Loading presentation...

Present Remotely

Send the link below via email or IM

Copy

Present to your audience

Start remote presentation

  • Invited audience members will follow you as you navigate and present
  • People invited to a presentation do not need a Prezi account
  • This link expires 10 minutes after you close the presentation
  • A maximum of 30 users can follow your presentation
  • Learn more about this feature in our knowledge base article

Do you really want to delete this prezi?

Neither you, nor the coeditors you shared it with will be able to recover it again.

DeleteCancel

Make your likes visible on Facebook?

Connect your Facebook account to Prezi and let your likes appear on your timeline.
You can change this under Settings & Account at any time.

No, thanks

ACUTE KIDNEY FAILURE- Case Study

No description
by

Lindsey Berenbach

on 8 May 2014

Comments (0)

Please log in to add your comment.

Report abuse

Transcript of ACUTE KIDNEY FAILURE- Case Study

.... PARAMEDICS ARRIVE
and find the patient is:
- hypotensive
- BP: 90/60
- P: 120
- R: 24

WHO:
JUDY DOWNS
WHERE:
DRIVING HOME
WHEN:
LATE ONE NIGHT
WHAT:
ACCIDENT- LOST CONTROL OF HER CAR
WHY:
TO AVOID HITTING A DEER
HOW:
CAR STRUCK A TREE & ROLLED INTO A DITCH
3 HOURS LATER...
THE PATIENT
CASE STUDY
ACUTE RENAL INJURY

BY: Lindsey Berenbach, Brielle Adamson, & Christina Amadio
During the first few hours after Ms. Downs' admission, the nurse notes:

- Urinary output has dropped from 55ml to 45ml to 28ml of clear yellow urine an hour.
- The physician orders:
500ml intravenous bolus fluid challenge,
STAT urinalysis
Miniscreen (SMA 7)


The fluid challenge elicits only a slight increase in urine output.
Urinalysis results show a specific gravity of 1.010 and the presence of WBC's, red and white cell casts and tubular epithelial cells in the sediment.

The MD makes a diagnosis....


ACUTE RENAL FAILURE


He orders a nephrology consult.
QUESTION 1:

- What abnormalities are there in Ms. Downs' lab work

- What are the possible causes for these abnormalities?

- What do these abnormalities mean for this client’s overall state of health?


#1: ABNORMALITIES/CAUSES/MEANING:

Specific Gravity-
is normal but on the low side (normal 1.010-1.025) r/t intrarenal kidney failure (trauma, crash injuries)
WBC in urine –
r/t glomerulonephritis from the intrarenal kidney failure (inflammation of the glomerular capillaries/ type of kidney disease in which the part of your kidneys that helps filter waste and fluids from the blood is damaged.)
RBC cast –
bleeding in the kidney/glomerulonephritis
WBC cast –
acute kidney injury
Tubular epithelial cells –
reflect damage to cells in the kidney (tubule cells)
BUN is increased –
r/t kidney failure and glomerulonephritis; Normal BUN: 6-20mg/dL
Creatinine-
is increased (normal is 0.6-1.1mg/dL for women) – r/t kidney failure; kidneys are not functioning properly
Urine-
is decreasing steadily
Potassium-
is WNL but very close to being high
Glucose-
is high; kidneys are not filtering glucose from the blood/patient may be diabetic

Miniscreen reveals:

Na:
142mEq/L
K:
4.9mEq/L

Cl:
100mEq/L

BUN:
28mg/dL

Creatinine:
2.2mg/dL
Glucose:
158mg/dL


MINISCREEN RESULTS
Na:
142mEq/L
K:
4.9mEq/L
Cl:
100mEq/L
BUN:
28mg/dL
Creatinine:
2.2mg/dL
Glucose:
158mg/dL

She is alert and in severe pain, with a fractured right femur.

After immobilizing Ms. Downs' neck and back and extricating her from the car, they apply a traction splint to her leg and transport her to the local hospital.

Ms. Downs is admitted to the intensive care unit.
MINISCREEN RESULTS
Na:
142mEq/L
K:
4.9mEq/L
Cl:
100mEq/L

BUN:
28mg/dL

Creatinine:
2.2mg/dL
Glucose:
158mg/dL


QUESTION 2:
What was the most likely specific precipitating factor for Ms. Downs' acute renal failure?
Did anything else contribute to her risk?
ANSWER:
1) Her trauma from the accident
2) Related to the diabetes – high levels of sugar cause the kidneys to work too hard

Ms. Downs' right leg was placed in skeletal traction.

One unit of whole blood has been infused and she is receiving a second unit.

An indwelling urinary catheter and a nasogastric tube are in place.

