Fluid Overload questions

oramar · May 3, 2004

That the O2 helped her heart pump better so the fluid got to her kidneys which then excreted it. It's a pushme pullya situation.

Janet Barclay · May 3, 2004

Not silly to think about fluid overload ever!

Remember, though, that the crackles of pulmonary edema sound different than retained secretions or atalectasis- they are best heard at the bases, and sound like saran wrap rubbed between your fingers. Also check neck veins for distention and listen for a third heart sound.

250 an hour sounds like a lot, but with a septic patient, the fluid is largely third spaced into the interstitium.

Your assessment about the patient's sats was a great one.

Janet

Tweety, BSN, RN · May 3, 2004

Agree that your assessment skills are right on target. A patient with 250 cc/hr, hypoxia and crackles one would think "pulmonary edema". Kudos for calling the doc on that one.

Another thing besides what Janet mentioned above was what was the BUN and Cr.? Off topic story: I had a coworker of mine a while back get all upset over this "wet" patient. She called the doc and got lasix. As the charge nurse I went to assess the patient and to me it seemed like he had pneumonia, as he coughed up his secretions and was showing signs of dehydration, plus this patient was heplocked and taking poor p.o. (scarey nurse). Sure enough his BUN was in the range of dehyration.

zacarias, ASN, RN · May 3, 2004

Not silly to think about fluid overload ever!
Remember, though, that the crackles of pulmonary edema sound different than retained secretions or atalectasis- they are best heard at the bases, and sound like saran wrap rubbed between your fingers. Also check neck veins for distention and listen for a third heart sound.
250 an hour sounds like a lot, but with a septic patient, the fluid is largely third spaced into the interstitium.
Your assessment about the patient's sats was a great one.
Janet

Thanks all for your replies! It's nice to know I did OK int hat situation.

You know I can imagine edema crackles sound different than atelectasis but unless I can compare them one right after the other, I don't know if I can always distinguish them. I know pulmonary edema crackles are much coorificer and wetter sounded though.

stevierae · May 3, 2004

Agree that your assessment skills are right on target. A patient with 250 cc/hr, hypoxia and crackles one would thing "pulmonary edema". Kudos for calling the doc on that one.
Another thing besides what Janet mentioned above was what was the BUN and Cr.? Off topic story: I had a coworker of mine a while back get all upset over this "wet" patient. She called the doc and got lasix. As the charge nurse I went to assess the patient and to me it seemed like he had pneumonia, as he coughed up his secretions and was showing signs of dehydration, plus this patient was heplocked and taking poor p.o. (scarey nurse). Sure enough his BUN was in the range of dehyration.

In these types of patients, would a CVP line have made assessments easier? Just curious--in the OR, anesthesia always puts in a CVP line if there is any possibility of fluid overload or just to more closely monitor their pulmonary status and pick up on or hopefully avoid 3rd spacing--or INADEQUATE volume replacement.

I agree, though, good old fashioned nursing assessements like Zac did are still required--looking at your patient, listening to his heart & lungs, looking at O2 sat, etc. Good job, Zac!!

heart queen · May 4, 2004

I think you did GREAT! I agree that CVP monitoring is especially helpful, drop a central line and transduce it.. but this patient was most likely on the floor, not even a tele unit... from what I've learned here on the BB, few tele units even are credentialed to transduce. So you're left with basic assessment skills.... shiver... give me a line any day!

Great job zac. Even at 35, fluid overload, with a healthy EF is a possibility. Your patient was getting 6 liters in a 24hr. period.... the vasculature, cardiac output is roughly 5-8 liters, so at 250 per hour, all that fluid is going to start shifting somewhere. Even with severe ICU type sepsis, where we pump in even 8 liters in 24 hrs. it starts to shift. Now you know to add the o2, keep watching the sats and listen to the lungs more frequent, then call again. But, I'm wrong.. you already knew that!

You da bomb!

stevierae · May 4, 2004

I think you did GREAT! I agree that CVP monitoring is especially helpful, drop a central line and transduce it.. but this patient was most likely on the floor, not even a tele unit... from what I've learned here on the BB, few tele units even are credentialed to transduce.

