Question

Ms. Barkley is a thin & frail 64 year-old that is presenting to the ED from a nursing home for acute abdominal pain, nausea & vomiting x2 days. She receives a CT scan to further evaluate the pain. The findings show no acute bleeding, but with a small bowel obstruction. She is being admitted for bowel rest. You receive the following orders from the provider:

• Continuous telemetry

• Strict I/O

• Keep SpO2 >92%

• Strict NPO

• Hydrocodone/Acetaminophen 5-352 q6 PRN

• Ondansetron 4mg PRN

She is admitted to the unit & the CNA reports the following vitals to you:

HR 103, RR 16, BP 118/68, SpO2 96%, pain 6/10. At the end of the shift, you note that the patient has not voided all shift. You help her up to the bathroom & she voids 200ml of very dark, concentrated, foul-smelling urine.

1. As the nurse, what should you do with this information?

2. What diagnostic workup would you anticipate?

The provider orders a 1L bolus of saline and labs to be drawn. 6 hours after the bolus, the nurse performs a bladder scan on the patient, which reveals 60ml of urine. Further assessment shows that Ms. Barkley has crackles in her lungs & her SpO2 is 89%. The renal function panel drawn earlier has the following pertinent results: creatinine 3.6, BUN 56, KCl 5.5, Mg 1.4.

3. What orders would you expect from the provider?

4. What do you anticipate is physiologically going on with Ms. Barkley? How is this treated?

Over the past few days, Ms. Barkley begins to show renal improvement. Her urine output improves, in addition to her renal function labs. Her small bowel obstruction resolves without surgical intervention & she is able to begin taking in PO food & fluids.

5. How could this complication have been prevented in Ms. Barkley?

Answer 1

1. As the nurse, what should you do with this information?

• Check her intake and output chart and asses
• Check for dehydration
• Check kidney function
• Check for side effects of any medication she's taking

2. What diagnostic workup would you anticipate?

• Upper urinary tract infection
• Severe dehydration
• Kidney failure
• Metabolic disorders
• Diabetes
• Bladder infections

3. What orders would you expect from the provider?

In this condition, elevated serum creatinine level (1.5 to 3.0 mg/dL),chronic renal insufficiency is present and implies that progression to CRF and ESRD is suspected.

Orders to expect

• trimethoprim-sulfamethoxazole (antibiotic) and the H2-blocker cimetidine are 2 commonly prescribed drugs that lowers the secretion of creatinine.
• WH 30+
• Chitosan suppliments

4. What do you anticipate is physiologically going on with Ms. Barkley? How is this treated?

• Acute renal failure
• Bladder infections
• Severe dehydration
• BUN
• Diabetes
• Metabolic disorders

Treatment

1. Treated with antibiotics and h2 blockers
2. Hydrate the patient
3. Avoid vigorous activities
4. Reduce high protein intake

5. How could this complication have been prevented in Ms. Barkley?

It could have been prevented by taking plenty of oral inputs to keep her hydrated every time. And by dietary changes.