The MD orders:
Aluminum Hydroxide:
10ml q2h via the NG tube
Pepcid:
20mg intravenous soluset every 8 hours
Morphine:
6mg IV q4h PRN for pain
Excess fluid volume r/t
compromised regulatory mechanism (renal failure)

Monitor I&O
Monitor daily weights (same time of day, same scale)
Monitor cardiac functioning (HR, BP, JVD)
Labs (BUN, Creatinine, HGB, HCT)
Monitor respiratory function (lung sounds)

- Risk for decreased cardiac
output r/t fluid overload

Monitor cardiac functioning (BP/HR, EKG changes, heart sounds)
Assess skin color and mucous membranes (abnormal: cyanosis or pallor)
Monitor I&O (decreased UO is an early sign of bleeding/hypovolemia)
Assess LOC

Acute pain r/t trauma

Administer pain medication as ordered (Q4h)
Monitor for signs/symptoms of ARDS (low O2 sat, rapid breathing)
Assess pain using 1-10 scale
Educate patient on pain management techniques (guided imagery, repeat demonstration)

3 NURSING DIAGNOSIS
QUESTION 4
Why did the physician prescribe aluminum hydroxide and Pepcid?
What is the classification and action of these medications?
Consider both the acute renal failure and Ms. Downs' placement in the intensive care unit.
- Aluminum Hydroxide – Antacid – relief of heartburn, sour stomach, peptic ulcer pain, and to treat peptic ulcers

- Pepcid – Histamine-2 Receptor Antagonist – blocks acid producing cells in the stomach

– Both are given to patients with an NG tube to prevent ulcers from forming in the stomach

** Aluminum Hydroxide may cause constipation and may accumulate to toxic levels (monitor) **

QUESTION 5: Ms. Downs' is at risk for respiratory distress related to potential fluid volume excess.

Why is she at risk for fluid volume excess?
How would the nurse assess Ms. Downs for fluid volume excess?
What clinical manifestations would the nurse expect to find if this client was experiencing fluid volume excess?
ANSWER:

Renal disorder impairs glomerular filtration that resulted to fluid overload.
With fluid volume excess, hydrostatic pressure is higher than the usual, pushing excess fluids into the interstitial spaces.

Since fluids are not reabsorbed at the venous end, fluid volume overloads the lymph system and stays in the interstitial spaces leading the patient to have edema, weight gain, pulmonary congestion and HTN at the same time due to decrease GFR, leading to decrease ability of the kidney to concentrate urine and impaired excretion of fluid thus leading to oliguria.

- Assessment and manifestations: Weight gain, edema, bounding pulses, SOB, crackles/rales, decreased urinary output, increase in BP, JVD, restlessness, anxiety, change in mental status (lethargy or confusion)
Why is she at risk for fluid volume excess?
How would the nurse assess Ms. Downs for fluid volume excess?
What clinical manifestations would the nurse expect to find if this client was experiencing fluid volume excess?
QUESTION 6

How does her fractured femur further
contribute to risk for respiratory distress?

ANSWER

When you break a bone, fat tissue from the bone marrow can leak into your blood. It may lead to a disorder known as Fat Embolism Syndrome (FES)

FES symptoms: Dyspnea, Tachypnea, Hypoxia and can lead to neurological issues

Lung function damage from FES can cause conditions such as hypoxia (the tissues in the body don’t get enough oxygen), and in severe cases, acute respiratory distress syndrome (ARDS), a sudden failure of the respiratory system.

If she is in severe pain, it may also alter respiratory status

After just 3 days of oliguria, Ms. Downs' urine output has begun to increase.

By the end of the 4th day she is excreting about 60 to 80 mL/hr of urine.

Although her BUN, creatinine and K levels remain high, they never reached a critical point, and dialysis is not required.

She is transferred from the ICU on the 5th day of admission.

When Ms. Downs' is able to begin eating, she is placed on a low potassium diet, restricted to 50g of protein.

Her renal function gradually improves and she is discharged with her BUN and creatinine nearly normal.

She verbalizes her understanding of the need to avoid nephrotoxic substances until approved by her MD.

QUESTION 7

Why was Ms. Downs' placed on these dietary restrictions?
ANSWER
Potassium is not excreted optimally in patients with AKI, blood levels of these electrolytes tend to be high. Restriction of these elements in the diet may be necessary, with guidance from frequent measurements.

Low protein diet
- When protein is ingested and used by the body, protein waste products are created. Healthy kidneys have millions of nephrons that can filter this waste. It is then removed from the body in the urine. Healthy kidneys can easily remove protein waste, even when very large amounts of protein are eaten.

Unhealthy kidneys lose the ability to remove protein waste. Protein waste starts to build up in the blood. As kidney function continues to decline, more waste accumulates. A lower protein diet may be prescribed to help reduce waste accumulation. Reducing protein intake may help slow the progression of kidney disease.

QUESTION 8
DISCHARGE PLAN
Take your meds as directed (explain times to take, how to take, side effects)
Avoid any nephrotoxic substances (ASA, NSAIDs)
Get plenty of rest. It is normal to feel very tired with acute kidney failure. Your symptoms may get even worse if you become overtired. Pace your daily activities.
Dietary modifications:
Low Potassium, Sodium, Protein, Phosphorus; High calorie.
Weigh yourself daily
– same time every day – keep a record of everything you eat & drink
Contact your healthcare provider-
if you are experiencing little to no urinary output, sudden chest pain, trouble breathing, you have a fever (>101), dizzy, lightheaded, you are unable to eat or drink due to vomiting or nausea
Have patient verbalize understanding of the need to follow all teaching precautions
Full transcript