WHAT? You mean they don't have the CVP water manometers anymore?

I was going to say the "old-fashioned" CVP manometers, but I thought then I would REALLY be showing my age (50, LOL!) We used them routinely right through the '80s.

Yeah, nowadays we transduce CVP lines and look at the tracing on the datascope, but we still keep the water manometers around for the "older" anesthesiologists who prefer them...they really ARE older, like in their 60s...

Personal note to Zac--do you by chance work at Harbor View? Awesome, awesome, awesome trauma center--A "trauma center's" trauma center.

Or Virginia Mason?

Please don't say you work at Swedish...... :uhoh21: :uhoh3:

heart queen · May 4, 2004

stevierae, yup, No manual transducing unless your in an older facility, yes, sorry to say, back with 80's technology. For some ungodly reason, this is considered a higher level of care, fewer and fewer med surg. floors do it. I'm pretty sure that few step down's do that type of H20 manometer reading. Go figure, so simple and accurate.

WHAT? You mean they don't have the CVP water manometers anymore?
I was going to say the "old-fashioned" CVP manometers, but I thought then I would REALLY be showing my age (50, LOL!) We used them routinely right through the '80s.
Yeah, nowadays we transduce CVP lines and look at the tracing on the datascope, but we still keep the water manometers around for the "older" anesthesiologists who prefer them...they really ARE older, like in their 60s...
Personal note to Zac--do you by chance work at Harbor View? Awesome, awesome, awesome trauma center--A "trauma center's" trauma center.
Please don't say you work at Swedish...... :uhoh21:

zacarias, ASN, RN · May 4, 2004

Personal note to Zac--do you by chance work at Harbor View? Awesome, awesome, awesome trauma center--A "trauma center's" trauma center.
Or Virginia Mason?
Please don't say you work at Swedish......

No I don't work at Harborview but I LOVE that place! It is awesome and have worked there in the past and did clinicals there. I would consider it in the future. I work it's sister hospital, the UW! I actually don't mind Swedish.......

Ok, so I work on gen Med floor with telemetry but we don't ever monitor CVP on our floors. Some of our patients do have TLCs though I wonder how hard it would be to set it up? It sounds like it wouldn't be cost efficient, especially since not everyone is really at risk for fluid overload on the med floor.

Stevie, are you from Seattle? You seem to know it.

Tweety, BSN, RN · May 4, 2004

WHAT? You mean they don't have the CVP water manometers anymore?
I was going to say the "old-fashioned" CVP manometers, but I thought then I would REALLY be showing my age (50, LOL!) We used them routinely right through the '80s.
Yeah, nowadays we transduce CVP lines and look at the tracing on the datascope, but we still keep the water manometers around for the "older" anesthesiologists who prefer them...they really ARE older, like in their 60s...
Personal note to Zac--do you by chance work at Harbor View? Awesome, awesome, awesome trauma center--A "trauma center's" trauma center.
Or Virginia Mason?
Please don't say you work at Swedish...... :uhoh21:

Oh no, most floor nurses don't even know what they are and how to use them. But they can be useful if used properly.

In most cases on med-surg units, it's assessment and xrays and labs than can diagnose pulmonary edema.

critcarenurse16 · May 4, 2004

WHAT? You mean they don't have the CVP water manometers anymore?
I was going to say the "old-fashioned" CVP manometers, but I thought then I would REALLY be showing my age (50, LOL!) We used them routinely right through the '80s.
Yeah, nowadays we transduce CVP lines and look at the tracing on the datascope, but we still keep the water manometers around for the "older" anesthesiologists who prefer them...they really ARE older, like in their 60s...
Personal note to Zac--do you by chance work at Harbor View? Awesome, awesome, awesome trauma center--A "trauma center's" trauma center.
Or Virginia Mason?
Please don't say you work at Swedish...... :uhoh21:

OMG-- we still use the "old fashioned" water manometers.

It's not me showing my age, but the docs who woun't let go of the past... LOL:chuckle