CASE STUDY FOR ACUTE KIDNEY INJURY

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Jose Garcia, a 65-year-old Hispanic male, was admitted to the hospital for an open cholecystectomy. He is married and has two sons and two daughters and four grandchildren. He is a retired investment banker. He speaks English as a second language. Source of income is his pension. He has health benefits through his previous place of employment. Mr. Garcia reports that he has had abdominal pain that radiates to the right shoulder following some of his meals. He also reports nausea and sometimes vomiting when this occurs. This has been occurring for at least six months. He also reports that nothing has helped to relieve the pain nor the nausea and vomiting. He reports his health as good otherwise. Mr. Garcia reports no major illnesses, no past surgeries, nor any previous hospitalizations. His parents are still alive and in fair health, having hypertension, heart disease, and diabetes. Recent lab work includes the following: TEST WBC RBC Hgb Hct Platelets Sodium Potassium Chloride Total CO2 Glucose BUN Creatinine NORMAL VALUES 5000-10,000/mm3 4.7-6.1 million/mm3 14-18 g/dl 42-52% 150,000-400,000/mm3 135-145 mEq/L 3.5-5.0 mEq/L 90-110 mEq/L 23-30 mEq/L 70-105 mg/dl 10-20 mg/dl 0.6-1.2 mg/dl PRIOR TO SURGERY 8.4 5.1 16.2 49.8% 235,000 142 4.7 103 24 99 15 0.8 Current medications at home are MVI 1 tablet daily, Tylenol ES 1000 mg prn for pain. Mr. Garcia has NKA. VS are temp 37 C, pulse 78, resp 18, BP 134/74. Mr. Garcia is alert and oriented x 3, communicates appropriately, has full cognitive ability. Color of skin, mucus membranes, nail beds are pink. Has +2 pedal and radial pulses. No edema present in lower extremities. Capillary refill is less than 3 seconds. Homan’s sign is negative. Apical pulse is 78 and regular. S1 and S2 are clearly noted. Chest is symmetrical with downward sloping of ribs, spine is straight, and scapulae are placed symmetrical. AP diameter of chest is less than transverse diameter and ration is 1:2. No use of accessory muscles. Respirations are 18 of moderate depth and regular rhythm. PERRLA. Sclera icteric. Acuity is 20/20 with corrective lenses. Last visual exam was 3 months ago. Has adequate hearing. Reports no alterations in taste or touch. Denies any pain. States usually awakens at 7 a.m. and goes to sleep at 12 MN. States feels rested when he awakens. Takes no sleep medications. Has no scars. Abdomen is round and soft. Bowel sounds active x 4 quadrants. Reports having a BM qd and had a soft, brown stool this AM. Voids clear amber urine several times a day. Is able to participate in all activities of daily living. Moves all extremities equally, has full ROM to all extremities. Ambulates without assistance. Has no history of falls. Height is 5’10”. Weight is 192 lbs. Reports appetite is usual. Teeth are intact, no sores noted in mouth. Denies difficulty in swallowing. Drinks no caffeinated beverages. Has been eating a diet as tolerated. Is sexually active with his spouse. No history of STD’s. Last prostate exam and PSE was 9 months ago with no abnormal findings. Overall appearance is appropriate. Patient denies any other problem in his life. He has maintained a positive attitude about his current health condition. He believes that surgery will correct the problem. Has some anxiety in regards to the surgery, anesthesia, and pain afterwards. He states he is Catholic and in times of stress he turns to God and prayer and that provides him with comfort. He states he is satisfied with his life. He was born in Cuba and moved to the US in the 1960’s. Major life focus at this time is “enjoy life with his wife who is also of Cuba descent and children and grandchildren”. He reports having friends at On Top of the World, the retirement community where he lives, who will help out as needed. He reports enjoy eating typical Cuban foods. Mr. Garcia had unexpected complications immediately following his surgery. He had an excessive amount of blood loss and went into shock, which has resolved. Two days later your initial assessment includes: He is asleep, slow to arouse and nods off easily and frequently during the assessment. He is able to state he is in the hospital, but does not remember the name of the hospital. His older daughter spent the night with Mr. Garcia and is pacing the room. She states, “He’s getting worse, isn’t he”? Vital signs are temp 38 C, pulse 112 and irregular, resp 32, deep and labored, BP 196/100. PERRLA. Crackles are auscultated throughout the lung fields. There is a murmur present. Abdomen is distended, and bowel sounds are present. Abdominal dressing