Fluid bolus for patient with end stage renal disease?

[lovin]

I am a new nurse and I have a few lingering questions from my last shift.

Here is a little about my patient:

- end stage renal disease

- end stage liver disease

- non complaint with meds and dialysis

- found down with ammonia over 130. Ammonia levels below 90 for the past few days after dialysis.

After getting report from the night nurse here is what I found:

- ammonia over 190 in results from the am labs

- increasing confusion and lethargy

- itchy skin

My action:

- Notified provider about lab result and lethargy. He increased lactulose (45g QID).

- Continued monitoring

Throughout the 12 hour shift:

- Pt became increasingly lethargic.

- no pee or poop

My final action:

- Called the provider. Received order for fluid bolus and more lactulose (60g QID).

My question:

- I gave the fluid bolus, and went home. But now I am wondering if I should reminded the provider that this is a patient with end stage renal disease on dialysis.

What would you do? Could I have been a better advocate for this patient?

Thanks for your input.

[Altra, BSN, RN]

If you're worried about fluid overloading this patient remember - this patient can always be dialyzed.

[Chisca, RN]

The patient has plenty of fluid it's just in the wrong space. Fluid bolus will be a temporary measure to increase vascular volume and hopefully blood pressure. A CVP would be nice. The fluid is not going to stay in the blood because the albumin level is so low from the liver failure. Unless this patient gets a liver transplant the end is near.

[SwansonRN]

How big was the bolus? I'm sure it was okay, maybe the patient was a little dry from dialysis the day prior. How was his albumin? You may want to ask if they want to give albumin with the fluid so it doesn't just third space.

[CapeCodMermaid, RN]

Sometimes patients are between a rock and a hard place....or dehydration and fluid overload....or or or....If the patient is on dialysis the extra fluid can be dialyzed.

[07302003, ASN, RN]

As others have said, there is no way to fix this patient without a liver transplant, and if they're non-compliant it's unlikely they are listed or will be listed.

With the boluses just pay attention to breathing, that they don't get fluid overloaded.

But again, they can be dialyzed or intubated if needed. No long term solution though.

The only thing to do differently is to remind the MD that patient is ESRD on HD (because there's no way all docs can keep all the patients straight), which might only lessen the amount of the bolus, but boluses are given to these patients if they're dry.

And in terms of advocacy, the patient sounds like they're end of life, end of disease process, so making sure they and the family understand and end of life wishes are respected.

[NurseKatie08, MSN]

This patient sounds like they need a liver transplant, if not a liver-kidney. What was the etiology of their liver & renal disease? I work on a liver & kidney transplant med surg floor....sadly this sounds like one of our typical patients. It sounds as if they could benefit from Lactulose enemas. I also agree with a PP who suggested maybe getting some albumin on board so things don't just third space.

[Esme12, ASN, BSN, RN]

It is usually useful to start out every encounter.....especially if the provider is unfamiliar with the patient.

"Hi! This is DayShiftNurse calling about Mr. Compliance. He is the end stage renal failure/liver failure of Dr. SoandSo who was admitted on Blah with Blah and an ammonia level of Blah that was decreased to Blah and is now Blah. He is increasingly lethargic. Mr. Compliance usually has x urine output but has had none since the blah round of dialysis yesterday....." Albumin is a consideration however dialysis is probably the best way of removing fluid as with the liver failure you will never correct the lab itself.

The next conversation that needs to be addressed is code status

[lovin]

Thanks for the responses. I did assess for overload, although the bolus was given late in my shift. Embarrassingly, I did not think about double checking albumin levels or asking for albumin to go with the fluids. This was an interesting patient because he had very little edema -- I don't know where the fluids were going....

Esme 2, Your suggestion to add more background information before calling the doc is a good one. They have so many patients and I am realizing that giving them a full clinical picture, rather than just a brief sketch would benefit my patients and myself.

I love being a new nurse, but there is SOOO much to learn. Thank you all for your input!

[just keep swimming]

First time posting from my phone, so we will see about formatting and auto correct...

This wasn't mentioned in previous responses so I just wanted to throw it out there and see if anyone else has experienced this...

In patients with end stage liver disease, ammonia can get concentrated during hemodialysis, especially if a lot of fluid is removed. Could the doctor have been trying to undo this effect? Just a guess....thoughts?

[Sun0408, ASN, RN]

With ESRD, I would not expect must urine, if any at all unless the pt made urine on a regular basic.. As for the worsening condition, that is expected with ammonia levels that high.. Only so much we can do.. Code status would be the next step.. The bolus, I wouldn't worry too much unless your pt was showing signs of not tolerating it.. HD pts can and do get fluid boluses but generally in smaller amounts..

[Chisca, RN]

Could the doctor have been trying to undo this effect? Just a guess....thoughts?

My thought would be it might be theoretically possible to dilute out the ammonia with fluid but that it would require so much fluid that you would drown the patient, even if they weren't a renal patient. Current hemodialysis technology cannot remove NH3. I do remember working with some doctors that tried using a charcoal based based therapy that they called "liver dialysis" but they had to get a waiver from the FDA because it was only approved for acetaminophen overdoses. It worked, if you just go by lab values, but all the patients died. But the first 15 of Willhem Kolff's patients died in 1943 before that 16th patient survived and you know the rest.