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
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
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.
A patient doesn't need to have IVF just to receive the Vanco. The first thing that I think needs to be addressed is the lack of bowel sounds. He's nauseated and vomiting and hasn't had a bowel movement. No bowel sounds. Seems like he might have a bowel obstruction or an ileus. Is his abdomen soft or firm? Sorry had to reread. Perhaps he's septic. He's got a fever, low grade but has one, low urine output. And his wound is positive for MRSA. Perhaps he needs some IVF. I wouldn't jump right out and say dialysis. I think he's septic.
Last edit by RN1982 on Oct 25, '08
I agree with Michigan, I don't think dialysis is in order.
How do you know he's acute renal failure? He could just be volume depleted. You need to know what his current BUN/Cr are to decide ARF verses dehydration. You would also need to know his vital signs other than the low grade temp.
I think with the n/v the patient should be made NPO and given IVF's begining perhaps with a bolus to fluid resuscitate/challenge him.
Also if he does have ARF, note that the IV Vancomycin ordered might be a nephrotoxic dose. I'm not sure if any of the other meds are nephrotoxic either.
On the other hand, he could have too much fluid on board and need a diruetic. What do his lungs sound like? Any edema anywhere. Skin turgor?
First do a good head to toe systematic assessment, review vitals and labs....then "diagnose"....then come up with interventions......depending on your findings........i.e. fluid bolus, diuretics, dialysis, etc.
Last edit by Tweety on Oct 25, '08