Double Fluid mess ups

[anon456, BSN, RN]

I just wanted to post this for all the newer nurses, but also to remind people who don't run into this on a daily basis on your units.

I work peds and we have a lot of patients who are tube-fed either through an NG or a g-tube depending on their conditions/syndromes, etc. Of course when they come in they are often NPO and have IV fluids running. I have had two cases where I took over the care of patients who had both IV fluids and tube-feedings running at the same time. One patient has come back from OR much earlier that day before I got on shift and because there was not an order to d/c IV fluids when restarting tube-feedings, the patient got both. I took over care of the patient at 7 PM but didn't notice the double fluids until about 8:30 PM when I finally had a chance to do a full assessment. The patient was a cardiac baby who also had a trach and some pulmonary disease. I saw that the patient was having increased work of breathing and wet lungs. We had to give several doses of Lasix before the baby finally was able to pee off enough fluid to recover. The MD sat by bedside for about 2 hours and we came close to transferring the patient to ICU.

The lesson is that you have to ask yourself-- why does this patient need both IV and tube-feeds?? It is common when a patient is starting feeds back up to increase feeds slowly and subsequently decrease IV fluids. Last night I had a patient we were doing this on. I had to increase the feeds by 5mL/hr every 6 hours, but the MD did not write the order to decrease IV fluids at the same time. I did it anyway and then called the MD later when I had time and they confirmed that I was supposed to do that, and they apologized for not putting in in the order. I try to look for a TOTAL FLUID ORDER, such as for a baby, 37mL/hr total fluids between IV and tube feeds.

The website www.mdcalc.com has an excellent tool for peds nurses to calculate maintenance fluids, appropriate bolus amounts, and mg/kg/hr urine output. I use it all the time to double check the doctors.

THanks for listening. :-) Nursing humbles me daily.

[Biffbradford]

That may be true in pediatrics, but does not necessarily hold true universally.

[anon456, BSN, RN]

That may be true in pediatrics, but does not necessarily hold true universally.

Can you give some examples and explain? I guess I just assumed that no one should run excessive amts of fluids beyond what is appropriate for their size/condition. Not talking about boluses-- that's a different situation of course.

We do get adult patients also (18 and up, many of them with "peds" diagnoses like congenital heart problems, rare syndromes, or patients the MD's have decided to keep following when they turn 18) and the same rules apply to them in our hospital.

[ChristineN, BSN, RN]

That may be true in pediatrics but does not necessarily hold true universally.[/quote']

Maybe not, but as someone who has worked adults and PEDs you should always know why your pt is on fluids/feeds and if there is a real need for both. Especially post-op or after unit transfers orders can get messed up and accidents can happen

[nurseprnRN, BSN, RN]

Yet another example of why a well-educated RN holds the line between "just following doctor's orders" and the safe provision of the medical plan of care. Good spot. And yes, it can absolutely be just as critical for an adult as a baby.

On the other side of the coin, when my 135-pound teenager was admitted to a famous children's hospital post trauma we were awakened every hour by the IV pump alarming that her hourly fluids were completed. Apparently they had a protocol that no more than one hour's worth of fluid was dropped down into the volutrol, to prevent accidental fluid overload in small people, and when that ran dry, the pump beeped. It was as if I were speaking Urdu to explain why this was unnecessary in an adult-sized person with no cardiac or renal pathology. No critical thinking skills in that department, I guess.

[SoldierNurse22, BSN, RN]

It varies widely by unit, policy, patient and condition. I had patients on tube feedings or getting TPN that were getting fluids at the same time. I have also had patients who were on a schedule where it switched back and forth from TPN to fluids based on the time of day. As aforementioned, critical thinking is key.

[Biffbradford]

I come from an ICU background and even 99% the long termers, perhaps a month or more out, who were on tube feeding had IV fluids running. Perhaps not at 100cc/hr, but it might vary from day to day, week to week. Never say never.

[Esme12, ASN, BSN, RN]

Yet another example of why a well-educated RN holds the line between "just following doctor's orders" and the safe provision of the medical plan of care. Good spot. And yes, it can absolutely be just as critical for an adult as a baby.

