Is 1 L of NS bolus/ hour excessive (total of 3L) for a patient that came in wuth dehydration and acute renal failure

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Good day,

I am a new nurse and there is something that is bothering me. I work at a hospital and I received report from the ED nurse transferring the patient's care to me in medsurg floor (pt is med surg). I had to call the ED nurse back to clarify how many boluses the pt needs because the MAR shows 3 doses of NS 1L/hr. He said pt needs 3 of them and then I asked which bag of the 3 is currently running. He told me it was the first one.

When patient arrived to our unit, pt's IV tubing is not connected to him. When I checked, IV is barely in the skin and you can see a big part of the catheter out. I tried flushing it because maybe it works, but pt flinched in pain. Pt is not very cooperative with IV insertion but I did it. I then started the 1 bag of NS bolus ordered that was scanned in ED but was never started. Then the other 2 after the first. He received a total of 3 L/3 hours. To my horror, as I was reading the doctor's notes it states there--will give 1 bolus now. Does this mean pt only needed to get 1 bolus instead of the 3 that was listed in the MAR? This is the reason why I clarified with the ED nurse, besides I have never given a bolus on my floor before as it is usually taken care of in our ED. If I was familiar with this ED doc only ordering 1 fluid bolus, I would have questioned the what was in the MAR. But I don't work with him and never really given fluid bolus before so I am not sure what is considered appropriate amount of fluids to what is excessive.

Is 3L/3hrs of NS too much for a pt with acute renal failure and dehydration with creat of 5.5, gfr of 13, CK of 1042. I don't remember the rest of the labs. Another concern is that he is receiving continuous infusion of NS @ 125mL/hr as per doctor's order.

I should add, pt is AO, no edema, no SOB, up and walking. I was just concerned that I may have messed up his electrolytes or something worse that I may not know about right now.

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Specializes in ACNP-BC, Adult Critical Care, Cardiology.

You will probably get a lot of responses with some "armchair theorizing" of what should and should not have happened with your patient.

To me, your best course of action in this situation is your assessment of the patient at the time this is happening and your ability to loop the provider or physician responsible for this patient's medical care. Patients coming from the ED are initially managed by an ED physician but in most hospitals (assuming yours is the same), another hospital-based provider assumes care of an admitted patient (hospitalist, resident physician, attending physician, NP, PA-C, etc). The ED physician is no longer in charge of that patient.

So, I would call whoever is now in charge of the patient and clarify that the ED hadn't even started the first liter bolus and that the note from the ED physician states that only 1 L bolus is to be given. I would ask if further boluses are required. I bet that provider would appreciate that information and would tell you if further boluses are needed and what the rationale for that is rather than asking people on-line who have no clear idea what is really going on with the patient.

BTW, shame on that ED nurse for sending a patient with a busted PIV.

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Thank you so much. That's what I am going to do.

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It may be too much too fast for a cardiac patient. Or it may not be enough for a relatively healthy at baseline patient. No way of knowing. Ask the MD.

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Pt is 48 YO, and he does not really have any past med hx, except psych DO and HTN. As we monitor him, his BP is below 100, that's why even if he was uncooperative, we convinced him for IV insertion to get him started on fluids. He was dehydrated also because he has been walking around and has not been keeping track of his nutrition. We think he is homeless, but pt denies, gets offended when asked.

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Don’t ask if he’s homeless. Ask where he stays. I’ve had some who don’t like the stigma or don’t believe couch surfing/shelters/motels equates to homeless. And tell him you are asking just to make sure he’s safe if he’s still refusing to answer. ?

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Specializes in orthopedic/trauma, Informatics, diabetes.

When I was doing clinical, we had a pt in the ED that his living status was unknown. He was so dehydrated that it took 3L and 3 hours before he started to make any urine. We put a Foley in to get strict I&Os. I think they slowed his fluids down once he started making urine.

Bottom line, for that pt, it was appropriate, but like others said, need cardiac hx, etc.

As a new nurse, I would have seen if you could find a friendly face to explain rationale.

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1. At places I've worked, if the ED had ED orders that they did not complete and the patient was admitted in the meantime, you (floor/unit) would check with the admitting physician to see if these are still desired and if so they are placed as admission orders by the admitting physician/provider. I am not saying this is how it is done everywhere. I think it's pretty common though; your doctor is in charge now and has made a plan and entered orders based on his/her own assessment - you get your orders from your doctor for any treatments you are to provide to the patient, not from the ED nurse (although it is great that you clarified with the previous nurse exactly what had taken place).

It sounds like your admission order is for NS @ 125ml/hr - so ask your doc if s/he is aware that the patient didn't get any boluses in the ED and whether any additional fluids are desired above and beyond the NS @ 125/hr.

2.

4 hours ago, motongever said:

To my horror, as I was reading the doctor's notes it states there--will give 1 bolus now.

A bolus just means the amount is going in fast; it doesn't define/describe the volume that the bolus will be. The "1" bolus s/he was referring to may well have been 3L.

3. Is there a relationship between your patient's renal function and your patient's dehydration?

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Hi there

His kidneys are plugging up with myoglobins. Aggressive fluid resuscitation will hopefully restore his renal function. 1 lit bolus followed by 3 liters with one liter/hr is a reasonable and conservative initial approach then 125 ml/hr for maintenance is also reasonable. I highly doubtful that the MD wants only 1 liter bolus. You mentioned he is homeless. There are many possibilities for rhabdo- illicit drug use, etoh, viral infection (HIV), muscle injury (fall, street fights). The goal is get him to pee again. I would have placed at least guage 20 (preferably 18)in a large vein in the ED to get the ivf into him asap. To answer your question dehydration is one of the leading prerenal cause of Aki compounded with elevation in his ck. Etoh can potentially do that in the homeless population.

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7 hours ago, beekee said:

Don’t ask if he’s homeless. Ask where he stays. I’ve had some who don’t like the stigma or don’t believe couch surfing/shelters/motels equates to homeless. And tell him you are asking just to make sure he’s safe if he’s still refusing to answer. ?

Yes, that was the report that I got from the ED nurse that he is defensive when asked if he was homeless. I ask in a different way, but when pt got to me pt just keeps saying I am so tired, I can’t answer no more. ?

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6 hours ago, JKL33 said:

1. At places I've worked, if the ED had ED orders that they did not complete and the patient was admitted in the meantime, you (floor/unit) would check with the admitting physician to see if these are still desired and if so they are placed as admission orders by the admitting physician/provider. I am not saying this is how it is done everywhere. I think it's pretty common though; your doctor is in charge now and has made a plan and entered orders based on his/her own assessment - you get your orders from your doctor for any treatments you are to provide to the patient, not from the ED nurse (although it is great that you clarified with the previous nurse exactly what had taken place).

It sounds like your admission order is for NS @ 125ml/hr - so ask your doc if s/he is aware that the patient didn't get any boluses in the ED and whether any additional fluids are desired above and beyond the NS @ 125/hr.

2.

A bolus just means the amount is going in fast; it doesn't define/describe the volume that the bolus will be. The "1" bolus s/he was referring to may well have been 3L.

3. Is there a relationship between your patient's renal function and your patient's dehydration?

Thank you so much I will remember to inquire with the hospitalist from now on if this happens again instead of calling back the ED nurse.

Thank you for clarifying that 1 bolus could mean 3L. I did not know that.

Yes, they were looking at degydration causing the AKI.

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9 hours ago, motongever said:

Thank you so much. That's what I am going to do.

Wait...you posted up here asking for advice in real time on a patient that acute? *walks away shaking my head*

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