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.

[cocolococna]

It doesn't matter if your scenario is ARF, what the patient is presenting to you, suggests otherwise. You can't just determine that the patient needs dialysis because the urine output is 250/12hours. To me thats big woop. The patient has a positive wound culture, low grade fever, is vomiting, no bowel sounds, no bowel movement. Are you trying to convince me that the patient is truly in acute renal failure? It's not working. Plus you do not have a current set of labs to back it up. You are not looking at the big picture. There is something else going on with the patient which is causing the acute renal failure. That is what you should focus on.

Can you tell me how the other group killed Stan? I bet they suggested dialysis.

O.K. I get it. I don't know how the other group killed him, but they were the first to use the simulator. A good assessment head to toe is first. Knowing what to look for is helpful. Thank you. I will let you know how it goes with "Stan".

[TiredMD]

Think less about the kidneys and more about the liver.

[nursej22, MSN, RN]

My first thought in reading this was it sounds like a scenario for med students not nursing. But on second thought I realize that nurses are expected to know what patients needs and nudge the doctor in the right direction using SBAR.

I agree with previous posters: thorough head to toe assessment, and VS. Pt needs labs--metabolic panel, CBC, maybe lactate, lipase, amylase, and abd xray to check for ileus. If the pt is in ARF as determined by the the BUN/Cr. they will need fluids, most likely NS, but if they are acidotic, might get bicarb. Vanco dosing will depend on renal function. A nephrology consult may be ordered.

Nursing priorities would be ABCs and pain control.

[casi, ASN, RN]

I'm a fellow nursing student also in the middle of the renal section.

I wouldn't jump to ARF right away.

My first concern would be possible bowel obstruction. I'd bug the doc for an abd xray.

His output would only really concern me if his lungs sounded wet, his intake vs output were off, and he had an increase in weight since surgery. I'd also want my renal labs and electrolytes stat. Once labs come back and I/O, lung sounds, edema, and weight had been assessed I'd worry about his output. It's important to note that his IV was locked the day before and he's not tolerating liquids well at all. When assessing I/Os consider emesis another form of output.

[cherrybreeze, ADN, RN]

I feel at a total loss without any labwork. You need those now, not in the morning. Change them to stat. Add a Vanco peak and trough to that, too, to see if his dose is theraputic.

Classic signs/symptoms of a post op ileus, so he needs to be NPO, have an abd xray.

There's a lot more that's already been addressed, so I won't repeat. Just a couple of thoughts.

[Daytonite, BSN, RN]

these case scenarios are to teach you to problem solve. can you not think of the one major tool that nursing school gives you to help problem solve?

the nursing process

to solve this case, begin working through the steps of the nursing process starting with assessment. prioritize the problems and treatments using maslow's hierarchy of needs unless your program wants you to use some other guideline. it is my habit to group information and symptoms in these case scenarios so that they make more sense to me. keep in mind that they are given to you to stimulate critical thinking. many times there are red herrings thrown in all over the place. just because there is a medical diagnosis thrown in the title, keep in mind that you are in nursing school. we are not doctors although we need to be aware of what doctors are likely to order.

step 1 assessment - collect data from medical record, do a physical assessment of the patient, assess adl's, look up information about your patient's medical diseases/conditions to learn about the signs and symptoms and pathophysiology

• emergency open cholecystectomy for obstructive jaundice
  • http://www.surgeryencyclopedia.com/ce-fi/cholecystectomy.html - cholecystectomy
    
  • complications of general anesthesia include breathing problems (atelectasis, hypoxia, pneumonia, pulmonary embolism), hypotension (shock, hemorrhage), thrombophlebitis in the lower extremity, elevated or depressed temperature, any number of problems with the incision/wound (dehiscence, evisceration, infection), fluid and electrolyte imbalances, urinary retention, constipation, surgical pain, nausea/vomiting (paralytic ileus)

  [*]surgical wound is positive for methicillin resistant staphylococcus aureus (mrsa)

