Question

Joyce Jones, age 45, was admitted to the emergency room following a major automobile accident in which her husband was killed. She had massive abdominal injuries and a fractured femur. She was taken immediately to surgery for repair of a lacerated liver and perforated ileum. She had two units of blood during surgery and two units while she was in the recovery room. The fifth unit of blood was discontinued in surgical intensive care because she developed a transfusion reaction.

   On the day after surgery, her urine output declined to 10-20 ml/hr. Increasing her fluid intake with plasma expanders and blood did not increase her urine output. Lab results indicated an elevated urinary sodium, BUN 70 mg/dl, and serum creatinine 4 mg/dl.

   Her urine output stabilized at 20-25 ml/hr on the third day after surgery. She was diagnosed as having acute tubular necrosis.

   Because of a persistently elevated serum potassium and severe hypertension (BP 190/120), she was started on hemodialysis using an external cannula. She resented all the “plumbing” in her body and expressed a desire to die.

Questions:

1. What clinical indicators that Joyce is in the oliguric phase of acute renal failure?
2. How could you assist Joyce in dealing with her depression?
3. What are the usual indications for using hemodialysis in the management of acute renal failure?    
4. What is the nursing care of the external cannula when not in use?
5. What is the goal of medical and nursing management of this patient?

Answer 1

Ans.

1)

Common Clinical Indicators for Acute Kidney Injury/Failure:

• Decreased urine production-less than 0.5 mL per kg per hour for more than 6 hours
• Edema
• Confusion
• Fatigue/lethargy
• Nausea/vomiting/diarrhea
• Abdominal pain
• Metal taste in mouth
• Increased BUN
• Increased serum creatinine level-increased in greater or equal to 0.3 mg per dL or greater than or equal to 1.5 to twice the patient’s baseline
• Increased potassium
• Anemia
• Proteinuria
• Metabolic acidosis
• Seizures
• Coma
• Abnormal GFR
• Chest pain/pressure

Common Clinical Indicators for Acute Kidney Injury/Failure:

Edema. Confusion. Fatigue/lethargy. Nausea/vomiting/diarrhea.

Oliguric Phase: The most common initial clinical mani- festation of AKI is oliguria, defined as a reduction in urine output less than 400 mL/day. Oliguria is manifested with- in 1 to 7 days of kidney injury. This phase typically lasts 10 to 14 days but can last months in some cases.

2)

Indications for dialysis (ie, renal replacement therapy) in patients with AKI are as follows: Volume expansion that cannot be managed with diuretics. Hyperkalemia refractory to medical therapy. Correction of severe acid-base disturbances that are refractory to medical therapy.

When the patient is euvolemic, or even volume overloaded, and still remains oliguric despite maximal support, one should not await further organ damage, and dialysis should be initiated

Dialysis is the removal of substances from intravascular circulation by filtration.1 Typically, dialysis is ordered when kidney function declines to 10–15% of normal function.2 The National Kidney Foundation’s Kidney Disease Outcome Quality Initiative (K/DOQI) recommends that planning for dialysis begin when patients reach chronic kidney disease stage 4, which is when glomerular filtration rate or creatinine clearance reaches below below 30 mL/min.3 However, this is not the only indication for the initiation dialysis. A subset of acute and chronic renal failure indications are provided below:4

Indications of dialysis in acute renal failure (ARF)

Severe fluid overload

Refractory hypertension

Uncontrollable hyperkalemia

Nausea, vomiting, poor appetite, gastritis with hemorrhage

Lethargy, malaise, somnolence, stupor, coma, delirium, asterixis, tremor, seizures,

Pericarditis (risk of hemorrhage or tamponade)

bleeding diathesis (epistaxis, gastrointestinal (GI) bleeding and etc.)

Severe metabolic acidosis

Blood urea nitrogen (BUN) > 70–100 mg/dl

Indications of dialysis in chronic renal failure (CRF)

Pericarditis

Fluid overload or pulmonary edema refractory to diuretics

Accelerated hypertension poorly responsive to antihypertensives

Progressive uremic encephalopathy or neuropathy such as confusion, asterixis, myoclonus, wrist or foot drop, seizures

Bleeding diathesis attributable to uremia

A simple mnemonic is used to remember the indications for dialysis: A-E-I-O-U.5

Dialysis: Indications

AEIOU:

Acid-base problems

Electrolyte problems

Intoxications

Overload, fluid

Uremic symptoms

The normal bodily pH averages 7.4. Respiratory centers act to maintain the pH between 7.35 and 7.45 and the kidneys act to remove bicarbonate or ammonium in response to acid-base changes. In severe kidney disease, this homeostatic mechanism is disrupted, and the body can rapidly turn acidotic or alkalotic regardless of compensation from the respiratory centers. This acid-base problem is an indication for dialysis, where these molecules can be removed and normal pH can be restored.6

The kidneys normally actively secrete potassium from the distal convoluted tubule and loops of Henle. When kidney failure or injury sets in, hyperkalemia can easily develop. Symptoms of hyperkalemia include fatigue, myalgia, and muscular weakness. Severe hyperkalemia can present as tented T-waves on an EKG and progression to ventricular fibrillation. Dialysis removes excess potassium from the bloodstream and returns the body back down to physiological levels.6

Overdose and intoxication of substances that are found in the blood may be an indication for dialysis. These drugs should have a low volume of distribution and shouldn’t be highly bound to plasma proteins. Unfortunately, some common overdose or intoxicant drugs like digoxin and tricyclic antidepressants have volumes of distribution in hundreds of liters, and are not readily removed by dialysis.6 Ethanol is easily removed via dialysis, as are some anti retroviral drugs, aminoglycosides, and antibiotics.7

Indications for fluid resuscitation are numerous, ranging from hypovolemia to hypotension.6 When patients regain clinically acceptable statuses, the fluids administered are then considered to be fluid overloads, and should be removed to prevent iatrogenic heart failure. Dialysis can be used to remove excess fluids from patients’ bodies.

Uremia often develops in chronic kidney failure, brought on by the inability to excrete nitrogenous wastes, parathyroid hormone, proteins and other physiological substances in toxic levels.8 Since these substances are floating in the bloodstream, dialysis can easily clear the body of these toxins to restore physiological homeostasis.

3)

What is the nursing care of the external cannula when not in use?

It’s a large catheter and big vessel watch for bleeding, maintain sterile technique when
changing dressing ( Q3rd day), watch for S/Sx of infection ( errythema, drainage,fever

4)

What is the goal of medical and nursing management of this patient?

Maintain fluid balance and maintain perfusion.
Goal: to stop and reverse ARF
Focus: watch patient status continuously (ICU), adequately hydrate, replace blood as
needed, watch for cont. blood loss, prevent infection (administer prophylactic
antibiotic)