1/2NS +20meq KCL and urine output

[sediaz]

Backstory. . .pt admitted for pneumonia. Hx fr 5 years ago included a mass in her colonwith mets to liver. Her eyes were very jaundiced. A physician mentioned to me that cxr showed worsening pneumonia. Next time I am assigned this pt I'm told at report that the am colonoscy had been cancelled the night before because pt unable to complete prep due to N/V. Later in the am the surgeon called and asked me why procedure was cancelled. I told him what I'm been told. He wrote orders for pt to consume 4L of golytey plus tap water enemas plus obtain consent for colonoscopy for next am. He mentioned dropping an NG tube if pt unwilling to drink prep. Geez!

Daughter of pt calls and states that, as POA, she doesn't want anything done that will not improve prognosis of her parent. Surgeon talked with daughter and she signed consent.

Colonoscopy was done. Bowel was almost completely blocked by mass in third quadrant. The surgeon wanted to schedule a repeat colonoscopy plus stent placement for the following day and ordered mag citrate +enemas X 2+obtain consent.

I was told in postprocedure report that Respiratory had been called immediately after procedure and that that pt had been put on rebreather mask.

Pt was returned to unit and RR ranged between 24-30 each time I counted. HR stayed in the 80s. O2 was at 96% on 4L humd. She had no c/o pain but it was obvious to all of us that she was going downhill.

The surgeon came it to see pt later in the day and planned to proceed with 2nd colonoscopy if pts respiratory status improved. He ordered an EKG and chem 7 to be done.

I called primary physician group and requested that pt be seen. I felt that doing more would only make her last days worse.

Meanwhile, I took the mag citrate in to pt and encouraged pt to drink it. Pt wasn't interested in complying nor intrested in resuming liquid diet. I know that it's important to hydrate after a colon prep but it just wasn't happening. There was an order for pt to be NPO p midnight for the planned procedure.

An oncologist came to see patient and cancelled the procedure, talked with daughter and DNR forms were signed and placed on chart.

I felt much thankfulness toward this doctor. My pt wouldn't be subjected to another colon prep +enemas.

Then the lab called with a panic value on Potassium; 7.4. I called the primary care group and reported this value plus mentioned that pt's IVfluid was 1/2 NS +2o of K. He had me change the fluid to NS.

By the time he came to the unit it was change of shift. I didn't see the orders he wrote but know that they included redoing the lab work and Kayexcelate and Insulin.He also wrote for morphine.

I go home.

I keep thinking about what I didn't do.

Urine output. Other than one incontience change done prior to pt's colonoscopy, I don't know if there was anymore urnine output during my shift. On the graphic sheet the CNA had charted "inc".

Her 1/2 NS + KCL rate was 70 mls/hr.

I remembered last year as a brand new nurse being told that you don't hang IV fluid containing potassium unless you know that pt has voided.

My hope is that when the labs were redone it would be found that the K was WNL.

When someone is DNR, our focus becomes palliative.

I feel that I missed a beat re the urine output. I'm thinking that a straight cath might have been ordered. I don't think the pt would have wanted it but it might have eased pt.

Thanks in advance for reading this. It was my first experience being an advocate for a patient. Istarted outplanning to ask about IVfluid with K and started rambling about my pt.

I don't know if patient recovered or if pt died. One nurse told me that sometimes a procedure, such as the colonoscopy, "activates" the cancer cells and it spreads agressively. Considering there were mets to the liver already plus the worsening pneumonia, I think it's over.