Help a new grad understand?!

LovingLife123 · Jan 20, 2017

Sounds like she was dehydrated and she was third spacing her fluid. Meaning the excess fluid was not in the cellular space anymore.

You can be what we call dry but still have some excess fluid. That fluid was moving into that "third" space. The lasix was being used to try and pull it off. That often happens with CHF. Especially with the U/O going down. It often takes several doses to get all that fluid off. Lasix has a short half life. I will often administer lasix and get huge U/O for about 4 hours, then it falls right back off.

datalore · Jan 20, 2017

Think of the fluid compartments your body has: 1. inside the cells, 2. between the cells, 3. inside the vascular system. You can be dry in one and overloaded in another at the same time. You can be dehydrated (low intravascular volume) while still third-spacing (the the extracellular space). Someone with low serum albumin can't hold the fluid in the vessels, and it leaks everywhere, so you end up with a dry, hypovolemic, extremely edematous patients. A ton of lasix will pull fluid out of the intravascular space (and hopefully take the third spacing with it, though it doesn't always get enough of it). So, dehydrated with edema. Also, don't forget lasix is harsh on kidneys, not surprised their creatinine went up if they were taking more than they were supposed to.

tara07733 · Jan 20, 2017

Think of the fluid compartments your body has: 1. inside the cells, 2. between the cells, 3. inside the vascular system. You can be dry in one and overloaded in another at the same time. You can be dehydrated (low intravascular volume) while still third-spacing (the the extracellular space). Someone with low serum albumin can't hold the fluid in the vessels, and it leaks everywhere, so you end up with a dry, hypovolemic, extremely edematous patients. A ton of lasix will pull fluid out of the intravascular space (and hopefully take the third spacing with it, though it doesn't always get enough of it). So, dehydrated with edema. Also, don't forget lasix is harsh on kidneys, not surprised their creatinine went up if they were taking more than they were supposed to.

So when do you get really good at putting all the 'pieces' together. I'm in my 3rd semester of an ASN program and I feel like I should already know the rationale behind what you wrote -- and I get some of it-- but I wish I had your knowledge, like, 1st semester.

Is it just a practice and exposure thing?

datalore · Jan 20, 2017

So when do you get really good at putting all the 'pieces' together. I'm in my 3rd semester of an ASN program and I feel like I should already know the rationale behind what you wrote -- and I get some of it-- but I wish I had your knowledge, like, 1st semester.
Is it just a practice and exposure thing?

Yes! Definitely practice and exposure -- the repeated exposure reinforces the concepts. And, if you have good physicians around you they'll teach you more nuances as they prescribe certain things for certain patients. I'm finishing up my first year as an RN after graduating from an ASN program, and it was after graduation that it all *really* clicked. And even then it took a few months of working! You will get there.

riRN16 · Jan 20, 2017

So, because she was taking more than her regular dose, the patient became dehydrated. The fluid that she did have started to move from the cellular to the extracellular space. And so the lower dose was given to prevent further dehydration at once but administered more frequently to try and pull out that fluid? If the patient came in taking a dose that was less than prescribed would treatment be similar? I'm thinking her creatinine would also be up in that situation because she's getting fluid buildup and they would also have to put her on a diuretic, right?

datalore · Jan 21, 2017

So, because she was taking more than her regular dose, the patient became dehydrated. The fluid that she did have started to move from the cellular to the extracellular space. And so the lower dose was given to prevent further dehydration at once but administered more frequently to try and pull out that fluid? If the patient came in taking a dose that was less than prescribed would treatment be similar? I'm thinking her creatinine would also be up in that situation because she's getting fluid buildup and they would also have to put her on a diuretic, right?

Because he was taking more diuretic than recommended, the patient (a) was probably (vascularly) very dry, which can (b) cause mild kidney dysfunction and/or acute kidney injury. Both things increase creatinine. Creatinine is cleared by the kidneys, and is a product of muscle metabolism. If your kidneys disappeared *POOF* right now, your creatinine would go up by about 1.2 per day, just because you have muscles and that's how much creatinine you make a day. If the kidney is not working properly because of dehydration, acute kidney injury, etc, it is not clearing creatinine appropriately, hence creatinine increases.

So, CHF is treated by diuretics, then what happens if the patient isn't taking enough diuretic? More fluid stays in the intravascular space. This increases the stretch of the heart. Frank-Starling law is a fancy way of saying the heart pumps more blood as it stretches out, until it stretches too much then it stops working effeciently. THAT is CHF. There is too much fluid in the vascular space, the heart stretches too much, and blood starts backing up into the lungs and body. When it backs up into the body, you get edema. When it backs up into the lungs, you get SOB and pulmonary edema, crackles, a nagging cough, low O2 sats, etc. So if this patient had not been taking their diuretics at all... what would happen to them? How would they present and what symptoms/signs would they have that would be different than what really happened? Creatinine would likely not be effected, because they're not dehydrated and there's not enough diuretic to injure the kidney. But another lab, one that is an indicator of CHF, may elevate -- which one would that be?