  [*]history of hypertension

  [*]history of hyperlipidemia

  [*]acute renal failure

  • http://www.fpnotebook.com/renal/failure/actrnlflr.htm
    
  • http://www.fpnotebook.com/renal/failure/actrnlflrcs.htm - causes
    
  • http://www.merck.com/mmpe/sec17/ch233/ch233b.html - acute renal failure - signs and symptoms

  [*]smokes one pack of cigarettes per day

  [*]allergic to penicillin

  [*]atorvastatin (takes at home) - lipitor

  [*]baby aspirin (takes at home)

  • treatments:
    • saline lock
      
    • saline lock flush 0.9% ns every shift
      
    • clear liquid diet
      
    • incentive spirometer
      
    • treated with vancomycin
      
    • in contact isolation

    [*]medications:

    • vancomycin 1g every 12 hours (side effects are nausea, nephrotoxicity--look for elevated bun--uremia, leukopenia, neutropenia)
      
    • enalapril 20 mg po once daily (antihypertensive - renal failure is a life threatening side effect of this drug)
      
    • atirvastatub 10 mg po once daily (is this the same lipitor - atorvastatin - listed above that he takes at home? it causes liver dysfunction)
      
    • hydromorphone 1-2 mg every 2-4 hours ivp prn pain (causes respiratory depression)
      
    • 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 (levenox) 40 mg sq once daily (side effects include hemorrhage and thrombocytopenia)

    [*]lab

    • cbc, electrolytes, bun, creatinine, glucose in am

step #2 determination of the patient's problem(s)/nursing diagnosis - make a list of the abnormal assessment data - match your abnormal assessment data to likely nursing diagnoses, decide on the nursing diagnoses to use

• weighs 100 kg (220 lbs)
  
• admitted with complaints of abdominal pain and yellow skin
  
• third post-op day:
  • nausea (ileus, arf?)
    
  • vomiting (ileus, arf?)
    
  • absent bowel sounds (ileus)
    
  • urine output 250ml/12 hour shift (arf)
    
  • low grade fever (the mrsa?)
    
  • no bowel movement (ileus)

the fall in urine output is the first sign of the arf. the nausea and vomiting are signs that it is worsening. they, along with no bowel movement, are also a sign of no paristalsis which happens when there is gi surgery. the bun and creatinine will probably be elevated. the cause? could be renal disease from his hypertension or toxicity from his enalalpril use. with hypertension, hyperlipidemia and a smoking history this man's arteries are probably a constricted mess and if it wasn't his kidneys, it would have been his brain, lungs or his heart that had a problem eventually. vancomycin is also nephrotoxic, but was he getting it long enough to cause this much of a response?

[lsyorke, RN]

The fall in urine output is the first sign of the ARF. The nausea and vomiting are signs that it is worsening.

I have to disagree. The fall in urine output occurred after the discontinuation of IV fluids and in the presence of vomiting. Dehydration should be the first consideration, in the absence of labs. Not saying that ARF may not be a potential cause, but it's not the first one that should be jumped on with the lack of information provided.

[Daytonite, BSN, RN]

I have to disagree. The fall in urine output occurred after the discontinuation of IV fluids and in the presence of vomiting. Dehydration should be the first consideration, in the absence of labs. Not saying that ARF may not be a potential cause, but it's not the first one that should be jumped on with the lack of information provided.

Read the information on Acute Renal Failure in the Merck Manual that I referenced. The OP is doing an assignment for school and needs referenced facts. The information that is supplied in the scenario and its relationship to textbook information is not a mistake.

[TiredMD]

This case scenario is a classic presentation of acute cholangitis. Since the patient is receiving Vancomycin, which does not cover enteric organisms, he is essentially receiving no treatment for his condition. Mortality is high.

[lsyorke, RN]

Maybe I'm not understanding what they're supposed to be doing. Are they supposed to find the signs of ARF, or figure out the priorities and their possible causes with this patient?

[leslie :-D]

This case scenario is a classic presentation of acute cholangitis. Since the patient is receiving Vancomycin, which does not cover enteric organisms, he is essentially receiving no treatment for his condition. Mortality is high.

'

so how would decreased urine fit in?

it sounds like the pt is septic...

leslie

[TiredMD]

'

so how would decreased urine fit in?

it sounds like the pt is septic...

leslie

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