Transcript ACUTE RENAL FAILURE: CASE STUDY #1 • Joyce, age 45, was admitted to the emergency room following a major automobile accident in.

ACUTE RENAL FAILURE: CASE STUDY #1
• Joyce, age 45, was admitted to the emergency room following a major
automobile accident in which her husband was killed. She had massive
abdominal injuries and a fractured femur. She was taken immediately to
surgery for repair of a lacerated liver and perforated ileum. She had two units
of blood during surgery and two units while she was in the recovery room.
The fifth unit of blood was discontinued in surgical intensive care because
she developed a transfusion reaction.
• On the day after surgery, her urine output declined to 10-20 ml/hr.
Increasing her fluid intake with plasma expanders and blood did not increase
her urine output. Lab results indicated an elevated urinary sodium, BUN 70
mg/dl, and serum creatinine 4 mg/dl.
• Her urine output stabilized at 20-25 ml/hr on the third day after surgery.
She was diagnosed as having acute tubular necrosis.
• Because of a persistently elevated serum potassium and severe
hypertension (BP 190/120), she was started on hemodialysis using an
external cannula. She resented all the “plumbing” in her body and expressed
a desire to die.
QUESTIONS FOR DISCUSSION
1. What are the possible causes of acute tubular necrosis that Joyce developed?
2. What clinical indicators that Joyce is in the oliguric phase of acute renal failure?
3. What are the critical nursing assessments indicated when caring for Joyce?
4. What are the priority nursing diagnoses for Joyce?
5. How could you assist Joyce in dealing with her depression?
6. What are the usual indications for using hemodialysis in the management of acute renal
failure?
7. Joyce wants to know if she is going to be on hemodialysis for the rest of her life. How
would you answer this question?
8. What is the nursing care of the external cannula when not in use?
9. What is the goal of medical and nursing management of this patient?
Answers to #1
1. What are the possible causes of acute tubular necrosis that Joyce developed?
Trauma= hyperkalemia (inc. K+ in main intracellular fluid)
Transfusion reaction
Hypovolemia
Toxicity in the liver
2. What clinical indicators that Joyce has in the oliguric phase of acure renal failure?
Decrease urine output <30 cc/hr
3. What are the critical nursing assessments indicated when caring for Joyce?
Replace fluid by: 10 = 240 cc/24 hrs.
20 = 480 cc/24 hrs.
24 hr urine output + 500 cc (insensible loss) = 740 cc fluid replacement
Monitor daily weights (weight is a good evaluator of fluid status)
4. What are the priority nursing diagnosis for Joyce?
FVE, FVD, Altered tissue perfusion, High risk for bleeding, Toxicity r/t hyperkalemia,
Pain, Impaired gas exchange, Ineffective airway clearance r/t increase sputum
secretions.
Answers to #1
5. How could you assist Joyce in dealing with her depression?
Need psych consult, ask patient if she has suicidal ideation (plan of hurting herself),
need frequent checks.
6. What are the usual indications for using hemodialysis in the management of acute
renal failure?
Decrease creatinine clearance, hyperkalemia, transfusion reaction .
7. Joyce wants to know if she is going to be on hemodialysis for the rest of her life. How
would you answer this question?
Be honest with the patient. “We don’t know.” (Acute condition can become chronic)
8. What is the nursing care of the external cannula when not in use?
It’s a large catheter and big vessel watch for bleeding, maintain sterile technique
when
changing dressing ( Q3rd day), watch for S/Sx of infection ( errythema,
drainage,fever)
9. What is the goal of medical and nursing management of this patient?
Maintain fluid balance and maintain perfusion.
Goal: to stop and reverse ARF
Focus: watch patient status continuously (ICU), adequately hydrate, replace blood as
needed, watch for cont. blood loss, prevent infection (administer prophylactic
antibiotic)
ACUTE RENAL FAILURE: CASE STUDY
#2
• T.C. is an 80 year-old farmer who is diabetic. His history
includes smoking for 50 years (but not in the past 10 years),
angina, hypertension, and atrial fibrillation. T.C. has been on
nifedipine (Procardia) 20 mg qid and digoxin (Lanoxin) 0.375
mg qd. He adjusts his insulin (regular and NPH) depending on
his activity (he occasionally helps his sons with livestock and
field work). T.C. underwent triple coronary bypass surgery
yesterday.
• The postoperative course was uncomplicated until it was
determined in the postanesthesia recover area that he was
bleeding. T.C. was returned to surgery and five units of blood
were administered during the second operation. Today, T.C.’s
urine output is less than 5 ml/hr and he is diagnosed with acute
tubular necrosis (ATN).
QUESTIONS FOR DISCUSSION
1. Since T.C. ‘s blood pressure never dropped below 80/50 in the recovery area and
surgery, what contributes to the poor kidney perfusion that led to ATN? Consider
his original medical problems.
2. Identify the relevant nursing diagnoses for T.C.
3. T.C. ‘s serum creatinine climbs to 5.4mg/dl and his BUN to 101mg/dl. He is becoming
more irritable and lethargic. The family (wife, 5 children and spouses, numerous
grandchildren) maintain a vigil at the bedside.
4. What can you do to help the family?
5. Laboratory values indicate that dialysis is necessary, but prior to the initial surgery.
T.C. indicated that he wanted no heroic measures taken if the surgery did not go
well. He refuses dialysis and the family supports his decision. What can the nurse
do to comfort both the patient and his family?
6. Is it feasible that the ATN will reverse itself?
7. Is dialysis considered a heroic measure in this situation?
Answers to #2
1.Since T.C.’s blood pressure never dropped below 80/50 in the
recovery area and surgery, what contributed to the poor kidney
perfusion that led to Acute tubular necrosis? Consider his original
medical problems.
CVD(cardiovascular disease), HTN (increase pressure < a drop to
have symptoms of tissue perfusion as 100 below.
2. Identify relevant nursing diagnosis for T.C.
FVE, Altered tissue perfusion r/t DM, CAD,HTN, loss of blood,
Decrease cardiac output r/t loss of blood,
Altered Nutrition r/t DM
Potential for injury r/t toxic, imbalance blood sugar
3. T.C.’s serum creatinine climbs to 5.4 mg/dl and his BUN to 101 mg/dl.
He is becoming irritable and lethargic. The family (wife, 5 children
and spouses, numerous grandchildren) maintain a vigil at the
bedside. What can you do to help the family?
Answers #2
4. Give emotional support. Explain that patient undergone massive loss of
blood and this contribute to poor functioning.” Hopefully, he’ll come out
of it, and we’re doing everything we can.”
5. Lab. Values indicate that dialysis is necessary, but prior to the initial
surgery T.C. indicated that he wanted no heroic measures taken if the
surgery did not go well. He refuses dialysis. What can the nurse do to
comfort both the patient and his family?
6. Explain kidney failure and dialysis is indicated to help get rid of toxic
substances in the system to prevent patient from dying.
7. Is it feasible that ATN will reverse itself?
Yes, it is feasible, there’s a potential for reversibility.
***Is dialysis considered a heroic measure in this situation?
Maybe so, like CABG which will possibly prolong life
Case study presentation by
Lorena Reyes-Melad
Queen Lepana
and
Julma Ramos