Question

Mr. Rover is a 59-year-old man admitted from the ED to the medical unit at 0930 for antibiotic treatment and monitoring due to urosepsis. His PMHx is significant for Type 1 Diabetes with an A1C last month of 8.2. He has BPH and HTN. His wife of 35 years states that he has not been compliant with his diabetes in all the years she has known him. He has no surgical history. No known allergies. His admission orders are: 1. Vital Signs q4hr 2. IV NS 0.9% 100ml/hr 3. Flagyl 250 mg IV q12 hr 4. CBG monitoring TID before meals.

1. Due to the patients PMHx and current diagnosis, what do you want to check prior to insertion of an IV cannula into the patient’s skin.
2. Where on this patient is the best place to have an IV and why?
3. You started his IV NS at 120ml/hr and hung the first bag of Flagyl IV which is premixed and a total of 200 ml of fluid at 1130hrs. Mr. Rover’s vital signs were within normal limits and his CBG pre-lunch which you took at 1145 hrs was 6.8mmol/L. You left him sitting up in bed waiting for lunch while you left to check on another patient. At 1330 you return to see Mr. Rover. Another nurse had turned off the Flagyl while you were busy with your other patient and your lunch. Mr. Rover is asleep, but you notice that he is holding his hand over the IV site.
4. Looking at your fluid intake how much fluid has he had by 1330? How much should he have had by 1330 if the IV has started at 0930? Is there a discrepancy yes or no, if yes, state why?

Answer 1

ANSWERS:-

1) What do you want to check prior to insertion of an IV cannula in to the patient skin?

* Check the skin for any signs of infection, breaks or cuts, skin discoloration and edema.This patient has a past history of type 1diabetes and his glycosylated hemoglobin (HBA1C) is 8.2 which is very high.This can cause peripheral neuropathy and perpheral vascular diseases damaging peripheral blood vessels and nerves.

2) The best place to have an IV in this patient is,

* Veins on the dorsal and ventral surface of the upper extremity which is his non dominant arm. Choose veins like cephalic, basilic or metacarpal which is soft, and palpable.

* Choose site which will not interfere with patient's activities of daily living.Avoid areas that are painful and hard and sites distal to previous venipuncture.

3) How much fluid has he had by 1330?

* He has had tolal of 440ml of fluid from 1130 to 1330.

* NS at 120ml/hr started at 1130, so for 2hr (till 1330) 240 ml of NS is infused.

* Flagyl volume = 200ml

* So total fluid= 240 +200= 440ml

4) How much fluid should he have had by 1330 if the IV has started at 0930?

*Doctor's order is to start NS at 100ml/hr.

* If IV NS was started at 0930 at 100ml/hr, he should have had 400ml of NS by 1330(4hrs) and 200ml of flagyl.

* Total fluid = 400+ 200= 600ml over 4hours.

5) Is there a discrepancy yes or no? If yes state why?

* Yes there is a discrepancy in the fluids received by the patient.

* If the nurse had started IV as ordered by the doctor that is NS-100ml/hr from 0930, the patient have had received 400ml of NS and 200 ml of glagyl over 4hrs.Total of 600ml

* That is 600/4= 150 ml/hr.

* Now patient received total 440 ml over 2hrs.

* 440/2= 220 ml /hr.

* The infusion rate is very high and can cause fluid over load and other complications in patient like pulmonary edema etc