is clean and dry. No urine output is noted for the past several hours. Urine output for the last 24 hours is 270 mL’s. He has 3+ pitting edema of both feet and lower legs. Pedal pulses are not palpable. Orders include: BRP only I&O VS q4j 500 mg Na+, 30 g protein, 2500 cal diet Total fluid PO intake not to exceed output of previous 24 h plus 400 mL’s Saline lock, change site q72h Vasotec 1.25 mg IV q6h prn Systolic greater than 140 or diastolic greater than 100 Furosemide 40 mg IV bid MOM 30 mL PRN constipation Ativan 0.5 mg PO HS PRN, may repeat x 1 Consent for Tessio catheter insertion Oxycodone 2 tablets PO every 4 hrs. PRN for moderate to severe post-op pain Lab data are as follows: LAB: TEST WBC RBC Hgb Hct Platelets Na+ K+ CL- Total CO2 DATES: 2nd day postop 12.4 3.1 9.4 28.1% 168,000 130 5.4 94 1st day postop 9.0 3.2 9.7 29.0% 167,000 135 5.0 104 16 85 63 3.1 287 15 Glucose 76 BUN 81 Creatinine 4.2 Serum Osmolality TEST Urine Specific Gravity ABG’s pH PaCO2 HCO3 pO2 O2 Sat Base Excess mOsm/kg 285 NORMAL 1.010-1.025 7.35 – 7.45 35 – 45 mmHg 21 – 28 mEq/L 80 – 100 mm Hg 95 – 100% +/-3mEq/L 2nd day postop 1.010 7.30 30 14 88 93% -1 1st day postop 1.010 7.39 32 20 92 95% +1 1. Explain the changes in the lab data. 2. At this time, what is Mr. Garcia’s major stressor? 3. What precipitated the problem? (How would this be classified?) 4. What are other causes for acute renal failure? 5. Explain hypoperfusion and its relationship to the development of acute renal failure. 6. What psychological, sociocultural, spiritual, and development problems relate to Mr. Garcia? 7. What nursing actions would you employ related to Mr. Garcia’s daughter? 8. After analyzing the medical plan for Mr. Garcia, identify the TOP priority nursing diagnoses and actions for him. 9. Mr. Garcia’s latest K+ is now 6.4. The physician has prescribed a Kayexalate enema. What is the rationale for a Kayexalate enema? 10. What would be the EXPECTED outcomes of treatment? 3rd day postop 0700. On initial rounds, while assessing Mr. Garcia, you note his last 8 hr urine output was 1200 mL’s urine. Two hours after emptying the foley bag, it contains 300 mL’s. Mr. Garcia tells you he is very thirsty. His eyes and mucous membranes look dull; little saliva is present in his mouth. His underarms and groin are warm and dry. Skin turgo is poor. VS – T 38C, P 120 IRREG, R 34, B/P 102/54 TEST WBC RBC Hb HCT Platelets Na+ K+ CL- BUN Creatinine OSMOLALITY UPDATED MEDICAL PLAN 3rd day postop 18.4 6.1 15.4 46.2 143 131 2.8 105 54 3.2 293 2,500 calorie, 50 gm protein diet Progressive ambulation IV fluid D5 1⁄2 NS with KCI 20 mEq/L at 200 mL’s/hr. Potassium extend tabs 10mEq PO every 0900 and 2100 Colace 100 mg every AM D/C furosemide 11. What phase of the disease process has Mr. Garcia entered? 12. What are the characteristics of this stage? 13. What is his most urgent nursing diagnosis now? 14. For which electrolyte imbalance(s) must Mr. Garcia be observed at this time? 15. Analyze Mr. Garcia’s new medical plan. What is the rationale for the changes? 4th day postop 0700. The night nurse reports Mr. Garcia has been restless during the early morning hours. He has also been a bit confused. You find Mr. Garcia turning and moving restlessly about in bed. He says, “Something is wrong. I can’t get right”. He is confused. His skin is warm and dry. VS – B/P 80/40, P 162, R 36, T 39.1 No urine has appeared in the foley bag since 6 a.m. 16. Based on analysis of this data, what is your conclusion regarding Mr. Garcia’s condition? 17. What sequence of nursing actions would you prescribe in PRIORITY order? The M.D. came in to see Mr. Garcia and remained at his bedside until he stabilized. The medical plan included: remove vascular cath and culture establish a new IV line, then remove present angiocath and culture culture blood, culture urine stat ceftriaxone 1 g BID IVPB begin stat after cultures vancomycin 1 g IVPB one dose after cultures By the next morning it became clear, based on lack of urine output and changes in lab values, this most recent insult has wiped out Mr. Garcia’s renal function. Mr. Garcia and his wife live in a rural area and it would be difficult for him to travel for hemodialysis. During grand rounds, the physician asks your assessment of Mr. Garcia’s ability to be successful with peritoneal dialysis. You relate the Garcia’s are highly motivated, flexible, conscientious people with excellent learning ability. After a thorough explanation of peritoneal dialysis, the Garcia’s agree it is their best option. 18. What is the function of the peritoneal catheter? 19. What serves as the membrane across which dialysis occurs? 