Question

A.S. is a 70-year-old white woman who presented to the emergency department because of a 4-day history of increased shortness of breath and generalized weakness. A.S. stated that she has been able to do her daily chores at home independently, but for the past few days, it was getting difficult for her to get around and that she needed to take frequent breaks because she was short of breath and had no energy. She has a long history of heart failure, type 2 diabetes, and hypertension. She is admitted with a tentative diagnosis of acute kidney injury (AKI).

Subjective Data

• Has been having headaches on and off, with nausea and dizziness
• Reported that she had not been taking her medications regularly at home because of “forgetfulness”
• Has not been urinating a lot
• Feels “puffy” in her legs and hands

Objective Data

Physical Examination

• Blood pressure 178/96, pulse 110, temperature 98.9°F, respirations 24, and an oxygenation of 93% on room air
• Alert and oriented to person, place, and time
• Mild jugular venous distention
• Fine crackles in bilateral lower lobes
• Heart rate regular, no murmurs
• Bowel sounds normoactive and present in all four quadrants
• 2+ edema bilateral lower extremities and hands

Diagnostic Studies

• Echocardiogram shows decreased left ventricular function
• Urinalysis: Urine dark yellow and cloudy, protein 28 mg/dL, negative for glucose and ketones, positive for casts, red blood cells and white blood cells
• 24-hour urine output = 380 mL
• Laboratory Tests:

*	Hemoglobin	8 g/dL
*	Hematocrit	23.8%
*	RBC	2.57 million/mm3
*	WBC	4.7 mm3
*	Sodium	132 mEq/L
*	Potassium	5.2 mEq/L
*	Calcium	9 mg/dL
*	BUN	36 mg/dL
*	Creatinine	4.9 mg/dL
*	BNP	182 pg/mL

Case Study Questions

                        Name:                                                                         Date:

• 1. A.S. has to have a 24-hour urine collection performed, as she is not urinating a lot. Describe in steps the collection procedure by the nurse.
• 2. What is your interpretation of A.S.'s BUN, Cr, and BNP?

BUN (10 -20 mg/dL)

Cr (<1.2 mg/dL for women <1.4 mg/dL for men)

BNP (<100 pg/mL):

3. Should you be concerned about A.S..'s potassium level of 5.2 meq/L? (Yes/No)

List two treatment types that the health care provider might prescribe if deciding to treat A. S. hyperkalemia.

1.

2.

• 4. Based on A.S.’s presentation, what nursing assessments, interventions, and monitoring skills need to be performed by you the registered nurse? Student must list at least six:
• 5. What orders do you as the nurse, anticipate the physician will order? Student must list at least six (frequencies not necessary to list; only what you think the physician will order):

6. Explain what might have contributed to A.S.’s present condition as described above? What are two evidence-based preventive health care provisions/programs that if put in place early might have prevented this from occurring?

Explain what might have contributed to A.S.’s present condition:

Evidence-based Preventive Health Care Provisions/Programs:

1.

2.

7. What is the significance of A.S.’s Hemoglobin, Hematocrit, and RBC levels being significantly decreased?

8. You are planning discharge for A.S. What would you include in your discharge instructions/teachings and what other interdisciplinaries/health professionals would you include? Student must list at least five each:

Nursing Teaching/Instructions                    Other Health Professionals

1.                                                             1.
2.                                                             2.
3.                                                             3.
4.                                                             4.
5.                                                             5.

Answer 1

1.A.S. has to have a 24-hour urine collection performed, as she is not urinating a lot. Describe in steps the collection procedure by the nurse.

Answer:

As A.S is not having adequate urinary output, measurement of 24 hour urine output is required in order to understand the status of the kidneys, their  functioning and the need for a renal replacement therapy.

The standard procedure of 24 hour urinary collection :

1.Patient counselling

The nurse must explain the procedure to the patient that the urine for 24 hours has to be collected in order to understand exact urine output,complete the urinary analysis and obtain results for deciding further treatment.

2.Arranging supplies:

The nurse must arrange the supplies required for the procedure which are gloves, bedpan or bedside urinal, a large sterile bottle with cap or stopper ,a measuring cylinder/graduate  and arrange for cool storage/clean refrigerated storage.

3. preparation for the procedure:

All the supplies are collected and the bottle is labelled appropriately with the patient's name, age,sex and the inpatient number including the time of starting the urinary collection

4.Collection of urine sample.

The overnight sample of the urine need not be collected and the patient is asked to void  the the overnight urine into the toilet and flush it. The collection of urine starts after the patient has voided the overnight urine. The time of the collection of the first urine sample is noted.

The patient is explained about the procedure of urine collection into a bedpan or bedside urinal and the same is measured and transferred  to the urine bottle using proper hygienic precautions.

5.Storing urine.

The bottle can be stored in a cool environnement / refrigerator or an ice cooler with proper sterile hygienic precautions.

Once the 24 hours urine has been collected,the bottle is then sent to the laboratory for investigations.

Practical considerations for urine collection in A,S

As A.S is  70 years old, has dizziness, nausea ,increased shortness of breath and generalized weakness. and also has forgetfulness with respect to her medications, it is probable that the patient may not comply with the 24-hour urine collection instructions, forgetting to use the bedpan or bedside urinal or to keep the urine aside for transfer of the urine into the bottle.also patient has low urine output. Hence it may be advisable that the nurse inserts a foley's catheter into the urinary bladder with proper sterile precautions noting the time of insertion.

