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 dont know. (Acute condition can become chronic) 8. What is the nursing care of the external cannula when not in use? Its 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, hell come out of it, and were 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, theres 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