Introducing
Your new presentation assistant.
Refine, enhance, and tailor your content, source relevant images, and edit visuals quicker than ever before.
Trending searches
833
Case Study
Marina, Bianca, Kelsey, Kristin, Melissa, Jessica
Meet the Patient
W.A. is a 70-year-old African American female who presented to the emergency department with fever, severe nausea, vomiting, and diarrhea. She is being admitted to the intensive care unit (ICU) with a diagnosis of kidney failure and septicemia. Her previous medical history includes glaucoma, chronic kidney failure, hypertension, and insulin-dependent diabetes mellitus. She had a left above-the-knee amputation 1 year ago.
Meet the Patient
Subjective Data
- W.A.'s daughter states she was able to do her daily chores at home independently, but for the last few days it was getting difficult for her to get around and that she needed to take frequent breaks because of shortness of breath and no energy. Her daughter also reports that W.A. had been complaining of headaches with nausea and dizziness for the past few days.
- Goes to hemodialysis 3 days a week
Objective Data
- Blood pressure 178/96, pulse 110, temperature 101.5° F , respirations 28
- Oxygen saturation 86% on 15 LPM via mask
- Oriented to name only
- Crackles in bilateral lower lobes
- 2+ edema bilateral lower extremities and hands
- Abdomen is distended with hypoactive bowel sounds x4 quadrants
Diagnostic Studies
- CBC: Hemoglobin 7 g/dL, hematocrit 23.8%, RBC 2.57 million/mm3, WBC 14.8 mm3
- Chemistry Panel: Serum sodium 132 mEq/L, serum potassium 6.0 mEq/L, calcium 9.3 mg/dL, phosphorus 6.0 mg/dL, glucose 197 mg/dL, albumin 2.4 U/L, serum blood urea nitrogen 77 mg/dL, serum creatinine 7.30 mg/dL, eGFR African American 10, BNP 182 pg/mL
- Urinalysis: Dark yellow and cloudy, protein 28 mg/dL, positive for casts, positive for red blood cells and white blood cells, positive for glucose and ketones
What is Multiple Organ dysfunction Syndrome?
Failure of two or more organ systems in an acutely ill patie...
Multiple Organ Dysfunction Syndrome (MODS)
Failure of two or more organ systems in an acutely ill patient such that homeostasis cannot be maintained without intervention
TIME
W.A.’s Organ Involvement
W.A.’s Organ Involvement
Lungs
- Crackles bilaterally, increased RR of 28, O2 Sat of 86% on 15 lpm
Brain
- Oriented to name only
Kidneys
- RBC 2.57, Hgb 7, Hct 23.8, BUN 77, Cr 7.3, eGFR 10, 2+ edema on bilateral lower extremities and hands
Liver
- RBC 2.57, Hgb 7, Hct 23.8, albumin 2.4, distended abdomen, 2+ edema on bilateral lower extremities and hands
GI tract
- Hypoactive bowel sounds x4 quadrants and abdominal distension
Septicemia
What do you think the orgin is of W.A.'s septicemia?
Answer
- hemodialysis three days a week
- UTI as well, she was positive for casts.
- WBC is elevated
- crackles in the lower lobes
Laboratory Results
Laboratory Results
CBC:
- Hemoglobin: 7 g/dL
- Hematocrit: 23.8%
- RBC: 2.57 million/mm3
- WBC: 14.8 mm3
Chemistry Panel
- Sodium: 132 mEq/L
- Potassium: 6.0 mEq/L
- Calcium: 9.3 mg/dL
- Phosphorus: 6.0 mg/dL
- Glucose: 197 mg/dL
- Albumin: 2.4 U/L
- Blood Urea Nitrogen: 77 mg/dL
- Creatinine: 7.30 mg/dL
- eGFR African American: 10
- BNP: 182 pg/mL
Urinalysis
- Dark yellow and cloudy, protein 28 mg/dL, positive for casts, positive for red blood cells and white blood cells, positive for glucose and ketones.
What other tests will be ordered?
- Blood cultures
- Urine analysis
- Specific gravity
- Urine Na+
- Platelet levels
- DIC screening
- Lactate levels
- Liver enzymes
Collaborative Goals
Restore tissue perfusion
- Recovery of organ function (kidneys, GI tract, respiratory)
- Recovery of baseline B/P
- CVP to 8 to 12 mm Hg
- MAP greater than or equal to 65 mm Hg
- Urine output greater than or equal 0.5 mL/kg/hr.
- Control blood glucose (140-180 mg/dL)
- *intensi...
- Control blood glucose (140-180 mg/dL)
- *intensive glucose control (81-108 mg/dL actually increases mortality)
- Prevent stress ulcers
- Normalize ABGs
- Normalize lactate levels
- Manage bacterial infection/septicemia (antibiotics)
- Keep O2 sats above 90%
Minimize O2 demand
Restore fluid volu...
- Minimize O2 demand
- Restore fluid volume
- Decrease temperature
- Meet nutritional demands
- Prevent skin breakdown
- Maintain integrity of oral cavity
- Manage pain and keep at an acceptable level for t...
