IV bolus to CHF patient. Need your opinions please

[lsvalliant]

Im a home health nurse and got orders today by a primary doctor to infuse 1 Liter of LR with 20meq K over 3-4 hours every day for 7 days. This pt has CHF with +4 pitting edema and SOB with mod exertion. I refused to give it and consulted her cardiologist who agreed with me. The primary MD states the cardiologist doesnt know whats going on and pt needs the fluids based on the labs. Whats your opinions? I'm still refusing to carry out the order. What do you think?

[beeble]

State your concerns and ask primary MD to call/consult with cardiologist.

[umcRN, BSN, RN]

State your concerns and ask primary MD to call/consult with cardiologist.

agree. if she's in congestive heart failure then the lungs are overloaded and the rest of the body might look dry (in the labs). It's a fine line with these patients balancing their fluids and I would not feel comfortable bolusing that patient with fluid if they already cannot handle the fluid they have on board

[ckh23, BSN, RN]

What did her labs say that makes the MD think she needs fluid? How did her lungs sound?

[MN-Nurse, ASN, RN]

The primary MD states the cardiologist doesnt know whats going on and pt needs the fluids based on the labs. Whats your opinions?

"The labs"??

My opinion is that if you are going to spend the time asking for opinions, at least provide the data necessary to do so.

[TiffyRN, BSN, PhD]

I worked with adult heart patients a long time ago. They really can be intravascularly "dry" and at the same time very edematous, and as well as poorly tolerant of fluid boluses. I would not think the home is the appropriate place to manage this patient. Sometimes patients like this do better with something like albumin that will help draw fluid from the extravascular space. But very cautiously. These patients go into overload so easily.

[Esme12, ASN, BSN, RN]

Ima home health nurse and got orders today by a primary doctor to infuse 1 Liter of LR with 20 meq K over 3-4 hours every day for 7 days. This pt has CHF with +4 pitting edema and SOB with mod exertion. I refused to give it and consulted her cardiologist who agreed with me. The primary MD states the cardiologist doesn't know whats going on and pt needs the fluids based on the labs. Whats your opinions? I'm still refusing to carry out the order. What do you think?

I would question the order as well. why does the MD want more fluid in a fluid over loaded patient? What are the labs? Is the U/O low? Is the K+ low? One liter over 3-4 hours for a week" Not a good idea.

Without the labs I can't give you an exact reason for giving the fluids but what you have given me I would hold the fluids and call/listen to the Cardiologist.

[NO50FRANNY]

Diluting the patient without enough K+ to make a difference and potentially overloading them? Oral potassium would be a much safer option, I agree with previous posters, with-hold the fluids and listen to the cardiologist.

[amoLucia]

A question --- what are you doing about the original order that has not been carried out? How can you resolve that there still exists an order that is not being implemented? You've left it just hanging somewhere up in the air because of different opinions.

Just to be clear ---I wouldn't be comfortable giving the IV fluids as ordered either. I believe that you have discussed this issue with your agency administration. Do HHAs have a consultant MD available? What happens if this lady suffers further decline r/t to the abnormal labs that have not been treated by the HHA (you DO have an order which her Primary believes will work).

Where does this crazy order go next???

[nurseprnRN, BSN, RN]

what lab results are we talking about here? i tend to agree with you base on your report of physical exam findings, and i doubt very much if any lab results can trump that, but it would be useful to have some idea of what "labs" the physician is basing his plan of care on. for example, she may have an elevated bun, but this can still be seen in people with congestive failure because the kidneys aren't seeing decent blood pressure so they aren't making much urine, and giving more electrolyte-rich volume is not a good idea.

more data, please.

[Medic09, BSN, RN, EMT-P]

I would just like to point out that calling an edematous CHFer 'fluid overloaded' simply may not be correct. The problem isn't 'too much fluid' in the body. The problem is 'fluid in the wrong place'. That's why there is some movement away from giving Lasix, for instance. There are other ways to pull fluid out of the lungs, without diuresing it completely out of the body.

Of course, ultimately the two docs should talk to each other. For the sake of the discussion here, the people who want more data are right. Labs and meds. Along with clinical findings, we need some idea about real fluid status. Is the pt. really overloaded, or maybe actually running dry with what fluid there is in the wrong place (the lungs and interstitial spaces). This may require more nuanced Tx than simple 'fluid-yes or no'. Also, is the pt. on ventilatory support such as BiPAP? For many pts. in the ER and ICU, positive pressure support (at least at night) helps move fluid out of the lungs and improves oxygenation without mucking around with chemistry. CPAP and BiPAP have become more common and affordable outside the hospital.

[turnforthenurse, MSN, NP]

I worked with adult heart patients a long time ago. They really can be intravascularly "dry" and at the same time very edematous, and as well as poorly tolerant of fluid boluses. I would not think the home is the appropriate place to manage this patient. Sometimes patients like this do better with something like albumin that will help draw fluid from the extravascular space. But very cautiously. These patients go into overload so easily.

This is very true. I still would have questioned that order, though. Then I would have had the patient's cardiologist consult with the primary MD.