#11347 Question Attached

CASE STUDY FOR ACUTE RENAL FAILURE

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

NORMAL VALUES

PRIOR TO SURGERY

WBC

5000-10,000/mm3

8.4

RBC

4.7-6.1 million/mm3

5.1

Hgb

14-18 g/dl

16.2

Hct

42-52%

49.8%

Platelets

150,000-400,000/mm3

235,000

Sodium

135-145 mEq/L

142

Potassium

3.5-5.0 mEq/L

4.7

Chloride

90-110 mEq/L

103

Total CO2

23-30 mEq/L

24

Glucose

70-105 mg/dl

99

BUN

10-20 mg/dl

15

Creatinine

0.6-1.2 mg/dl

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 q4h
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:

DATES:

TEST

2nd day postop

1st day postop

WBC

12.4

9.0

RBC

3.1

3.2

Hgb

9.4

9.7

Hct

28.1%

29.0%

Platelets

168,000

167,000

Na+

130

135

K+

5.4

5.0

CL-

94

104

Total CO²

15

16

Glucose

76

85

BUN

81

63

Creatinine

4.2

3.1

Serum Osmolality

mOsm/kg 285

287

TEST

NORMAL

2nd day postop

1st day postop

Urine Specific Gravity

1.010-1.025

1.010

1.010

ABG’s
pH

7.35 – 7.45

7.30

7.39

PaCO²

35 – 45 mmHg

30

32

HCO³

21 – 28 mEq/L

14

20

pO²

80 – 100 mm Hg

88

92

O² Sat

95 – 100%

93%

95%

Base Excess

+/-3mEq/L

-1

+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. Two hours after emptying the foley bag, it contains 300 mL. 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 turgor is poor.
VS – T 38C, P 120 IRREG, R 34, B/P 102/54

TEST

3rd day postop

WBC

18.4

RBC

6.1

Hb

15.4

HCT

46.2

Platelets

143

Na+

131

K+

2.8

CL-

105

BUN

54

Creatinine

3.2

OSMOLALITY

293

UPDATED MEDICAL PLAN/ORDERS

2,500 calorie, 50 gm protein diet
Progressive ambulation
IV fluid D5 ½ NS with KCI 20 mEq/L at 200 mL’s/hr.
Potassium extend tabs 10mEq PO BID
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 634, 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?