Question

Grace Santos is a 45-year-old female patient admitted to hospital 3 days ago with a diagnosis of pneumonia. IV access was initiated 74 hours ago. The RN used a 20 g cathlon and was successful on her 2nd attempt at initiation. The IV is insitu in the right forearm.
Grace has been on IV antibiotics now for 72 hours and has shown great improvement.
Grace has been receiving cefuroxime 750 mg IV q8h x 5 days.
Grace is allergic to penicillin and has experienced an anaphylactic reaction in the past.
Grace has no significant medical hx and takes no prescribed medications.
This morning her WBC count was within normal limits and her respiratory status had improved.
However, over the last 4 hours you have noticed her respiratory status has declined, she is sitting up in orthopneic position, and you have auscultated coarse crackles to the bases of both lungs. Her O2 sats are now 90% on RA. Her BP is 145/80, HR 100 and RR 26. Her temp is 37o C.
Her IV has been infusing at 150 mL/hr now for the past 3 days. Grace had her last dose of IV antibiotics at 0600.
The secondary line is still hanging with the last empty bag of antibiotics still hanging.
The IV pump was cleared at 0600 before her dose of antibiotics.
The primary and secondary tubing are labeled.
The tubing was originally primed 74 hours ago.
The bag of NS is labeled. It is 0700 and your 12-hour shift has just begun.
Her urine output has decreased and the following physician orders have been received:
Furosemide 40 mg IV stat
Ventolin 2.5 mg by nebulizer q2h PRN
Saline lock IV between antibiotic doses
Strict intake and output
Daily weight
CBC
electrolytes
O2 to keep sats above 92%

What do you think is happening?
What other assessments will you need to make?
How will you collaborate with the RN?

Documentation required:
 24 hour fluid balance record – complete for your shift
 focus charting:
o initial assessment completed at 0730
o any follow up assessments related to medication administration
 MAR
Other Data:
Intake:
 0800 – 1 cup coffee, 4 oz milk
 1000 – 12 oz water
 1200 – 1 cup tea, 120 mL jello.
 1400 - 12 oz water
 1700 – 1 cup milk
Output:
 0630 – urine – 50 mL
 0900 – urine – 600 mL
 1000 – urine – 500 mL
 1200 – urine – 550 mL
 1330 – urine – 450 mL
 1600 – urine – 350 mL
 1800 – urine – 300 mL

Answer 1

#. The patient is having fluid overload.

#. Assessment include :-

Risk factors for CHF

Increase in weight

Ask for orthopnea , paroxysmal nocturnal dyspnea

Examine pitting edema

Observe for jugular venous distension

Chest X-ray, ECHO

Look for ascites

Hemodynamic evaluation

#. Inform the RN about the patient's condition . Communication of the vital assessments made will help in collaborating with the RN for further management of the patient. Advice her to have strict Intake and Output record .