Renal Case Studies

1
Renal Case Studies

• Nursing 2904
• Carol Isaac MacKusick, MSN, RN, CNN

2
Maria

• Maria is a 38 year old female, admitted to the
  hospital via the ED after being involved in a
  serious MVA.
• At the scene, EMTs noted the following
• BP 76/42
• Tight belly, hypoactive bowel sounds
• Pt c/o abdominal pain

3
Maria

• It is revealed that rescue of the client from the
  auto took approximately 45 minutes. It is
  assumed that help arrived on the scene 30 45
  minutes after the accident occurred
• Upon exam in the ED, it was noted that her spleen
  was ruptured immediate surgery was performed

4
Maria

• Family members state that there is no significant
  medical history with Maria
• She is a Hispanic female, slightly overweight at
  146 pounds, height is 5 foot 3 inches
• She is a first grade teacher
• She is a practicing Catholic
• She is single

5
Maria

• After surgery, Maria is transferred to the ICU of
  the hospital
• 2 days post surgery, you notice that urine output
  has decreased to approximately 25 ml / hour times
  2 hours
• Maria is relatively well controlled for pain at
  this point, and she is alert and oriented

6
Maria

• After initial injury, how did Marias body
  respond to the low blood pressure she was
  experiencing?
• Osmoreceptors inhibit ADH production
• Stretch receptors vasoconstrict peripheral
  arterioles
• Chemoreceptors stimulate production of
  aldosterone
• Baroreceptors stimulate ADH production

7
Maria

• Which type of ARF is Maria most at risk for
  developing?
• ATN
• Postrenal
• Prerenal
• intrarenal

8
Maria

• Five days have passed since the accident.
  Marias urine output has fallen to 350 ml / 24
  hours. Her MD orders a diuretic challenge, and
  no response is noted. Her BP is 165/94. Maria
  appears anxious, edematous, and c/o shortness of
  breath. Her weight has increased 2.1 kgs since
  admission.

9
Maria

• What is happening to Maria?
• Prerenal failure
• ATN
• Postrenal failure
• Intrarenal failure

10
Maria

• Marias BUN is 100 mg / dl. She is confused and
  drowsy. She has a diagnosis of ARF secondary to
  acute tubular necrosis. Her urine output has
  remained at 350 ml / day for the last 3 days.

11
Maria

• What stage of ARF is Maria in?
• Oliguric / anuric
• Onset
• Early diuresis
• Late diuresis

12
Maria

• Maria c/o extreme thirst. Together with the
  dietitian, you compute her daily fluid allowance
  to be
• As tolerated
• 200 ml / hour
• 2000 ml / day
• 850 ml / day

13
Maria

• One week has passed. Marias urine output has
  increased slightly, and is now 450 ml / 24 hours.
  Her BUN and CrS have stabilized.

14
Maria

• According to the latest data, which of the
  following stages of ARF is Maria in?
• Oliguric / anuric
• Late diuresis
• Onset
• Early diuresis

15
Maria

• Maria is experiencing what you believe to be
  uremic syndrome. She is complaining of tingling
  and numbness of her hands and feet. She is
  easily bruised, and has a slight urine odor to
  her skin.

16
Maria

• The tingling and numbness are most likely caused
  by
• Hyperkalemia
• Hypocalcemia
• Stimulated stretch receptors
• Peripheral neuropathy

17
Maria

• Skin bruising in ARF is secondary to the effects
  of
• Her EPO injections
• Decreased NH4 levels
• Severe hypocalcemia
• Uremic toxins affecting platelet aggregation

18
Maria

• Marias PO4 level is elevated. Why?
• Hypermagnesemia
• Hypocalcemia
• Hypomagnesemia
• hypercalcemia

19
Maria

• You know that Maria is at risk for development of
  metabolic acidosis primarily due to
• Decreased excretion of K
• Increased excretion of hydrogen ions
• Increased excretion of K
• Decreased excretion of hydrogen ions

20
Maria

• Maria has an order to receive emergent dialysis.
  She is hemodynamically stable, and she is 8 days
  post abdominal surgery. She has generalized
  edema, and severe electrolyte abnormalities.

21
Maria

• What type of dialysis therapy should Maria most
  likely receive?
• Hemodialysis
• Peritoneal dialysis
• SCUF
• CVVHD

22
Maria

• Marias urinary output returns to normal. Her
  BUN and CrS are stable, as are all other major
  electrolytes. Her GFR is computed at 90 ml /
  min. She is to be discharged home for further
  recovery.

23
Maria

• Maria asks how long her kidneys will not work at
  100. You reply
• Your kidneys will never be the same
• You should continue to see improvement over the
  next year
• Things will actually get worse for you over the
  next 6 12 months, and you should plan on
  scheduling regular dialysis treatments
• This is a normal kidney function

24
Maria

• How long will Maria remain in the convalescent
  phase of ARF?
• 3 4 weeks
• Three months
• 6 12 months
• Forever

25
Maria

• During the convalescent phase, it is important
  for Maria to avoid
• Fatty foods
• NSAIDs and OTC herbals and cold medicines
• High protein diets
• Contrast dye