NUR440 Case Study 5 Renal
NUR440 Case Study 5 Renal
Popular in Course
verified elite notetaker
Popular in Department
This 0 page Study Guide was uploaded by tophomework Notetaker on Saturday November 14, 2015. The Study Guide belongs to a course at a university taught by a professor in Fall. Since its upload, it has received 48 views.
Reviews for NUR440 Case Study 5 Renal
Report this Material
What is Karma?
Karma is the currency of StudySoup.
You can buy or earn more Karma at anytime and redeem it for class notes, study guides, flashcards, and more!
Date Created: 11/14/15
NUR440 Case Study 5 Case Study Five Acute Renal Failure ML is a 32yearold AfricanAmerican woman who was involved in a motor vehicle crash MVC 3 days ago She was driving the vehicle when she lost control of the car and slid off the side of the road hitting the embankment Her history is significant for diabetes Her medication regimen includes insulin 7030 for which she takes 12 units in the morning and evening On admission her weight was 125 pounds Her skin was pale and cold Her vital signs were as follows BP 7840 mm Hg P 140 bpm RR 42min and shallow She was disoriented and confused Bony deformities were obvious in the left and right shins She was diffusely tender to touch more so over her right chest During the course of her first 3 days the following findings and treatments occurred The insertion of a Foley catheter was difficult and revealed gross hematuria Her lab results revealed Hgb 122 Hct 36 WBC 11200 blood glucose 180 Urinalysis revealed a pH of 6 a specific gravity of 1018 4 occult blood 1 protein and RBCs too numerous to count Chest xray films showed multiple faint rib fractures on the right side Heart size was normal and there were no other remarkable findings on the xray film or ECG Initial serum electrolytes and amylase were normal as was her ABG Her fractures were confirmed to the shaft of the right femur and left tibia and fibula She was treated with warmed blankets 2 units of PRBCs and 4 L of saline Her blood pressure came up to 11678 Urine output was 55 ml over the next 90 minutes A CT scan of her head with contrast infusion was normal A CT scan of her abdomen showed some ascitic uid and a probable hematoma of the spleen The abdomen was explored and a lacerated spleen was removed ML required an additional 4 units of blood during the surgery For the last 3 days ML39s urine output has averaged 40 to 50 mlhr and her mean arterial pressure MAP was 60 to 80 The patient was alert and communicative The color of her urine became gradually lighter however the BUN rose to 75 mgdl with a serum creatinine value of 45 mgdl Other lab tests revealed calcium 62 phosphorous 82 uric acid 132 LDH 473 CPK 12000 urine osmolality 370 urine creatinine 52 During this period the patient underwent internal fixation of the lower extremity fractures ML was diagnosed with acute renal failure ARF 1 Define acute renal failure and its cause in the case of ML ARF occurs quickly over a few day or weeks with a sudden reduction in the glomerular filtration rate GFR resulting in elevation of blood urea nitrogen BUN plasma creatinine and cystatin C levels The retention of these products in the blood disrupts the electrolyte acidbase homeostasis and uid volume equilibrium ARF is usually associated with oliguria less than 30 mlhr or less than 400 mlday and is caused by any condition that reduces blood ow blood pressure or kidney perfusion ML s ARF was most likely caused from hypovolemia and crush injuries The hypovolemia caused her blood pressure to drop consequently reducing the ow of blood to her kidneys producing NUR440 Case Study 5 ischemic damage from inadequate tissue perfusion impairing tubular endothelial function perfusion pressures decrease and eventually equal GFR Due to ML s accident and the crush injuries she sustained in the accident skeletal muscles release myoglobin into the bloodstream Myoglobin released into the bloodstream blocks the tubules and may result in intrarenal AKI What laboratory tests are helpful in the evaluation of acute renal failure Describe how lab data can be used to determine the type of ARF Many tests are useful when evaluating kidney function however there is no one single test that will detect a decrease in kidney function Rather it is best to review simultaneously all laboratory tests serum and urine to determine the kidney s function The BUN is a byproduct of protein metabolism and increases when the kidney function decreases The BUN is elevated due to the decrease in GFR urea excretion by the kidneys is hindered and is therefore retained Other causes of an increased BUN may be related to hypovolemia dehydration protein metabolism and chronic poor nutrition Normal BUN is 525 mgdl Creatinine is also a byproduct of cell metabolism it is slightly higher in males than females due to the muscle mass difference The serum creatinine levels are affected by fewer factors than the BUN it is therefore a more reliable indicator of kidney function Normal serum creatinine level is 0515 mgdl Impaired excretion of the kidneys generally increases serum creatinine levels The most useful kidney function indicator is the creatinine clearance because it measures the amount of creatinine excreted within a 24hour period This indicator measures how well the kidneys are removing creatinine and provides a reliable estimate of GFR normal level is 110120 mgdl Cystatin C is a serum marker also available however it is not often used in clinical practice The cystatin C is released by most cells in the body at a constant rate