Transcript
Mr. Gomes is admitted to the hospital for exacerbation of his heart failure. He is experiencing shortness of breath, has crackles 2/3 up bilateral lung fields, and his SpO2 is 91% on 2L of O2 via nasal cannula. He has 3+ pitting edema from his feet to upper calf, with the skin appearing tight, shiny, and with small intact blisters over his anterior shins. He states his weight normally ranges from 160-165; his admission weight is 180 lbs.
1. What fluid imbalance is Mr. Gomes experiencing? _____Fluid volume overload__________________
2. Based on his weight gain, how much fluid is he retaining? ___20# = 9 kg = 9 L, 15# = ~7kg = 7L
During the admission interview, Mr. Gomes says he recently travelled to see family for Thanksgiving. He says, “I can’t pass up mashed potatoes and gravy! And the turkey was brined, whatever that means.” He also admitted to stopping his diuretic, claiming he “would have spent half the visit in the bathroom.”
The nurse starts his IV, and administers furosemide 40 mg IV push.
3. What does the nurse need to know in order to administer this medication by this route safely? Where can the nurse find this information?
Dilution: can administer undiluted, or diluted with 0.9%NS or D5W ___________________________ rate of administration: __20 mg/min _____________________________________________________ Compatibility with running IV Fluids: check on Trissels IV compatibility at UNC, or stop a running IV, saline flush, med, saline flush. _______________________________________________________
4. What patient need does the nurse need to anticipate related to the furosemide? ___He will need to use the urinal frequently, may need two urinals, will need them emptied frequently (on hourly rounds). _____________________________________________________________________________________
5. What routine assessments are required to manage this patient correctly? ____Strict I&O, daily weights______________________________________________________________________________
6. Two days later, Mr. Gomes’ weight is 175. How much fluid (in liters) has he lost? _about 2 liters
7. Mr. Gomes K+ on admission was 3.6. On day 3 of his hospitalization, it is 3.0 despite taking po Klor-con supplements. What additional assessments would be indicated by his hypokalemia? Prioritize them. _____
a. Respiratory: resp effort, lung sounds, SpO2
b. Cardiac rhythm: he should definitely be on telemetry
c. skeletal muscle weakness, compounded by a decrease in activity from his baseline
8. Mr. Gomes develops diarrhea and has 4 large loose stools in 8 hrs. The nurse notes that the stools are dark and tarry. List all the imbalances this will contribute to: ___________________________________
Fluid volume deficit, hyponatremia and hypokalemia from the diarrhea, anemia from the loss of blood.
9. Mr. Gomes vital signs are T 97.6po, HR 96, RR 18, BP 110/62, SpO2 94% on 2 L nc. He is taking po fluids freely. The nurse contacts the provider with an SBAR summary of his change in condition. What would be the recommendations/requests? Include labs, type of IV fluid if needed, and medications. ___ Hold or DC the furosemide
DC oral K+, change to K+ replacement IV to avoid irritating his upper GI system, repeat serum K+ level q 12 hrs
CBC q 12 hrs if the diarrhea has stopped, q 6 hrs if it continues
Serum electrolyte levels q day or q 12hrs.
Maintenance IV fluid: isotonic to replace loss of water and electrolytes in diarrhea, support blood pressure
10. Mr. Gomes is made NPO for an upper GI endoscopy. He is started on IV fluid. Does he need a different IV fluid than you had identified above? ___Change to a hypotonic solution that will replace insensible fluid losses. Dextrose needed since he is NPO. D5.45%NS with 40mEq K+/L would be a good choice.
11. Mr. Gomes has a new order for K+ 10mEq/100ml NS IV x 3. How will the nurse administer this medication?
Each 10 mEq bag infuses over 1 hr, monitor peripheral IV for complications due to irritation of the vein. He should be on telemetry since he is a cardiac patient anyway, and although this is not required for a patient to receive this concentration of K+, it is a benefit since his cardiac risk is higher than a patient without heart failure.
