Help! Post-OP TURP Fluid Excess Question

Daytonite, BSN, RN · Jun 8, 2008

when a patient on cbi for post-op turp starts developing signs of fluid volume excess, should you restrict fluids?

i looked very carefully at what you posted and assumed you posted exactly the way the question was presented on your test. the words, fluid volume excess, capitalized, stood out. that is a nursing diagnosis.

you never slow down cbi because of a patient's systemic fluid volume excess which is what restricting fluids would be treating. and, that is your critical thinking error. cbi is a local procedure being done to the urinary bladder to keep it continuously irrigated. it prevents urinary tract obstruction by flushing out blood and any small blood clots that may have formed after the turp surgery. the flow of fluid into the bladder may also have a tamponade effect and prevent further hemorrhage. it is a local treatment ordered by the physician whose complications include bladder distension due to an obstruction of the lumen of the catheter or infection due to contamination of the closed irrigating system.

cbi has nothing to do with the nursing diagnosis of fluid volume excess whose defining characteristics (symptoms) are: jugular vein distention; decreased hemoglobin and hematocrit; weight gain over short period; changes in respiratory pattern, dyspnea or shortness of breath; orthopnea; abnormal breath sounds (rales or crackles); pulmonary congestion; pleural effusion; intake exceeds output; s3 heart sound; change in mental status; restlessness; anxiety; blood pressure changes; pulmonary artery pressure changes; increased central venous pressure; oliguria; azotemia; specific gravity changes; altered electrolytes; edema, may progress to anasarca; positive hepatojugular reflex.

i would have recognized immediately that "fluid volume excess" written in capital letters like that was a nursing diagnosis and not a medical condition. every nursing diagnosis has specific defining characteristics (symptoms) to it just like each medical diagnosis has specific symptoms. you would need to have seen something (care plan book, nursing diagnosis reference, nanda taxonomy reference) with nanda diagnosis reference information in it to have been aware of this. here is a webpage on the diagnosis of excess fluid volume (the current label of this diagnosis) that includes the nanda information about it.

[color=#3366ff]excess fluid volume

in order to answer this question you would have need to know and apply the following information:

the purpose, goals and complications of cbi
what a nursing diagnosis is and what the elements are that make up a nursing diagnosis
- the defining characteristics (signs and symptoms) of fluid volume excess, the nursing diagnosis

[*]when you would restrict fluids in a patient

once you figured out #1 and that there was no connection between it and #2 and #3 you didn't even need to reach further in your mind to come up with any signs and symptoms of fluid excess, hyponatremia or think about why fluids would need to be restricted. also, the test was about post-op turp care, not fluids and electrolytes.

moonchic73 · Jun 8, 2008

Thank you for your input! I forgot to mention a couple of things:

In the scenario, the intake was MUCH greater than the output over 24 hours (even after taking into account CBI). There was no other data to go by (ie., signs of fluid excess, vital signs, lab results, etc) in order to come to the conclusion of FVE, just the I/O.

My professor also said my NANDA was correct, but that I still shouldn't decrease/hold PO or IV fluids.

Ultimately I think it was a very poorly written scenario. We had nothing to work with. But anyhow, just wanted to throw those things in there to see if they'd make any difference.

Thanks again :)

Daytonite, BSN, RN · Jun 9, 2008

OK, so you are trying to reason out why you don't restrict fluids when there is a fluid excess, is that what you are asking?

I don't think you were given enough information. I think this was a question of instituting interventions for complications of a treatment. Per the nursing process, you never perform any interventions (step #3 of the nursing process) until you have performed an assessment of the situation (step #1 of the nursing process) and determined the problem (step #2 of the nursing process). Part of the problem identification involves distinguishing the pathophysiology and etiology of why the problem has occurred before you can move on to planning the interventions. You weren't given enough information to do that here.

I kind of get your passion about this. The symptoms of TURP syndrome and fluid excess are pretty much the same (altered mental status, bradycardia, elevated blood pressure, confusion). However, is the treatment the same? Restricting/decreasing amount of fluids is only one intervention. There are others. Interventions are often based upon the pathophysiology and etiology of the symptoms manifested.

monitor status of the heart, lung, kidney, GI and skin
monitor electrolyte values
prepare to treat electrolyte imbalances
administer diuretics
monitor weight

You have to assess and determine how and which type of overhydration has occurred. It can be hypotonic, isotonic or hypertonic. There is a historical factor that seems to be lacking in the scenario information other than "intake was MUCH greater than the output over 24 hours". What intake: oral or IV? What else can account for input being greater than output? Was there miscalculation of the I&O? I have to tell you that I was a med/surg staff nurse for many years and had many post op TURP patients with CBI, or what we called thru and thru irrigation. Their I&O's were always messed up because people forgot to write down the amounts of irrigant they hung or amounts they emptied from the catheters. We often ran as much as 10,000 mLs, or five 2-liter bottles, over an 8-hour shift into these catheters to keep the urine that was draining at what the surgeons wanted as "light salmon color". So, my first question would be, how do I know the I&O figures are correct if that is what the fluid excess is being based upon?

alto2ree · Jul 23, 2009

Did you consider that the diagnosis of FVE was determined by the I&O.....if so is it off due to a problem with the 3 way foley....does it need to be flushed (is the output low because the urine cannot get out). In this case an assessment should be done to check for bladder distention and the color of the Fluid in the foley bag should be considered. Maybe the foley is blocked with a clot.

allnurses Guide · Jul 25, 2009

Perhaps if you could post the exact question we could be more helpful?