K+ and Minimal Urinary Output

head injury unit RN · Mar 21, 2005

did you document in your note that you questioned the doctors order??? either way though it was an order it should be the doc in trouble.

nursenatalie, ADN, RN · Mar 21, 2005

I have never given someone with low output a bolus out of the primary fluids like that, never had it ordered either. This pt had 40 of lasix and no urine output? I would say that would be a huge red flag. The night shift nurse knew about the lasix and still didnt report the low uop? 20 of kcl is added to all our post op patients primary fluid I dont think continuing that between bolus is a problem but this pt needed an NS bolus.

dmdrn · Mar 21, 2005

did you document in your note that you questioned the doctors order??? either way though it was an order it should be the doc in trouble.

Thanks for the reply. When I wrote the order I did write repeated and verified twice with MD. One of my friends felt I should have refused and not carried the order out. She said in a court of law I would be liable??????? The patient's Bun was 51, cr 1.1 and K that day was 3.3. Thanks!!

dmdrn · Mar 21, 2005

I have never given someone with low output a bolus out of the primary fluids like that, never had it ordered either. This pt had 40 of lasix and no urine output? I would say that would be a huge red flag. The night shift nurse knew about the lasix and still didnt report the low uop? 20 of kcl is added to all our post op patients primary fluid I dont think continuing that between bolus is a problem but this pt needed an NS bolus.

The pt did get a NS bolus of 250cc after the Primary bag bolus along with the lasix. I also never gave a bolus like that of D5W1/2NS+20K. I did not think it was too big of a deal since it was the 20K in a Liter of fluid. The pharmacist also did not question the order to come to think of it - they sent me a new bag of fluids after I sent the order. I think what it comes down to is I can't believe the night shift did not think this was a BIG deal. I am just hoping this does not come back on me. Thanks.

Sheri257 · Mar 21, 2005

did you document in your note that you questioned the doctors order??? either way though it was an order it should be the doc in trouble.

Not true, according to my nursing textbooks. Both the RN and the Doc are responsible.

Thanks for the reply. When I wrote the order I did write repeated and verified twice with MD. One of my friends felt I should have refused and not carried the order out. She said in a court of law I would be liable??????? The patient's Bun was 51, cr 1.1 and K that day was 3.3. Thanks!!

That's what they teach us in school. If something goes wrong both you and the doc would be liable. That's why you have the option to refuse the doc's order if you think it's unsafe.

:uhoh21:

dmdrn · Mar 21, 2005

Not true, according to my nursing textbooks. Both the RN and the Doc are responsible.
That's what they teach us in school. If something goes wrong both you and the doc would be liable. That's why you have the option to refuse the doc's order if you think it's unsafe.
:uhoh21:

You are right...its both. I was just wondering if anyone would disagree the way I handled the situation and if they would of approached it in a different way?????

Home Health Columnist / Guide · Mar 21, 2005

don't beat yourself up---sounds like you handled the situation well. it was the followup that was lacking.

in nursing school back when i remember that you never administer k+ if a patient has no urinary output

general rule: never administer k+ (potassium) to a patient with no urinary output due to chronic renal failure (crf) as most patients have high k+ due to retained wastes in body. dialysis treaments regulate amount of potassium in the body via solution used and time spent receiving treatment.

your patient was developing arf: acute renal failure post operatively, different treatment and approach.

only additional thing i would have done is ask doctor for when to repeat bun/creat/lytes.

see:

[color=#aa0000]medical:

[color=#aa0000]postoperative care of surgical patients

http://www.studentbmj.com/back_issues/0499/data/0499ed3.htm

"i gave her a litre of saline and then some frusemide to 'kick' the kidneys along"

http://www.jficm.anzca.edu.au/pdfdocs/journal/journal2004/j2004%20(a)%20march/occ%20essay.pdf

prevention of postoperative acute renal failure

http://www.jpgmonline.com/article.asp?issn=0022-3859;year=2002;volume=48;issue=1;spage=64;epage=70;aulast=reddy

nursing:

how acute renal failure puts the brakes on kidney function

http://www.findarticles.com/p/articles/mi_qa3689/is_200301/ai_n9190956

begalli · Mar 23, 2005

This patient's creatinine was 1.1 which is normal.

The BUN was 51 which is elevated.

Normal BUN to creatnine ratio levels are usually 10-20:1 The patient definitely had something going on with the kidneys where wastes were not being cleared effectively. BUT, given the fact that the patient had surgery (I wonder what was done?), this elevated ratio was probably due to dehydration.

A couple of causes of an increased BUN include dehydration, tissue damage (surgery), and meds (eg: lasix, vanco).

A high BUN:cr can be a sign of acute kidney failure most likey caused by shock or dehydration. In this case usually both numbers are elevated.

It was a bit odd that the doc ordered a bolus of maintanence fluid instead of just NS. The hypotonic 1/2 NS wasn't what that patient needed, but also probably didn't do any harm either as a maintanence fluid.

The K which was 3.3, needed to be addressed. If you think about it, that 200 ml bolus over one hour only delivered .02 meq's of KCL to your patient. That's nothing. The remaining fluid infusing at 100 ml/hr only delivered .01 meq's/hr for however many hours it ran (this is not a big deal either). Remember, the creatinine was normal so I don't think this would have contributed substantially to a K of 6.2 (I wonder if that specimen was hemolyzed?).

Often times following large surgeries, patients may experience acute renal problems. In this case, I betcha the patient just needed volume especially since the cr was edging toward the high normal side. Urine output of 25 ml/hr for 4 1/2 hours isn't that bad....

Which makes me think...was the patient's pressure low as well? Sometimes, especially with heart surgery, docs like to keep the pressure on the low side. Many people, especially the elderly are used to perfusing their kidneys at a higher pressure. If your patient was lower than they normally run, that could contribute to the low urine output as well. On the other hand, a high or increased blood pressure can cause an elevated BUN.

There are many things to assess when looking at a low urine output.

Why are you so worried about being liable? Liable for what? It's not like you gave the patient potassium replacements. You called the doc, you documented. You're fine.

In the ICU with our post-op patients, we usually don't pay much attention to the BUN if the creatinine is normal and usually treat it as a fluid problem. If that doesn't work along with lasix and checking other potential causes of a low urine output, then we start becoming suspicious of ARF.

The only thing I would have done differently, with what little I know about this patient, is recommend to the doc that we give at least a 500 ml bolus of NS or a volume expander. I also would have asked if that 6.2 K was verified by sending another specimen.