There's a delicate interplay between CHF and kidney function. The kidney is the way the body rids itself of fluids. The heart needs a certain amount of fluid -- but not too much -- in order to perfuse and oxygenate the body tissues. If a person is dehydrated, has kidney disease, etc etc, you see overlapping effects of CHF on top of kidney injury/failure.

You're doing great thinking through it and piecing this together, what else are you thinking about this patient now? Keep going! :)

riRN16 · Jan 21, 2017

Because he was taking more diuretic than recommended, the patient (a) was probably (vascularly) very dry, which can (b) cause mild kidney dysfunction and/or acute kidney injury. Both things increase creatinine. Creatinine is cleared by the kidneys, and is a product of muscle metabolism. If your kidneys disappeared *POOF* right now, your creatinine would go up by about 1.2 per day, just because you have muscles and that's how much creatinine you make a day. If the kidney is not working properly because of dehydration, acute kidney injury, etc, it is not clearing creatinine appropriately, hence creatinine increases.
So, CHF is treated by diuretics, then what happens if the patient isn't taking enough diuretic? More fluid stays in the intravascular space. This increases the stretch of the heart. Frank-Starling law is a fancy way of saying the heart pumps more blood as it stretches out, until it stretches too much then it stops working effeciently. THAT is CHF. There is too much fluid in the vascular space, the heart stretches too much, and blood starts backing up into the lungs and body. When it backs up into the body, you get edema. When it backs up into the lungs, you get SOB and pulmonary edema, crackles, a nagging cough, low O2 sats, etc. So if this patient had not been taking their diuretics at all... what would happen to them? How would they present and what symptoms/signs would they have that would be different than what really happened? Creatinine would likely not be effected, because they're not dehydrated and there's not enough diuretic to injure the kidney. But another lab, one that is an indicator of CHF, may elevate -- which one would that be?
There's a delicate interplay between CHF and kidney function. The kidney is the way the body rids itself of fluids. The heart needs a certain amount of fluid -- but not too much -- in order to perfuse and oxygenate the body tissues. If a person is dehydrated, has kidney disease, etc etc, you see overlapping effects of CHF on top of kidney injury/failure.
You're doing great thinking through it and piecing this together, what else are you thinking about this patient now? Keep going! :)

Thank you so much for taking the time out to explain this to me!! I feel I understand it much better now. And you've only been an RN for a year?! I sure hope I'm able to piece things together and to explain as well as you in a years time.

JadedCPN, BSN, RN · Jan 21, 2017

I just started working on my own last month and occasionally I have an issue fully grasping my patient and the rationale behind their plan of care. For example, yesterday I had a patient admitted with a creatinine almost double her baseline, though her BUN was WNL. She has hx of CHF and she said that for about a week she was accidentally taking 160 mg of Lasix daily instead of the 80 mg of Demadex she was prescribed. So was the creatinine high due to dehydration? But the patient had 1+ edema and reported having decreased urine output, but isn't that odd if she was taking so much Lasix? The doctor then put her on 20 mg of IV Lasix BID, which I again I don't quite understand- but after receiving 2 doses her creatinine did go down by 0.2. If such a high dose of Lasix put her in this position, why are we pushing more? Her BNP and cardiac echo were normal, but are we just being cautious because she has hx of CHF and don't want fluid overload? I really don't get it haha any help making sense of it?

Being a new grad, it is perfectly okay and understandable that you may not always understand the plan of care - however, it is your responsibility to ask questions so that you do understand the plan of care. You shouldn't give a medication that was ordered that you don't understand why it is given - it could have been accidentally ordered on the wrong patient, for instance. Just because a doctor placed an order doesn't mean you shouldn't also understand why that medication is being given prior to administering it, that is safe practice.

Even after over a decade of nursing, I never hesitate to ask a doctor why they ordered a certain medication if I don't understand, or ask about the plan of care. I need to know this information in order to safely take care of my patient, and if I can't figure it out on my own then I have the responsibility to ask someone who can help.

Glycerine82, LPN · Jan 22, 2017

I'm also a new grad, and I just wanted to say what you're experiencing is completely normal! Ask questions, use your nurse colleagues as tools, they have a wealth of knowledge.

One thing I find really refreshing is that my fellow nurses expect me to not know things, they all are fantastic and help me with rationales all the time.

The learning is just beginning, nursing school was just the tip of the iceberg.

I know often times with CHF patients the treatment is dangerous but not treating it is also dangerous, which is sometimes the problem.

I had a woman who had critically low sodium from all the lasix she was on, but when we stopped the lasix she would fill up. She ended up going on hospice. '

Sounds to me like she was way dehydrated from taking too much and her kidneys started to function poorly. The decreased OP isn't odd to me, since she was overdosing on the lasix and eventually there isn't going to be anything left that is being retained, if that makes sense.

I'd think the 20 mgs lasix is to keep her CHF under control.

TheCommuter, BSN, RN · Jan 22, 2017

Moved to the First Year After Nursing Licensure forum for more replies.