fluid overload ,sepsis, Pneumonia what?!?

[lilacscrubs]

Hello,

I am on my 1st 6 mos on the job in an acute care facility. I really need some advice on this pt and if I did the right thing and also what else could have been done. This has haunted me since I left work this morning.

Pt is 95 y/o with dx of PNA, DNI/DNR. 1st 2 days working with pt there was resp distress, very congested helped with full blast O2, suctioning chest pt.

End of 2nd day pt had jugular vein distention, brought it to attention of P.A covering documented it and endorsed it to oncoming shift.

3rd day, pt hard to arouse, (got on report pt hypotensive) monitored b/p, manual and machine readings very low. P.A/ PMD notified.

FULL on 0.9% N/S ordered bolus to bring up b/p, guys it was low like 68/37.

I continue my assessment I hear pt lungs sound full of crackles at bases, I also see pt arm with one good peripheral vein starting to swell. I again inform P.A his catty response was we should try to find a new peripheral. I told him 3 times pt was hard stick. He then read it in chart and reduced his cattiness 10-fold. Informed me he would put in referral for central line to be placed in A.M., and I should keep fluids going, because pt was probably septic.

I repeated to him the only good line pt had was taking fluid as fast as it could and the lung sounds were so coorifice I could not hear an apical heartbeat. Repeated b/p's were just as low. Pt had little urinary output by end of shift. Spo2 sats ranged from like 80's to 90's (but since the machine is not 100% I cant really rely. )

Did I do the right thing by giving the fluids so much about 2.5 liters , I documented , what else could I have done? I have a uneasy pit in my stomach.

Amikicin and zosyn were running too. I don't know if pt was septic or not, but with the already fragile resp state. I didn't want pt to suffer with congested lungs.

I felt good about my actions until I spoke with another nurse who said I should have stopped the fluids, when I saw the swelling and heard the lung sounds. But like I stated earlier pt had congested lung sounds from day prior, only today it was exacerbated. Kept on 100% 02.

I feel terrible , what could I should I have done?

[MelBel]

I think if you notified the MD and documented, you did all you can. I probably would have asked the MD if they would want some Lasix given...but other than that, exactly what you did.

[nservice]

What a hard position to be in. My instinct is to hold fluids and give lasix. Patient probably needed pressors instead of more fluid. Could the increased intrathoraxic pressure be causing the low b/p or was the sepsis causing the low b/p. It's hard to tell which to treat...septic shock or hypoxic shock? I'm interested in everyone elses responses.

[AprilRNhere]

What a hard position to be in. My instinct is to hold fluids and give lasix. Patient probably needed pressors instead of more fluid. Could the increased intrathoraxic pressure be causing the low b/p or was the sepsis causing the low b/p. It's hard to tell which to treat...septic shock or hypoxic shock? I'm interested in everyone elses responses.

This is what I was thinking. I'd also wonder what his white count was.

[lilacscrubs]

I spoke with a neighbor who has 20+ years of experience she told me next time check BUN Creatinine Na+ K+ and to flush the foley and then to come back back to the PMD with the info and to refuse to give fluids until they do something else, like pressors or lasix.

[lilacscrubs]

What a hard position to be in. My instinct is to hold fluids and give lasix. Patient probably needed pressors instead of more fluid. Could the increased intrathoraxic pressure be causing the low b/p or was the sepsis causing the low b/p. It's hard to tell which to treat...septic shock or hypoxic shock? I'm interested in everyone elses responses.

I wish I knew. I had a dx of PNA, not sepsis. The P.A was like the pt is probably septic. But at least I know for the future what to do. Thanks you though.

[UM Review RN, ASN, RN]

The problem is that septic patients need a lot of fluid, but if the heart cannot take it, a balance between fluids and diurectics needs to be achieved.

Hopefully, this patient is in ICU.

[TigerGalLE, BSN, RN]

Mmmm... Prognosis looks poor considering pt is 95... When you suctioned the pt were the secretions thick and yellow or were they white and frothy? Pt probably needed lasix.. I would of rapid responsed that patient (even though PA was there). That pt needs to be in the unit and fast. I probably would of asked which doctor was covering his orders and called that doctor directly. You did all you could do though. As long as you document what you told the PA and what the PA ordered... Don't worry.

Tiger

[xviii-xxv]

uhm yeah i would have d\c'd the iv for a while esp if i see vein distension.. but yeah u did what u thought was right at that moment for that particular situation, given the prognosis of the pt.and its tricky cause PNA, lung congestion, probably developing heart failure, the sepsis..man.. proper documentation and asking the PA for orders..its all fine..

[lilacscrubs]

Mmmm... Prognosis looks poor considering pt is 95... When you suctioned the pt were the secretions thick and yellow or were they white and frothy? Pt probably needed lasix.. I would of rapid responsed that patient (even though PA was there). That pt needs to be in the unit and fast. I probably would of asked which doctor was covering his orders and called that doctor directly. You did all you could do though. As long as you document what you told the PA and what the PA ordered... Don't worry.

Tiger

They were thick and yellow. I really thank you guys for all your responses. From the responses here and the responses I got from seasoned nurses I know I have a better idea of what to do next time. It's not just about me CMA though I also want the best most comfortable outcome for my pts.

[Virgo_RN, BSN, RN]

The patient was in septic shock. S/he needed to be in ICU receiving an inotrope and vasopressor.