Acute/ Chronic Renal Failure

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Hi guys,

just took my test (school test), and there was a question that I kept going back and forth and could not make up my mind which one to pick as an answer. The question was asking about. which patient does the RN need to see first after receiving the change of shift report. I eliminated 2 asnwers, and 2 were left: 1.) ESRD patient who started experiencing a new frequent oncet of early ventricular contractions, 2.) ARF patient who was Kussmauling with the rate of 26 breaths/ min, HR 100. They both are important, first one I thought was leading towards V-Fib? and the second one was in met. acidosis? So, which one you would assess 1st, correct me if I'm wrong and if someone could explain the rationals would really appreciate. Thank you guys!!!

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Hi guys,

just took my test (school test), and there was a question that I kept going back and forth and could not make up my mind which one to pick as an answer. The question was asking about. which patient does the RN need to see first after receiving the change of shift report. I eliminated 2 asnwers, and 2 were left: 1.) ESRD patient who started experiencing a new frequent oncet of early ventricular contractions, 2.) ARF patient who was Kussmauling with the rate of 26 breaths/ min, HR 100. They both are important, first one I thought was leading towards V-Fib? and the second one was in met. acidosis? So, which one you would assess 1st, correct me if I'm wrong and if someone could explain the rationals would really appreciate. Thank you guys!!!

Nursing test questions are notorious for questions like this.

Hint: when faced with one of these, "but I don't have all the information" questions that any logical brain would ask, don't read too much into them.

Which scenario (based on the limited data you've been given) could more immediately lead to death?

Someone with metabolic acidosis and a RR of 26, or a known ESRD patient with with significant EKG changes from baseline?

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Specializes in Dialysis.

PVC's are not life threatening. Metabolic acidosis is. This patient's kidneys have lost their ability to regulate acid/base and the pt is not going to last long without mechanical ventilation or emergent dialysis.

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Definitely the Kussmaul patient. The one with PVCs likely recently returned from dialysis so he just had a big drop in his K+ and is experiencing relative hypokalemia. He can handle the PVCs (for now) but an ACUTE renal failure patient is already showing signs of decompensating and needs intervention ASAP.

edit: We're not just talking about DKA here, we're talking about an emergent sign of coma or death.

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First one I thought was leading towards V-Fib?

Also, PVCs are more likely to lead toward V-tach esp in the setting of hypokalemia.

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Lol.

This is the classically aggravating test question because we don't have enough info.

Don't freak out at "acute," "ARF" and "Kussmaul."

If I'm taking what they give me at face value (which is minimal info) I'm going to be looking at which patient is in more imminent danger of dying...now.

An acidotic (yes, acidosis is a big deal) patient with a RR 26 and a HR of 100 or, an ESRD patient with a "new and frequent" onset of PVC's.

Think about it.

The acidotic patient with the RR of 26, or the patient having a sudden onset of a new, and potentially life-threatening hemodynamic instability...

People wave off PVC's because we see them so often...however in this case specifically, because these PVC's are "new and frequent"...the patient needs immediate asessment.

New and frequent PVC's can lead to V-tach in minutes or less, depending upon underlying etiolgies.

My .02.

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Definitely the Kussmaul patient. The one with PVCs likely recently returned from dialysis so he just had a big drop in his K+ and is experiencing relative hypokalemia. He can handle the PVCs (for now) but an ACUTE renal failure patient is already showing signs of decompensating and needs intervention ASAP.

edit: We're not just talking about DKA here, we're talking about an emergent sign of coma or death.

First, you're "assuming" a scenario in the test question, that hasn't been given.

Second, let's for fun assume this patient just returned from a dialysis tx as you suggested. Hypokalemia, even mild, is much less tolererated by an ESRD patient than a hyperkalemic state...

Hypokalemia - New Treatments, August 1, 2011:

Cardiac Effects

The most lethal consequence of hypokalemia is cardiac arrhythmias.

Electrocardiographic Effects. U waves >1 mm in height, T waves in the same lead; ST segment depression; T wave flattening, followed by inversion.

Atrial and ventricular ectopy, including ectopic atrial tachycardia, atrioventricular blocks, premature ventricular contractions, ventricular tachycardia and fibrillation.

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Specializes in Dialysis.

About the only thing that we can all agree on is this is a crummy question. PVC's signal nothing more than cardiac irritability. The real question is it because of cardiac ischemia, electrolytes, or one too many cups of coffee? There is some time to think about it unless you can show some hemodynamic instability from the ectopy. The patient with acidosis is heading for a crash at the point his respiratory system can't compensate for what his kidneys should be doing.

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About the only thing that we can all agree on is this is a crummy question..

The question is so crummy it's awesome. :)

And come to think of it, acidosis can cause hypercalcemia which isn't necessarily heart-friendly...so you've got a point there...

Wheeeee! Isn't it fun? :)

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