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]

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.

[RN1982]

You have to look at the big picture. Yeah, maybe down the line the patient may need dialysis. I've never had a patient receive dialysis because urine output is 250/12 hours. You need to look at all of your info. Fever, low urine output, no bowel sounds, patient is n/v, no bowel movement, positive for MRSA in surgical wound. You can't conclude from that info that dialysis is the appropriate treatment at the moment.

[Tweety, BSN, RN]

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.

[cocolococna]

I guess you are right. What kind of IV fluid should be hung. What do you suggest is the nursing priority?

[Tweety, BSN, RN]

Being old school, I'm not sure what you mean by "we have to do acute renal failure". So you already know the patient is in acute renal failure?

In this case, the Vancomycin might be part of the problem, coupled with the n/v.

Still you'd want to fluid challenge the patient to see if the kidneys respond.

[cocolococna]

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

[lsyorke, RN]

Flat and upright xray of the abdomen to rule out ileus/obstruction/perforation....NGT if confirmed. Ambulate the patient, IV fluids, hold po meds(switch to IV antihypertensives). Low grade temp 72 hours post op is not unusual. CBC,BUN, CREAT stat.

This does not appear to be a renal failure scenario(especially in the absence of a creatinine level), this is a post op intestinal problem.

[lsyorke, 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

You can't determine acute renal failure without a bun/creatinine. Remember...this may be a scenario that is testing your knowledge in renal failure...which means that you have to be able to tell when it's NOT renal failure.

[Tweety, 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

Then I like my answer better. The nursing priority would be first to do a thorough assessment, (mindful of the ABC's of course), getting some current labs is important too, and a review of the vital signs.

N/V, fever, sepsis can precipitate ARF, so your patient is at great risk here.

Also, as the above person mentioned n/v with the absence of bowel movement is telltale of a post-op ileus....you also need to know if he's passing flatus, is his abdomen distended, and what the bowel sounds are like.

Again, getting a thorough head-to-toe assessment, vital signs, and reviewing current labs will give you plenty of good information on how to proceed.

[RN1982]

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.

[cocolococna]

I guess that is what our teacher is expecting. It sounds right on target.