt in the CICU last week who had a sudden change in condition and I am trying to figure out why. At the time I was busy following the orders, giving the meds, etc. and didn't really have a chance to think about what was actually going on, so now I'm trying to sort through it to see what I should watch for if I ever encounter this kind of patient again. So, based on the following info, please let me know if I'm on the right track.
Pt. was a 74 year old female admitted for CHF exacerbation, c/o SOB. She had previously been admitted last summer and told she had renal insufficiency and referred for dialysis, but she left AMA before dialysis and never went to a renal doc.
When I came in her breathing was unlabored and her sats were 98-100 on 4L O2. Her main priority at this point was her hypertension, with systolic around or above 200. She was on a nitroglycerin drip (which was titrated to the max rate), which did not seem to be lowering her BP at all. She was also receiving 2 units of blood. The internal med MD came and was still concerned about her BP, so he ordered that she be placed on a Bumex drip. This was started after the blood transfusion had ended.
Meanwhile, her urine output was very low, around 0-20 cc/hr. Since she had just been admitted to CICU around 5am, the renal doc hadn't come to see her yet. Shortly after the Bumex drip started, the pt's daughter came to me and asked if her mom could have a fan. I went in the room and the pt was flailing around, diaphoretic, kept saying she couldn't breathe and felt sick. She had increased crackles in her bases and new audible wheezing. We called maintanence and got a fan up to her room, which provided minimal relief. Her BP was still over 200 systolic, and the internal med MD ordered IV push Bumex and IV push Lasix, and IV push Labetalol. Her BP remained high. I tried to keep her calm, explained that anxiety can make her breathing more difficult, and after a while, she expressed some relief, but not much. Her urine output remained the same despite all the diuretics. Finally the renal doc came up to speak with her about needing dialysis, which she still refused.
So from what I have been able to figure out, I think she was put into fluid overload r/t CHF and her very low kidney function. I am wondering if the diuretics caused this. Could it be that since the displaced fluid could not be excreted through the kidneys that the fluid simply backed up into her lungs? Or was the blood transfusion to blame because of the extra volume? Or was it just completely random?
I feel like there wasn't really anything we could do to reverse this problem because her kidneys weren't working and she refused dialysis, but I just wonder if it could have been prevented somehow. Any ideas?