and is filtered through the glomerulus and is not resorbed in the tubules Cystatin C is affected by fewer factors than the creatinine and BUN and may be detected earlier in acute renal failure than previously discussed laboratory tests Serum osmolality measures the concentration of vascular uid and dissolved particles in serum Normal serum osmolality is 275295 mOsmL Elevated osmolality indicates dehydration hemoconcentration and a decreased osmolality indicates uid volume overload hemodilution The anion gap measures the difference between the extracellular plasma cations and the anions The value represents the remaining ions present in the extracellular uid Normal anion gap is above 1114 mEqL Increases in anion gap re ects the overproduction or retention of acid products indicating metabolic acidosis where as a decreased anion gap indicates metabolic alkalosis The anion gap is a useful tool for determining acidbase imbalances however it does not determine the cause Hemoglobin and hematocrit HCT may indicate increases or decreases in intravascular uid volume Hemoglobin transports oxygen to the cells and hematocrit is the proportion of concentration of red blood cells in a volume of whole blood HCT is expressed as a percentage In normal uid balance the HCT level is approximately three times the hemoglobin level An increase in HCT is often indicative of a uid volume deficit due to the increased hemoglobin NUR440 Case Study 5 concentration within the blood A decreased HCT is indicative of the opposite uid volume excess and due to the dilutional effect from the extra uid Decreases may also be due to anemia blood loss liver disorders or hemolytic reactions Albumin is also present in the plasma and is 50 of total plasma protein in serum albumin Normal level is 35 5 gdl and it is responsible for the maintenance of colloid osmotic pressure Decreased albumin can be a result from protein calorie malnutrition Urinalysis provides information about the kidney s function as well Inspection and detection of urine color pH specific gravity osmolality glucose protein electrolytes sediment and hematuria present information on the kidney s function and condition with reference to uid and electrolytes Since hemoglobin and HCT assist with detecting changes in uid volume they may be an indicator for identifying prerenal acute kidney injury AKI The BUN to creatinine ratio is useful for determining prerenal AKI the BUN level is elevated in relation to the creatinine level 20 1 Creatinine is measured daily to follow a trend in kidney function Typically if the serum creatinine doubles this is re ective of a 50 reduction in GFR Fractional excretion of sodium FENa is also used to determine prerenal or intrarenal FENa below 1 suggests prerenal FENa above 2 suggests the kidney cannot concentrate sodium and the damage indicates intrarenalthis test is only valid in the absence of diuretics Urinary sodium may also be measured urinary sodium less than 10 mEqL suggests prerenal and greater than 40 mEqL suggests intrarenal Since diuretics alter resorption use of any diuretics will invalidate results and not re ect direct kidney function Increases in the acidity of urine indicate the kidneys are retaining sodium and acids from the body this occurs with intrarenal AKI A decrease in the acidity indicates the body is retaining bicarbonate both are indicative of intrarenal AKI Proteinuria is significant of intrarenal kidney disease as is sodium in the urine Changes in the electrolytes within the urine are strongly suggestive of intrarenal AKI The presence of sediment is also an indicator In prerenal AKI the kidneys are not damaged in intrarenal AKI tubules and glomeruli are damaged and allow casts and epithelial cells through where they are then found in the urine this is an abnormal finding indicating intrarenal AKI Gross hematuria is abnormal as well and indicates renal trauma or urinary tract bleeding Calcium is low normal range 85 105 Phosphorus is high maybe from the fractures or acidosis however her abgs or normal Creatinine is extremely high normal 5 15 BUN is high at 75 normal 525 Urine osmolality is low at 370 in AKI this value and output is decreased bc solutes and uids are being retained NUR440 Case Study 5 3 Describe the complete clinical course for a patient in acute renal failure ie oliguric diuretic etc In what phase of the clinical course is ML Acute renal failure ensues from the result of tubular dysfunction Cellular debris accumulates in the tubules and obstruction occurs Filtration is halted when the tubule hydrostatic pressure matches the pressure of the GFR The formation of urine is dramatically decreased from the obstruction swelling and decreased capillary blood ow The clinical course progresses through four phases onset phase oliguric or anuric phase diuretic phase and the recovery phase The onset phase is the period when cell injury occurs Ischemia is occurring at this time Blood ow is decreased and GFR decreases The blockage disrupts the integrity of the tubules and glomerular filtrate falls back into the kidney This phase may last hours to days If treatment is initiated at this time the damage can be reversed The longer this stage lasts the longer the recovery period The next phase is the oliguric or anuric phase this phase usually lasts from 58 days in the nonoliguric client and 1016 days in the oliguric client Debris continues to accumulate in the tubules and blocks the ow of urine This causes damage to the tubule membranes Glomerular filtrates ow back into the kidney because of this blockage