Got fired for changing fluid rate

[lolakbolak]

I was on orientation on days and then got moved to nights which is what I was hired to do. It was my first night on orientation with a preceptor and I was not feeling the best, was very tired got an admission at 2 am and was up for almost 24 hours already. This admission was somewhat unstable, her blood pressure was 70/40's and she was lethargic. She got a fluid bolus in the ED and then she had fluids going at 100 ml/hr. When she got to my floor her fluids were running by gravity. I asked the transferring nurse what the rate is he said we are just running it free right now. I wasn't sure what her meant. Told my preceptor I'm concerned about the low bp. She said she wasn't. I was rechecking her bp every half hour because I was terrified I would find her unresponsive even though it was every 4 hours. Anyway I rechecked the bp and it was still very low and patient was lethargic. I increased her IV rate to 200 ml/hr and called the physician immediately. He told me to give her a bolus of fluid and the rate would be 100 ml/hr after that.

I know I was in the wrong for changing the rate without an order first. I understand that now. Am I a lost cause? Should I just forget about this and move on?

[SionainnRN]

I just find it odd that in May of '12 the OP stated they were a new nurse that has worked one year in LTAC and one month later they posted they were an ICU nurse of 2 years in June of '12. I dunno...?

Yes it's very odd. Cause on this thread she says she's a new nurse. It would be nice if the OP could clarify.

[psu_213, BSN, RN]

I'm an ED nurse and bolus is always wide open. If its on a pump it's at 999 mL/hr if its on gravity it's unclamped.

At my hospital, if a physician writes a liter of fluid to be a 'bolus', policy is that it is infused of 1 hour (regardless of unit/floor/etc.). If the physician believes the pt cannot handle a liter in an hour, they should order a specific rate rather than a bolus. Either way, this does not mean the nurse should not monitor the pt for signs of overload.

[Good Morning, Gil]

Your preceptor wasn't concerned? And, only checking every 30 mins? Should have been checking pressures more frequently than that with pressures like that. You did check the cuff for appropriate fit, etc? I'm mostly concerned that your preceptor wasn't concerned. I'm assuming this is ICU, right? I hope? Definitely need to call the physician with a pressure that low for further orders, line placed, pressors, etc (or transfer to ICU if you're not ICU, call rapid response etc). I'm so sorry this happened to you; you seem like a concerned nurse, but too afraid to go above your preceptor and take action. If you know something is wrong, you have to proceed even if that means it makes you unpopular. I'm also sorry that you had a very uninvolved preceptor (or at least it sounds that way). But, you still have your own nursing judgment, and you have to use that (even when new in a facility).

[SionainnRN]

At my hospital, if a physician writes a liter of fluid to be a 'bolus', policy is that it is infused of 1 hour (regardless of unit/floor/etc.). If the physician believes the pt cannot handle a liter in an hour, they should order a specific rate rather than a bolus. Either way, this does not mean the nurse should not monitor the pt for signs of overload.

Little confused as to what you're getting at. The pt in this scenario had a bolus ordered in the ED then 100 mL/hr on the floor, so the doc was specific. And since this pt was hypotensive she was not at risk of fluid overload...where is that coming from?

[netglow, ASN, RN]

...And since this pt was hypotensive she was not at risk of fluid overload...

OK, since we are all being confused... ?!

[Tait, MSN, RN]

At my hospital, if a physician writes a liter of fluid to be a 'bolus', policy is that it is infused of 1 hour (regardless of unit/floor/etc.). If the physician believes the pt cannot handle a liter in an hour, they should order a specific rate rather than a bolus. Either way, this does not mean the nurse should not monitor the pt for signs of overload.

A patient should always be monitored for possible negative outcomes. It's our job.

[AOx1]

Back to the OP did you try other things first like trendelenberg?

This is no longer recommended as most RCTs haven't shown benefit, and some show harm.

[SummitRN, BSN, RN]

This is no longer recommended as most RCTs haven't shown benefit, and some show harm.

Thank you! This sacred cow was a good idea once, but we've known for well over a decade that Trendelenburg works in the first few minutes for the first few minutes following rapid hemmorage. After that intrinsic shunting/vasoconstriction render the central increase from trendellenburg near zero (unless medication or other pathology have inhibited these intrinsic compensatory measures).

Reserve trendelenburg for when you need central venous distention for a central line start.

[psu_213, BSN, RN]

A patient should always be monitored for possible negative outcomes. It's our job.

Which indeed was the exact point I was making in the last sentence of my post....

[psu_213, BSN, RN]

Little confused as to what you're getting at. The pt in this scenario had a bolus ordered in the ED then 100 mL/hr on the floor, so the doc was specific. And since this pt was hypotensive she was not at risk of fluid overload...where is that coming from?

My response was to both your post and to a post which read:

"

So, when they said "wide open" that means run the bolus full speed on gravity? I've asked nurses at work about bolus speed and have gotten a range of answers, mostly 250 to 500 mL/hr but never wide open on gravity."

I was not trying to imply the physician did not order a rate of the fluids. My only point was, there is a protocol (where I work anyway) for a bolus rate.

[psu_213, BSN, RN]

And since this pt was hypotensive she was not at risk of fluid overload...where is that coming from?

Unfortunately, that is not always true. I have seen CHF pt with low BP that will still be rehydrated gently and not have a liter just bolused into them. I've even seen boluses as low as 250 mL for CHF patients...especially those with poor renal function.

[NRSKarenRN, BSN, RN]

Thanks for all the advice offered to our member.

Acknowledging mistake, understanding how it happened and coming up with action plan to prevent re-occurrence will go a long way for next job interview.

Consider RN refresher course if in a tight job market area to show you've taken extra effort to update skills.