acute renal failure scenario

[cocolococna]

I have a scenario from my teacher that we have to do acute renal failure on a state of the art very expensive simulator. He breathes, coughs, vomits, pees, poops, bleeds, has vitals, talks, etc. The info. follows:

Location: Medical-Surgical Unit

History/ Information:

The patient is a 61 year old male with a history of hypertension and hyperlipidemia. His home medications include enalapril, atorvastatin and baby aspirin daily. He weighs 100 kg and smokes one pack of cigarettes per day. He is allergic to penicillin. The patient presented to the Emergency Department three days ago with complaints of abdominal pain and yellow skin and had an emergency open cholecystectomy for obstrictive jaundice. He was admitted to the Medical-Surgical Unit postoperatively. On the second postoperative day, his IV was converted to a saline lock and clear liquid diet ordered. On the third morning, he has nausea, vomiting, absent bowel sounds, urine output 250ml/12 hour shift, and low grade fever. He has not had a bowel movement. His surgical wound is positive for methicillin resistant staphylococcus aureus (MRSA), which is now being treated with vancomycin. He is in contact isolation.

Healthcare Provider's Orders:

Vancomycin 1g every 12 hours

Enalapril 20 mg PO once daily

Atirvastatub 10 mg PO once daily

Hydromorphone 1-2 mg every 2-4 hours IVP prn pain

Promethazine 12.5mg IV every 6 hours prn nausea

Oxycodone 5mg/acetominophen 325mg 1-2 tabs PO every 4-6 hours prn mild pain

Enoxaparin 40 mg SQ once daily

Saline lock flush 0.9% NS every shift

CBC, Electrolytes, BUN, Creatinine, Glucose in AM

Incentive spirometer

My husband is a nurse and says he should get immediate dialysis. What about fluids? He has Vanco q 12 hours piggyback, but piggyback to what? What do you think, anyone? The last group in our class killed "Stan". I don't want to do the same.

[RN1982]

I agree.

[Daytonite, BSN, RN]

That's what I was thinking as well. Cholangitis progressing to gram negative sepsis. I think the MRSA thing is a red herring.

Yes, I was thinking shock because of the fever, nausea, vomiting and decreased output. A few other symptoms are missing, but I was also thinking that the patient was developing a peritonitis because of the abdominal symptoms. By the 3rd post op day the patient should be showing signs of recovery from the surgery and evidence of peristalsis starting to return. That's not happening. Renal involvement secondary to massive infection is feasible. This is why it is always good to look at the possible complications of treatment (surgery, treatment). The symptoms that I was able to isolate out are so generic and can belong to several things. That leaves the answer to the scenario wide open and subject to a variety of correct answers based on the questions the program chooses to pose. If it is programmed to ask for ARF, the evidence for it is there. If it is programmed to ask for post op infection, that is there too. This is why I originally brought up the importance of breaking down the information and organizing it carefully and looking up signs/ symptoms and complications of medical diseases and treatments. Treatment for both doctors and nurses, in general, is aimed at the signs and symptoms that the patient has. Doc, you gotta agree with me on that. I harp about that all the time when I am answering care plan questions on the student forums.

[Virgo_RN, BSN, RN]

SIRS, anyone?

[Daytonite, BSN, RN]

my understanding of sirs and sepsis is that sirs has all the signs and symptoms of sepsis without the proof of an infection. once an infection is proven to be present then it officially becomes sepsis.

criteria for sirs is based upon the presence of two or more of the following signs/symptoms:

• pulse > 90 beats per minute
  
• temperature > 38° c or
• respirations > 20 breaths per minute or, blood gas of paco2
• white blood cell count 12,000 cells/mm³ or the presence of greater than 10% immature neutrophils

organ failure is a complication of sirs or sepsis. the scenario, however, only gives a symptom of a low grade fever with nothing about the other vital signs or labs.

in this case, mrsa has already been identified as an infecting organism and the patient placed in contact isolation. that could rule out sirs and put sepsis in the running for a potential medical diagnosis here with acute renal failure as a complication. i feel very uncomfortable with medical diagnosis. i am not a doctor and was never trained in medical diagnosis. i think it wrong that nursing instructors ask nursing students to ever do this. nursing students have a hard enough time learning how to nursing diagnose.

i'm very curious to know what questions the simulator is asking. i like to think that the safe route is to research the pathophysiology of the given medical diagnoses, know the treatment and complications, know why the drugs are being given and what their side effects are, and know what the symptoms and nursing treatment is for the patient symptoms that the scenario does give you. if the first group of students killed the patient off, it had to be because they made mistakes in how they prioritized the care. that has to be related to treating symptoms and knowing what gets treated first (abc's, maslow's hierarchy of needs and utilizing the nursing process to make decisions about care). i would not go into that simulator without having thoroughly completed what i started in my initial post which was to start laying out a care plan for this scenario. i didn't even get to step #3 planning (goals and nursing interventions) nor did i delve very deeply into each item as i would if i were one of these students.

[nrsang97, BSN, RN]

The pt sounds septic to me. NPO and fluids. Also ABD xray.