During this phase oliguria is present due to the damage and back ow and is sign of severe damage BUN and creatinine rise during this phase and the electrolytes are disturbed creating metabolic acidosis The kidneys are unable to excrete H ions resulting in metabolic acidosis The client may experience difficulty with respiration because the respiratory system is trying to compensate The build up of toxins continue without medical intervention the client may experience nauseavomiting and neurological complications such as headache twitching and stupor and within 10 days coma The diuretic phase usually lasts 714 days During this phase a period of diuresis occurs due to an increase in GFR Urine output may be as high as 2 4 Lday If the patient is receiving dialysis the polyuria may not be evident Tubular obstruction has passed during this phase however the edema and scarring within the tubules remain Due to the edema and scarring GFR has returned but the tubules still are not functioning normally therefore the kidneys are allowing uid through but no solutes are being excreted This large amount of diuresis may lead to hypovolemia The recovery phase is the last phase and is characteristic of kidney function returning to normal or near normal The GFR will be approximately 7080 in 12 years BUN and creatinine levels may not return to normal because of the damage that occurred to the kidneys Due to her increased levels of BUN and creatinine I would estimate ML is entering the oliguric or anuric phase ML s urine osmolality is decreased indicating uids and solutes are being retained indicating intrarenal AKI 4 Discuss complications the nurse should be alert for in this case and possible nursing and collaborative interventions NUR440 Case Study 5 Myoglobin and creatine are released from damaged muscles from crush injuries such as ML experienced a condition known as rhabdomyolysis Since myoglobin is nephrotoxic it is very important ML receive treatment immediately to preserve kidney function and prevent injury to her kidneys To preserve kidney function volume resuscitation alkalinized intravenous uids with sodium bicarb treatment will include administration of bicarbonate and mannitol regimen to prevent acidosis and hyperkalemia daily weights strict I amp O s monitoring of CK levels electrolytes watching for trends in creatinine levels and monitor of signs of compartment syndrome Treatment of acute renal failure will be directed towards correcting the primary disorder as well as correcting the uid and electrolyte disorders Potassium may be removed by administration of kayexalate or dialysis ML received contrast during her CT this will also contribute to her renal impairment We were not informed of her creatinine level on admission and do not have a baseline however clients with creatinine levels more than 15 mgdL from baseline are at increased risk for chronic kidney dysfunction Clinically contrast induced nephrotoxicity is a serum creatinine of 25 more than baseline within 4872 hours of the contrast exposure Fluid resuscitation is a primary treatment intervention to restore perfusion to the kidney Early intervention with uid resuscitation will assist in preventing intrinsic renal failure Collaborative efforts such as placing a central venous catheter for hemodynamic monitoring may be instituted Due to the nature of the process CVP monitoring would be valuable as well as monitoring of wedge pressure cardiac output and cardiac index It is important to be aware of dilutional hypnatremia as uid overload worsens with a client with oliguria Acid base imbalances should be monitored through the use of arterial blood gas values The physician may order hemodialysis initially hemodialysis may be ordered daily during the acute phase If the client is not hemodynamically stable CRRT may be ordered to maintain hemodynamics Since ML had exploratory surgery and her spleen was removed suggest reviewing nursing and medical notes from her surgery paying close attention to intraoperative and postoperative records When do patients require dialysis What is the difference between hemodialysis and continuous renal replacement therapy CRRT When would CRRT be the preferred method Indications for renal replacement therapy RRT include metabolic acidosis hyperkalemia uremia drug toxicity and volume overload Hemodialysis and CRRT are based on the same principles of utilizing a semi permeable membrane however hemodialysis is performed on an intermittent basis usually takes between 34 hours three times per week If hemodialysis were to be used on a patient who is hemodynamically unstable hemodialysis would only lead to further decline in hemodynamics In CRRT hemodialysis occurs constantly over many hours possibly even days The removal of solutes NUR440 Case Study 5 and uid is controlled over a longer period of time therefore maintaining hemodynamics CRRT would be the preferred method When a patient is hemodynamically unstable often the case When a patient is experiencing multisystem organ failure What nursing diagnoses apply in this case diagnoses must be complete With related to factors and as evidenced by signs and symptoms Ineffective kidney tissue perfusion related to decreased renal blood ow as evidenced by asteriXis and peripheral nervous system irritability elevated BUN
Are you sure you want to buy this material for
You're already Subscribed!
Looks like you've already subscribed to StudySoup, you won't need to purchase another subscription to get this material. To access this material simply click 'View Full Document'