- Manage pain and keep at an acceptable level for the patient
- Provide emotional support
- Provide spiritual support/resources
- Alleviate anxiety
- Prevent health care-acquired complications of disease management and care
Collaborative Care
Collaborative Care
- Rest
- Vasodilators to decrease blood pressure
- High flow oxygen 100% via nonrebreather mask
- Mechanical ventilation
- Assess tissue perfusion
- Initiate fluid therapy to replace fluids lost by vomiting and diarrhea
- Strict I &O and daily weights
- Diuretics
Collaborative Care Continued
Collaborative Care Continued
- Insulin to decrease glucose levels
- Antibiotic therapy
- Assess pain
- Apply EKG and continuously monitor for dysrhythmias
- Antipyretic medications
- Stress ulcer prophylaxis
- Monitor abdominal distention
Collaborative Care Continued
Collaborative Care Continued
- Dietary consultation
- Provide nutritional support
- Dialysis
- Monitor for signs and symptoms of potential DIC
- Possibly central venous or PA catheter for hemodynamic monitoring
Why would a CRRT be ordered?
Answer:
Answer:
- Removes large amount of fluids
- Removes Toxins
- Patients are dialyzed over a period of 24 hours
- History of Chronic Kidney injury
- Crackles in lower lobes bilaterally
- Urine output over last 4 hours only 20 ...
- Urine output over last 4 hours only 20 mL
- Potassium level 7meq
- Increased Blood Pressure
- Increased Respirations
- 2+ pitting edema LE and hands
- Shortness of Breath
Nursing Interventions for W.A
Nursing Interventions for W.A
- Promoting Oxygenation
- Maintaining Fluid Volume
- Promoting Tissue Perfusion
- Provide supplemental oxygen
- Sedation, mechanical ventilation, and analgesia
- Promote rest
- Continuous telemetry
- Obtain IV access
- Administer IV fluids
Nursing Interventions Cont.
- Administration of packed RBCs
- Vasopressor administration
- Diuretic administration
- Strict I&Os
- Hemodialysis
References
References
[Digital image]. (2011). Retrieved March 4, 2018, from http://medical-helpful-info.blogspot.com/2012/05/multiple-organ-dysfunction-syndrome.html
[Digital image]. (2017, January 11). Retrieved March 4, 2018, from http://aboutislam.net/counseling/ask-the-scholar/health-science/stopping-mechanical-ventilation-circulatory-support-cessation-heartbeat-permissible/
[Digital image]. (n.d.). Retrieved March 4, 2018, from http://medicalsupply.en.hisupplier.com/product-840903-BD-IV-Catheter.html
[Digital image]. (n.d.). Retrieved March 3, 2018, from http://www.ayushanandtrading.com/iv-fluids-4042031.html
[Digital image]. (n.d.). Retrieved March 3, 2018, from https://www.google.com/search?biw=1187&bih=630&tbm=isch&sa=1&ei= yzWbWqHkKcP6jwOGh4XoBA&q=blood pressure&oq=blood &gs_l=psy-ab.1.1.0l10.39462.42713.0.44127.8.7.1.0.0.0.158.678. 6j1.7.0....0...1c.1.64.psy-ab..0.8.684...0i67k1.0.-FkWn9LmQBM#imgrc=kyuZCuTwrr9BbM:
[Digital image]. (n.d.). Retrieved March 3, 2018, from https://www.indiamart.com/proddetail/ecg-monitor-14188490412.html
[Digital image]. (n.d.). Retrieved March 6, 2018 from
https://www.news-medical.net/health/Sepsis-(Septicemia)-Causes.aspx
[Digital image]. (n.d.). Retrieved March 6, 2018 from
https://www.diabetescarecommunity.ca/living-well-with-diabetes-articles/diabetes-management-articles/stem-cell-treatment-diabetic-kidney-disease-future-now/
A Nurse's Guide To Administering IV Insulin. (2017, February 14). Retrieved March 03, 2018, from https://www.pedagogyeducation.com/Infusion-Campus/Student-Union/Campus-Blog/February-2017/A-Nurse-s-Guide-To-Administering-IV-Insulin.aspx
CPT, W. D. (n.d.). High Blood Sugar Symptoms. Retrieved March 05, 2018, from https://www.diabetesselfmanagement.com/managing- diabetes/blood-glucose-management/high-blood-glucose/
Why Perfusion? (n.d.). Retrieved March 05, 2018, from http://hemedex.com/clinical/why-perfusion/
Pond Liner Blog. (n.d.). Retrieved March 05, 2018, from http://pondliner.blogspot.com/2012/07/is-my-pond-temperature- too-warm.html
1 in 25 Patients End Up with Hospital-Acquired Infections. (n.d.). Retrieved March 05, 2018, from https://articles.mercola.com/sites/articles/archive/2014/04/09/hospit al-acquired-infections.aspx
A Key Advancement in Hemodialysis. (2017, March 06). Retrieved March 03, 2018, from http://www.scientificanimations.com/key-advancement-hemodialysis/
Lewis, S. M., Dirksen, S. R., Heitkemper, M. M., Bucher, L., & Harding, M. (2014). Medical-surgical nursing: assessment and management of clinical problems (9th ed.). St. Louis, MO: Elsevier/Mosby.