Is my resident at risk for fluid overload/ CHF/ etc.

allnurses Guide · Mar 6, 2009

Surely the doc won't sign off on it then?

Valerie Salva, BSN, RN · Mar 6, 2009

I've seen orders to dilute tube feeding formulas with water a number of times over the years.

momtojosh · Mar 6, 2009

we have one of our 12 g-tube feeder that have diluted formula.....90cc of water with his 240cc can....we wait til the bag is empty before refilling.....he is on cont feeding at 70/hr

we have another guy .....he is on jevity(no water added) starting at 10am til 9:30 pm.........he gets 110cc of water 4x a day......240 flush with every med pour.....an extra 300 mixed with mirlax in the am and pm....and more which i can not think of right now without seeing the mar..i just know it is alot......he gets a purge and a residual check x4....if more than 100cc of res,hold feeding til 30 or less....... and people complain cause he is incont with a huge amount of urine....i would be too.....

morte, LPN, LVN · Mar 6, 2009

i read this post earlier, and was so angry, i put off answering. This is totally unacceptable, and her excuse is worse.....yes you can dilute formula, If it is required/ordered by MD. and yes you are correct it changes the amount she is getting. you could not be sure, at any given time, what nutrition she has gotten or not, AND, those off times are usually built in to allow for care/oob. this nurse is totally off base with this ordering, and i repeat, her excuse is worse.....has this patient had a weight gain? that seems like a lot of calories for an elderly woman. this needs to be referred to MD immediately; and a nutrition consult, if that is possible, as well. were is this nurse's critical thinking!!!!? and thoughts about scope of practice??? argh......and yes, with the original flush not dcd it is more water than needed, she will either go into fluid overload, if she has the disease process that causes that, or she will urinate large amounts, thereby altering HER onboard electrolytes....... good luck

lpnflorida · Mar 6, 2009

70cc x 6 hours = 360cc 1 can jevity is equal to 240 cc.. that would not be enough nutrition to keep a bug going.

Most of our tube feeds are at least at 70cc around the clock with h20 flushes from 100cc every 4 hours to 150cc every 4 hours.

Your patient is now receiving 880cc formula over 24 hours with 800 cc h20 total volume as you can see is 1680cc.

No I don't have a problem with this. The patient is receiving roughly 3 1/2 can of jevity per day. Nutrition Facts

Serving Size 8 fl oz (240.0 g)

Amount Per Serving

Calories 355Calories from Fat 106

% Daily Value*

Total Fat 11.8g18%

Dietary Fiber 5.3g21%

Sugars 51.1g

Protein 15.1g

Vitamin A 24% * Vitamin C 120%

Calcium 29% * Iron 24%

As to fluid overload, you need to look at volumes in and output. As long as they are close to each other is should not be a problem. You will also be looking at their lab values sodium level become low possible fluid overload starting, you will be checking extremities for edema, listening to lung sounds.

lpnflorida · Mar 6, 2009

Morte, thanks for bringing it to my attention of my incorrect calulation based on time..

so h20 intake is now 1200cc daily with roughly equal of 3 1/2 cans of jevity. Again this is not necessarily out of line. Renal patients have fluid restrictions of 1000cc in a 24 hour period.

morte, LPN, LVN · Mar 6, 2009

Morte, thanks for bringing it to my attention of my incorrect calulation based on time..
so h20 intake is now 1200cc daily with roughly equal of 3 1/2 cans of jevity. Again this is not necessarily out of line. Renal patients have fluid restrictions of 1000cc in a 24 hour period.

plus the other 1200 cc, from the undcd flush.....she would be getting 2400 cc, enough for an eighty kilo person, which i doubt this elderly lady is,lol.....and 1875 cal from the jevity....again, ? does she need this much, has she had a weight gain, and has there been a nutrition consult?.....

lpnflorida · Mar 7, 2009

2400cc total fluid intake in 24 hours is acceptable for a 150 pound/ 68.2 kg female.

I found these tables. I had forgotten what the actual formulas were, our dietician always figures them out for us.

Normal Fluid Requirements For DRI's on fluid: http://www.nal.usda.gov/fnic

* 30-35 ml/kg

* Holliday-Segar Method:

Body Wt Fluid (ml)

first 20 kg 1500

each additional kg 20 (consider 15 ml/kg if over 50 y/o)

Note that intakes high in Na, fiber or protein (>1.5 g/kg/d) can increase fluid needs

lashuna1028 · Mar 7, 2009

lpnflorida, Your calculations are still not adding up to what was written:

200cc q 4 hours= 1200cc

400cc BID= 800cc

200cc flush c meds (which is she gets BID)= 400cc

so far the H20 alone in a 24 hour period is 2400cc plus

Jevity 70cc/hr cont ( so lets say X 22 hours for transfer, bath etc)= 1540

so both combined equals 3940cc.. So this I think is way too much input for a bed bound elderly lad. Thats roughly 4000cc per day input!

And I'd say this lady weighs about 110 lbs so according to your Normal Fluid Requirements: 30-35ml/kg

110lb/ 2.2= 50kgs/1500ml-1750ml (and remind you she would be getting 4000ml)

So yes, that was one point I was trying to make about the order and also another point was the fact that it was not specific to what amount of formula I would be adding the water to at the given time.

Though one might think it doesnt matter it really does cause what if I walked in and the bag was at 500cc and I added 400cc of H20? That means she would be LOSING about half of her nutrition for about 12 hours (500cc+400cc=900/70cc=12.8 hrs)... Versus if the bag was full of formula. So if the NP or MD really wanted it to be diluted the order should have been like add 400cc H20 to __cc formula.. RIght?

lpnflorida · Mar 7, 2009

The way I calculated was the fact that the 400cc were not bolus they were added to the jevity, the bolus water was the 200cc twice that was how I figured out the calculation..