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.
Specializes in Critical Care; Cardiac; Professional Development.
My interpretation of that order would be to start the 1L immediately (in the ER) knowing the patient was to be transferred to the floor - and that the total of 3L was still to be given. That, however, is experience speaking. You were right to question it, but as you have indicated above, you now know to question the physician that wrote the order to get clarification. This is the kind of thing that will come easier and more comfortably as you get more of these kinds of patients.
The 3L over 3 hours isn't that crazy, even if the patient was a CHFer, depending on the severity of the situation. Severe dehydration can cause the kidneys to be injured - a difficult thing to rectify once it happens. Sometimes we have to weigh out two options, neither of which are ideal - possible CHF exacerbation vs possible renal injury. You get a similar conundrum when looking at sepsis in someone with cardiac problems. In the case of sepsis, given how swiftly it can kill a person, its theorized that we can intubate/resuscitate if the lungs get wet - that doing that is more likely to have a positive outcome than level 3/4 sepsis. Best practices now dictate that the fluid boluses be given. This may or may not have any bearing on a case of severe dehydration, but it doesn't sound like your patient had a cardiac history from what you are saying here in any case. 3L over 3 hours isn't that crazy.
Wait...you posted up here asking for advice in real time on a patient that acute? *walks away shaking my head*
sorry if I misinterpreted what I mean but I was at home and was coming back to work again and I did relay this concern to the nurse following me. I asked when I came back and pt is fine and the 3L was exactly what the doctor had wanted him to receive. I mentioned pt is AO, no edema, up and walking. So I don't know where you got the idea that pt is "that acute."
This is my first post here and I was surprised how everybody responded in a positive way to my question, but there's always gotta be that one person who won't be. Guess who that is. I don't like drama so go ahead keep walking away. Thanks for responding anyway.
As an ER nurse, and having been caught by reports of orders written, I always recommend reviewing orders written on new patients, unless you have a code going on, and your MD is right there. Next, always assess your patient during bolus administration. You will hear crackles if they are starting to get fluid overloaded. Never assume the orders are written in stone. You are responsible for your fluids administration.
As others have stated I would have just called the MD, explained what I saw (pt not connected to IV upon arrival, not sure how much NS given r/t poor documentation, new order is 125cc/hr, want to clarify what you want now etc) and carefully documented all that.
Nurse SMS, MSN, RN
6,843 Posts
My interpretation of that order would be to start the 1L immediately (in the ER) knowing the patient was to be transferred to the floor - and that the total of 3L was still to be given. That, however, is experience speaking. You were right to question it, but as you have indicated above, you now know to question the physician that wrote the order to get clarification. This is the kind of thing that will come easier and more comfortably as you get more of these kinds of patients.
The 3L over 3 hours isn't that crazy, even if the patient was a CHFer, depending on the severity of the situation. Severe dehydration can cause the kidneys to be injured - a difficult thing to rectify once it happens. Sometimes we have to weigh out two options, neither of which are ideal - possible CHF exacerbation vs possible renal injury. You get a similar conundrum when looking at sepsis in someone with cardiac problems. In the case of sepsis, given how swiftly it can kill a person, its theorized that we can intubate/resuscitate if the lungs get wet - that doing that is more likely to have a positive outcome than level 3/4 sepsis. Best practices now dictate that the fluid boluses be given. This may or may not have any bearing on a case of severe dehydration, but it doesn't sound like your patient had a cardiac history from what you are saying here in any case. 3L over 3 hours isn't that crazy.