IV bolus ordered because pt hypertensive

JustKeepSmiling, ADN, BSN, RN · Mar 20, 2015

IcuRNMaggie & SubSippie had nearly identical thoughts as I did.

Hypertension does not always equal hypervolemia.

It sounds to me perhaps the patient was septic. I'd correlate to lactic acid, WBC, v/s trend, ABGs.

Typically you see HR increase and BP drop in sepsis but in later stages anything can happen. The tachycardia is definitely cause for concern.

Also, afebrile does not mean no infection. A low temp is just as dangerous in sepsis as a high temp, it could be on the way down. Trends are critical.

The elevated BP in presence of sepsis could very well be related to volume depletion and the autonomic system's attempt to clam down vessels to increase blood return to heart thus in an effort to perfuse vital organs... but this cannot sustain for long and will result in decline. This is also making me think about how baroreceptors & the kidneys respond to low perfusion states...

Urine output is good. At least 30cc/hr?

What was the patient in for anyway?

edmia, BSN, RN · Mar 20, 2015

I'm thinking sepsis protocol. I'm sure a lactic acid was part of the work up.

Sent from my iPhone -- blame all errors on spellcheck

AgentBeast, BSN, RN · Mar 20, 2015

Sepsis. The first thing that happens is the heart rate goes up. Then after a while blood pressure starts to tank. Management of sepsis starts with fluid bolus and broad spectrum ABX.

Julius Seizure · Mar 20, 2015

Since he mumbled something about bacteremia, he might have suspected the patient was going septic, and one of the ways sepsis is managed is with fluids.
This is just a guess, though, and from the brain of a CVICU nurse, not a MICU nurse. So I haven't dealt much with treating sepsis.

Same thought that I had. CVICU nurse here too, and unless its a cardiac patient, in any other kind of shock, dont you give fluids pretty immediately?

Here.I.Stand, BSN, RN · Mar 20, 2015

The positive blood culture and the elevated HR lead me to think sepsis also; we give fluids because they're third spacing and will dry out. Like a PP said, hypertension doesn't = hypervolemia. Typically we see a drop in BP with sepsis, but this person's peripheral circulation could have been clamping down to shunt as much to the brain and kidneys as possible. If we had a CVP, we'd know for sure what the pt's fluid status is; but if the overall picture is a septic picture, the MD was probably anticipating that the CVP is low because of the 3rd spacing, and giving fluids to maintain a euvolemic fluid status.

Mully · Mar 20, 2015

If you can't explain something well, then you don't understand it well. Too complicated to explain = to complicated to comprehend... by anyone lol.

I agree with the previous posters here. If the patient was septic, then early, aggressive fluid resuscitation is your best treatment. How old was this patient? My guess is the sepsis was early enough that the patient still had a robust sympathetic response to it. Also if the patient had a strong heart, the increase in heart rate in response to the hypovolemia will increase his CO a lot. Couple an increased CO and a sympathetic response and you get hypertension. Still need fluid.

This is why the prudent, wise nurse must assess the whole picture to gain a good understanding of a patient's fluid volume status. This includes, but is not limited to, B/P, HR, Pulse pressure, urine output (Last 24 hours, last 3 hours, last 1 hour), daily weight, CVP, swan numbers, respiratory variation in waveforms, skin turgor, sunken eyes/facial appearance, etc. etc.

You don't need all of them, but you should assess as many as possible to get the fullest picture.

wanderlust99 · Mar 21, 2015

I am thinking early sepsis as well. What did his BP typically run at? Also, you need to know the patient's fluid balance. 24 hr and hospital stay, did the patient have an overall negative fluid balance?

sauce · Mar 21, 2015

a 500cc bolus isnt going to cause harm in most patients. he was probably just thinking about the other bunch of patients he has to take care of. I am sure if you ask him again he would give you an answer. No need to jump on a doctor for one quick remark.

whofan, ADN, BSN, RN · Mar 21, 2015

if the patient is septic, I know that we have a protocol where we will give fluids to help with the sepsis. I am not sure why he wouldn't explain this because it is not a hard concept, but that BP is really high..

michlynn, BSN, RN · Mar 21, 2015

I agree with basically everyone else, administering fluids goes along with the sepsis protocol. Pt seems like he was showing early signs and symptoms of becoming septic.

MatrixRn · Mar 21, 2015

Have to agree 500cc bolus is not a lot of fluid. The doc may be looking at the hypertension clamping down in the vessels centrally as well as peripherally, both would be a concern, but centrally even more so. If the body was holding fluid, a quick bolus will encourage urine output.

Are Enn · Mar 21, 2015

thanks for the comments. some things I have read and will answer:

I am unsure of admitting diagnosis. based on looks, age would be 70s-80s.

I am on a general medical floor, so things like lactic acd and ABGs are rarely ever drawn, unless they are initially drawn in the ER before admission. even if a lactic acid was drawn, I doubt the coworker had that value on the tip of his brain and was able to relay it to the physician.

besides what was present in the foley bag, which looked appropriate, I know nothing about the output. the physician did not ask anything about 24 hour I&Os.

baseline BP seemed to be 130s/80s.

I know infectious disease was on consult. would any of you had called infectious disease because of those vitals and newly returned positive prelim blood cultures before calling the admitting physician?

and can somebody explain the difference between edema and third spacing?