[Valerie Salva, BSN, RN]

Sorry, typo. We have to do this scenario exercise on the simulator and this is the only info. we have. No vitals, lytes, no values. I don't know if he has edema or is anemic, either. The scenario is for acute renal failure which is what we are studying now. Thanks

I really don't think this secenario gives enough info to decide on dialysis or not, but I know it's all you have to go by.

I would give IVF, and if the urine output didn't go up markedly in a short period of time, I would give IV Lasix with the fluids, but not dialysis with only this info.

[patwil73]

I have a scenario from my teacher that we have to do acute renal failure on a state of the art very expensive simulator. He breathes, coughs, vomits, pees, poops, bleeds, has vitals, talks, etc. The info. follows:

Location: Medical-Surgical Unit

History/ Information:

The patient is a 61 year old male with a history of hypertension and hyperlipidemia. His home medications include enalapril, atorvastatin and baby aspirin daily. He weighs 100 kg and smokes one pack of cigarettes per day. He is allergic to penicillin. The patient presented to the Emergency Department three days ago with complaints of abdominal pain and yellow skin and had an emergency open cholecystectomy for obstrictive jaundice. He was admitted to the Medical-Surgical Unit postoperatively. On the second postoperative day, his IV was converted to a saline lock and clear liquid diet ordered. On the third morning, he has nausea, vomiting, absent bowel sounds, urine output 250ml/12 hour shift, and low grade fever. He has not had a bowel movement. His surgical wound is positive for methicillin resistant staphylococcus aureus (MRSA), which is now being treated with vancomycin. He is in contact isolation.

If some called me for a medical response on said patient - this is what I would do:

Set of vitals - I am looking for hypotension, tachycardia, elevated respiratory rate, low saturations, and elevated temp (which you already mentioned).

Head to toe assessment - I am looking for: diaphoresis, weak pulses, distended or hard abdomen, s/s of infection at wound site, color and texture of emesis, review BT, color of urine - compare everything to prior assessments (did he have BT and now doesn't, has urine always been dark and cloudy or is this new, etc)

Review past meds especially did he get the Percocet anytime recently (remember it has tylenol which can decrease an otherwise higher fever).

I would order CBC, BMP, PT/PTT INR (in case he needs to go back to surgery they often like to know) and an abdominal x-ray. Depending on his vitals presentation I would expand to include an abg, and an ekg (if HR was changed and he was having trouble breathing)

Armed with this information - I would page the surgeon and call our inhouse hospitalist team if I was truly worried.

My concerns would be sepsis, perhap a perforation, or ileus (but keep an open mind for something else). Depending on the presentation he would either go to ICU or directly back to OR.

Assessment and trends will be your friends here - BP 85/42? normally 115/61 (could be a problem). HR 99 normally 60 (more convinced a problem)? Temp 99.8 but just had two percocet 1 hr ago? (things are looking worse) Pt says he feels like he is going to die? (Start getting really worried and pick up the pace!)

Hope this all helps

Pat

[Virgo_RN, BSN, RN]

my understanding of sirs and sepsis is that sirs has all the signs and symptoms of sepsis without the proof of an infection. once an infection is proven to be present then it officially becomes sepsis.

criteria for sirs is based upon the presence of two or more of the following signs/symptoms:

• pulse > 90 beats per minute
  
• temperature > 38° c or
• respirations > 20 breaths per minute or, blood gas of paco2
• white blood cell count 12,000 cells/mm³ or the presence of greater than 10% immature neutrophils

organ failure is a complication of sirs or sepsis. the scenario, however, only gives a symptom of a low grade fever with nothing about the other vital signs or labs.

the point being, that we do not have enough information to know what is going on with this patient. the goal of the exercise, it seems, is to get the students thinking and using the nursing process.

[Daytonite, BSN, RN]

The point being, that we do not have enough information to know what is going on with this patient. The goal of the exercise, it seems, is to get the students thinking and using the nursing process.

Absolutely! Agreed! To think and make decisions requires possession of as much knowledge as is available.

OP. . .I would note the post by patwil73. The simulator may ask what you would do for this patient and this poster pretty much nailed it on the head. Symptoms (manifestations) appear as pathology of a condition proceeds untreated. Follow the steps of the nursing process. Be cautious to the simulator giving you questions that place you somewhere within the steps of the nursing process already in action so you don't get confused as to what you should be doing at that point in time. The simulator is testing your critical thinking ability.

[cocolococna]

Absolutely! Agreed! To think and make decisions requires possession of as much knowledge as is available.

OP. . .I would note the post by patwil73. The simulator may ask what you would do for this patient and this poster pretty much nailed it on the head. Symptoms (manifestations) appear as pathology of a condition proceeds untreated. Follow the steps of the nursing process. Be cautious to the simulator giving you questions that place you somewhere within the steps of the nursing process already in action so you don't get confused as to what you should be doing at that point in time. The simulator is testing your critical thinking ability.

your info. was extremely helpful. I sent the websites to my teacher to pass on to the class. I will let everyone know how it goes. Thanks!