The first free flow of urine in the urine bag is discarded  and then foley's is connected to a urinary bag to start collecting the erine for 24 hours, in order to know the 24 hour urine volume.

What is your interpretation of A.S.'s BUN, Cr, and BNP?

Answer:

A.S has an increase in the levels of blood urea nitrogen, serum creatinine and BNP which indicate that she is suffering from acute kidney injury, heart failure and renal failure

Her levels of BUN, Cr, and BNPare elevated.
1.Cr (<1.2 mg/dL for women <1.4 mg/dL for men)--patient's value --4.9 mg/dL--elevated

2.BUN (10 -20 mg/dL)patient's value--36 mg/dL-elevated

The increase in blood urea nitrogen and blood creatinine levels in the setting of decreased urine output indicates acute kidney injury and acute renal failure

3.BNP (<100 pg/mL):patient's value 182pg/ml---elevated

The elevations of the baseline levels of BNP are seen in patients with acute and chronic renal failure, hypertension and patients with cardiac diseases ,old age and female sex which are the factors present causing the elevation of this level  in A.S.

Elevations of BNP levels greater than 400 pico grams per ml confirms the diagnosis of congestive heart failure

3.Should you be concerned about A.S..'s potassium level of 5.2 meq/L? (Yes/No)

Answer:

Yes

The normal serum potassium levels in an elderly patient is 3.5 to 5 meq per litre. A.S is an elderly female of 70 years in acute kidney failure and has elevated levels of potassium.; so this is a definite cause for concern as hyperkalemia can cause life threatening emergency

explanation

Patient is a case of acute renal failure and can suddenly precipitate higher levels of serum potassium in the blood which can cause serious cardiac effects like to bradycardia/dysrhymias or muscular problems like muscular tenderness, muscular weakness, severe fatigue, and frank muscular paralysis.

As patient is elderly and known case of heart failure, hypertension and at the risk of hyperkalemia due to acute kidney injury, potassium level of 5.2 Meq/L requires immediate concern and rigorous monitoring in addition to treatment as prescribed by physician

4.List two treatment types that the health care provider might prescribe if deciding to treat A. S. hyperkalemia.

Answer:

The two treatment types that the health care provider might prescribe if deciding to treat A. S. hyperkalemia.

1.medications promote the excretion of potassium by using the diuretics[lasix] or cation exchange resin medications(kayexalate with/without sorbitol]might be prescribed by the health care provider.

2.Infusion of intravenous glucose with insulin drip in order to promote internalization of potassium into the cells along with glucose absorption might be prescribed by the health care provider.

Additionally,

3. administration of intravenous calcium to decrease the cardiac toxicity if present and administration of soda bicarbonate to correct severe renal metabolic acidosis might be prescribed by the health care provider.

4. patients with rapidly increasing potassium levels or severe hyperkalemia in the setting of acute kidney injury may  need emergency dialysis in order to decrease the potassium levels if the other measures fail

5.Based on A.S.’s presentation, what nursing assessments, interventions, and monitoring skills need to be performed by you the registered nurse? Student must list at least six:

Answer:

The nursing assessment the registered nurse must perform are

1. assess the patient vital parameters, blood pressure and oxygenation and the apical impulse if patient is given digoxin
2. assessment of patient consciousness and orientation
3. Assess for patients urinary output and intake /output balance
4. assess for breath sounds clearing or worsening of the bilateral basal crepts
5. assess for increase in the edema,patient weight or decrease in the pedal edema
6. Assess the patient for improvement in for breathlessness, edema and feelings of weakness and fatigue.

The nursing interventions the registered nurse must perform are

1. Give the patient propped up position in bed, provide oxygen by nasal prongs and keep the patient rested and relaxed

2. monitor the patients fluid intake /output and take serial patient weight along with the vital parameters monitoring and monitoring of blood pressure and patient oxygenation.

3. Assess the patient level of consciousness, mentation ,anxiety and allay the patient anxiety by providing psychological support and empathetic counselling.

4.To monitor the laboratory investigations especially blood urea, nitrogen and serum creatinine and serum potassium along with the serum calcium and magnesium as the patient has acute kidney injury

5. Auscultate for improvement in the breath sounds and auscultate the heart at regular intervals

6. Prepare the patient for dialysis and assist for the same if the acute renal failure does not settle

The following monitoring skills need to be performed by the nurse:

1monitoring of the patients vital parameters, blood pressure and oxygenation

2. monitoring of the patient weight.

3 monitoring of the patient urine output.

4. monitoring of the patient fluid intake

5.monitoring of the patient's heart rate and ECG to rule out dysrthmias or bradycardia

6 monitoring of the patient's serum potassium levels, blood urea nitrogen and serum creatinine level and ABG for presence of acidosis

6.What orders do you as the nurse, anticipate the physician will order? Student must list at least six

Answer:

The orders the nurse anticipates that the physician will order are:

1. Strict monitoring of the vital parameters including blood pressure and oxygenation and input output monitoring.

2. oxygen support by nasal prongs as the patient is breathless and saturation is 93%

3. diuretics like Lasix to decrease the the edema and increase the urinary output.

4..Antihypertensive medications in order to decrease the blood pressure.

.5. Low dose digoxin to improve cardiac contractility as the patient is in heart failure

6. Sodium Bicarbonate to treat acidosis if present on ABG.

7 Cation exchange resins/ glucose insulin drip in order to decrease the hyperkalemia if not settling with the diuretic drugs.

8. ECG monitoring for the patient with the administration of calcium in case of cardiac toxicity due to hyperkalemia