20. What principles of fluid and electrolyte movement apply in peritoneal dialysis (what makes it work)? 21. What does the term “dwell time” mean? 22. What does the term “exchange” mean? 23. What is the composition of “typical” dialysis solution and what is the purpose of each component? 24. What is the temperature of dialysate at the time of infusion? Mr. Garcia has his catheter in place and is ready to begin dialysis. Preparation for dialysis procedure: Mr. Garcia’s assessment remains unchanged. VS – T 37.4 C, P 109 REG, R 28, B/P 190/96, WT 195 lbs. You secure the prescribed dialysate. Infusion of 1500 mL’s of dialysate is completed. You unclamp the catheter to begin drainage. One thousand mL’s drains and drainage stops. 25. What is the next nursing action? 26. If the remainder of the fluid does not drain, what would be the best nursing action? Your nursing actions are successful and the fluid begins to return. The fluid is blood tinged. 27. What does this mean and what nursing action is appropriate? 28. What might it mean if, during fluid return, the nurse notes brown or yellow fluid? 29. What would you do if Mr. Garcia’s pulse suddenly became rapid and irregular? Post-dialysis assessment: VS – T 38.3 C, P 112 reg, R 24, B/P 176/86, WT 191 Lab – NA+ 136, K+ 4.9, CO2 20, BUN 34, creatinine 3. 30. Based on this assessment, how has Mr. Garcia improved after dialysis? 31. What can you identify as possible additional problems? Mr. Garcia is stabilized and maintained on peritoneal dialysis. He continues to improve and is ready to go home. Mr. Garcia tells you he loves traditional Cuban food. 32. How would the nurse counsel him regarding his diet? 33. What discharge planning should occur related to Mr. Garcia’s family? 34. What are the most important elements to include in discharge planning for Mr. Garcia, including community resources?

Solution: CASE STUDY FOR ACUTE KIDNEY INJURY

  1. Changes in Lab Data:
    • WBC: Increased from 9.0 to 12.4 (indicative of infection or inflammation post-op).
    • RBC, Hgb, Hct, Platelets: Decreased from pre-op values (indicative of blood loss).
    • Sodium, Potassium, Chloride, Total CO2: Within normal range initially but may be affected by fluid and electrolyte imbalances post-op.
    • Glucose: Decreased from pre-op values (indicative of stress response).
    • BUN, Creatinine: Elevated from pre-op values (indicative of acute kidney injury).
    • Urine Specific Gravity: Normal, but low output suggests inadequate renal function.
    • ABG’s: Acidosis evident, possibly due to respiratory and metabolic factors.
  2. Major Stressor:
    • Mr. Garcia’s major stressor is likely the acute kidney injury following excessive blood loss post-cholecystectomy, leading to acute renal failure.
  3. Precipitating Problem:
    • Excessive blood loss during surgery precipitated the acute renal failure, which can be classified as prerenal due to inadequate renal perfusion.
  4. Other Causes for Acute Renal Failure:
    • Intrinsic renal injury (e.g., nephrotoxic drugs, acute tubular necrosis), obstructive causes (e.g., kidney stones, tumor), and postrenal causes (e.g., urinary tract obstruction) can also lead to acute renal failure.
  5. Hypoperfusion and Acute Renal Failure:
    • Hypoperfusion refers to inadequate blood flow to tissues, including the kidneys, which can lead to ischemia and acute renal failure due to decreased glomerular filtration rate (GFR) and subsequent impairment of kidney function.
  6. Psychological, Sociocultural, Spiritual, and Development Problems:
    • Mr. Garcia may experience anxiety and fear related to his deteriorating condition, language barriers, and cultural preferences for traditional Cuban foods. His spiritual beliefs may provide comfort during stressful times.
  7. Nursing Actions for Mr. Garcia’s Daughter:
    • Provide emotional support, clarify medical information, involve her in care decisions, and offer reassurance regarding her father’s condition and prognosis.
  8. Top Priority Nursing Diagnoses and Actions:
    • Acute Pain related to post-operative complications: Administer prescribed analgesics and monitor pain levels.
    • Risk for Fluid Volume Excess: Monitor intake and output, assess for signs of fluid overload, and adjust IV fluids accordingly.
    • Risk for Imbalanced Nutrition: Monitor dietary intake, provide education on renal diet restrictions, and refer to dietitian if necessary.
  9. Rationale for Kayexalate Enema:
    • Kayexalate helps lower serum potassium levels by exchanging sodium ions for potassium ions in the colon, facilitating potassium excretion through the stool.