On the other side of the coin, when my 135-pound teenager was admitted to a famous children's hospital post trauma we were awakened every hour by the IV pump alarming that her hourly fluids were completed. Apparently they had a protocol that no more than one hour's worth of fluid was dropped down into the volutrol, to prevent accidental fluid overload in small people, and when that ran dry, the pump beeped. It was as if I were speaking Urdu to explain why this was unnecessary in an adult-sized person with no cardiac or renal pathology. No critical thinking skills in that department, I guess.

and....I'll bet they had something bad happen (a sentinel event/near miss)and they got slapped and this was the "corrective action taken" to prevent further issues.

[uRNmyway, ASN, RN]

Yet another example of why a well-educated RN holds the line between "just following doctor's orders" and the safe provision of the medical plan of care. Good spot. And yes, it can absolutely be just as critical for an adult as a baby.

On the other side of the coin, when my 135-pound teenager was admitted to a famous children's hospital post trauma we were awakened every hour by the IV pump alarming that her hourly fluids were completed. Apparently they had a protocol that no more than one hour's worth of fluid was dropped down into the volutrol, to prevent accidental fluid overload in small people, and when that ran dry, the pump beeped. It was as if I were speaking Urdu to explain why this was unnecessary in an adult-sized person with no cardiac or renal pathology. No critical thinking skills in that department, I guess.

I get what you mean GrnTea, but the few pediatric floors where I worked, that was just protocol. The nurses had no say in the matter. So you could explain your reasoning until you were blue in the face, but unless they want to get back on the job hunt, or risk being reprimanded, they have to follow P&P. I'm not saying your explanation doesn't make sense, because it obviously does. But I have also worked with nurses who have used their so-called 'nursing judgment' and stopped treatments or monitoring because to them, it was dumb, it didn't make sense, etc. Doctor disagreed and they got in big doody.

[psu_213, BSN, RN]

Can you give some examples and explain? I guess I just assumed that no one should run excessive amts of fluids beyond what is appropriate for their size/condition. Not talking about boluses-- that's a different situation of course.

We do get adult patients also (18 and up, many of them with "peds" diagnoses like congenital heart problems, rare syndromes, or patients the MD's have decided to keep following when they turn 18) and the same rules apply to them in our hospital.

This is not so much the case for pts. with delicate fluid balance needs for cardiac and/or renal issues....but I have seen situations for adults where a tube feed is increased by X ml/hr and IVF rates are not decreased with each increase in tube feed rate. In such a case, IVF are often decreased (or turned off) within a few days, but I cannot recall seeing an order for "increasing TF rate by X and decrease IVF rates by X at the same time." Obviously it would be different in people who are sensitive to fluid volume increases (such as CHF, congenital heart defects, etc.).

[SoldierNurse22, BSN, RN]

I get what you mean GrnTea, but the few pediatric floors where I worked, that was just protocol. The nurses had no say in the matter. So you could explain your reasoning until you were blue in the face, but unless they want to get back on the job hunt, or risk being reprimanded, they have to follow P&P. I'm not saying your explanation doesn't make sense, because it obviously does. But I have also worked with nurses who have used their so-called 'nursing judgment' and stopped treatments or monitoring because to them, it was dumb, it didn't make sense, etc. Doctor disagreed and they got in big doody.

As long as you document your reasoning, discussions with physicians and CYA, you're not forced to do anything. We are held to a standard that is much higher than "because the doctor said so".

On that note, I'd much rather be blue in the face or searching for a job than trying to explain to a patient's family or a legal inquiry as to why I carried out an order that I knew was wrong.

[nurseprnRN, BSN, RN]

Agree wholeheartedly. "Nursing judgment" has to be more than, "I just don't like it/feel comfortable with it/understand it."

I don't know about any studies on sleep deprivation in small infants-- considering how many hours a normal baby sleeps, there should be-- but I can tell you that a 13-year-old and a 42-year-old get really, really cranky when they can't complete even one 90-minute sleep cycle in 48 hour (after that she got heplocked). Even setting that volutrol to three hours would have been better.