  10. Expected Outcomes of Treatment:
    • Stabilization of vital signs, improvement in renal function, resolution of acidosis, and relief of symptoms associated with acute kidney injury which can lead to ischemia and damage to renal tubules, resulting in acute renal failure. In Mr. Garcia’s case, the hypoperfusion caused by excessive blood loss during surgery likely contributed to his acute renal failure.
  11. Psychological, Sociocultural, Spiritual, and Developmental Problems:
    • Psychological: Mr. Garcia may experience anxiety, confusion, and fear related to his deteriorating health status and the need for additional medical interventions.
    • Sociocultural: Cultural beliefs, language barriers, and access to healthcare resources may impact Mr. Garcia’s understanding of his condition and treatment options.
    • Spiritual: Mr. Garcia finds comfort in prayer and spirituality, which may help him cope with his illness and recovery process.
    • Developmental: As a retired individual with grandchildren, Mr. Garcia may have concerns about his ability to maintain his role within the family and community.
  12. Nursing Actions for Mr. Garcia’s Daughter:
    • Provide emotional support and reassurance to Mr. Garcia’s daughter about her father’s condition and prognosis.
    • Encourage open communication and address any concerns or questions she may have regarding her father’s care.
    • Offer information about support services available for family members of hospitalized patients, such as counseling or support groups.
  13. Top Priority Nursing Diagnoses and Actions:
    • Priority Nursing Diagnoses: Acute Pain related to surgical procedure and complications, Impaired Gas Exchange related to respiratory distress, Risk for Decreased Cardiac Output related to fluid volume excess.
    • Actions: Monitor vital signs and oxygen saturation closely, administer oxygen therapy as prescribed, assess pain levels and administer pain medication as needed, monitor fluid intake and output, assess for signs of fluid overload or electrolyte imbalances.
  14. Rationale for Kayexalate Enema:
    • Kayexalate is a medication used to treat hyperkalemia by binding to potassium in the gastrointestinal tract and promoting its excretion through feces.
  15. Expected Outcomes of Treatment:
    • Resolution of hyperkalemia and electrolyte imbalances.
    • Improvement in renal function and urine output.
    • Reduction in symptoms such as confusion, fatigue, and edema.
    • Prevention of further complications such as metabolic acidosis or cardiac arrhythmias.
  16. Phase of Disease Process:
    • Mr. Garcia has entered the oliguric phase of acute renal failure.
  17. Characteristics of Oliguric Phase:
    • Decreased urine output (<400 mL/day), electrolyte imbalances, fluid overload, metabolic acidosis, uremia, and retention of nitrogenous waste products.
  18. Most Urgent Nursing Diagnosis:
    • Risk for Fluid Volume Excess related to oliguria and fluid overload.
  19. Electrolyte Imbalances to Observe:
    • Hyperkalemia, hypernatremia, metabolic acidosis.
  20. Analysis of New Medical Plan:
    • Focuses on correcting fluid and electrolyte imbalances, preventing complications, and promoting renal function recovery. Introduction of IV fluids, diuretics, and antibiotic therapy reflects management of acute kidney injury and infection.
  21. Conclusion Regarding Mr. Garcia’s Condition:
    • Mr. Garcia is experiencing worsening renal function and hemodynamic instability, likely due to complications of acute renal failure and fluid overload.
  22. Priority Nursing Actions:
    • Ensure patent IV access, administer prescribed medications, monitor vital signs and urine output closely, notify the healthcare provider of changes in condition, provide emotional support to Mr. Garcia and his family.
  23. Function of Peritoneal Catheter:
    • The peritoneal catheter is inserted into the abdominal cavity to allow for the infusion and drainage of dialysis fluid during peritoneal dialysis.
  24. Membrane for Dialysis:
    • The peritoneal membrane serves as the semipermeable membrane across which dialysis occurs during peritoneal dialysis.
  25. Principles of Fluid and Electrolyte Movement:
    • Dialysate solution is infused into the peritoneal cavity, where solutes and excess fluid move across the peritoneal membrane into the dialysate by diffusion and osmosis.
  26. Meaning of “Dwell Time”:
    • Dwell time refers to the duration that the dialysate remains in the peritoneal cavity before drainage, allowing for adequate exchange of solutes and fluid.
  27. Meaning of “Exchange”:
    • Exchange refers to the process of infusing fresh dialysate into the peritoneal cavity and draining used dialysate after a dwell period.
  28. Composition of Dialysis Solution:
    • Typically contains electrolytes (sodium, potassium, calcium, magnesium), glucose or icodextrin as osmotic agents, and buffer solutions to maintain pH balance.
  29. Temperature of Dialysate:
    • Dialysate is typically warmed to body temperature (37°C) before infusion to minimize discomfort and enhance solute transport.

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