Transcript Rapid Reasoning* Case Study 10 - Barlow Bird E

Case Study 10
Carli Prisbrey, Barlow Bird, Kim
Coats, Bree Rebman
Chief Complaint/HX of Present Illness
• Mr. Sandgren is an 84 year old man who was
admitted two days ago with a non-STEMI
Myocardial infarction. He had an angiogram at
1000 today and had a 90% proximal left anterior
descending (LAD) lesion successfully stented
and has had no recurrent chest pain and has
been clinically stable post procedure.
Would you like to know More…?
• It is now 1800 and despite receiving 1000 ml of
0.9% NS after the angio and taking 500 ml fluids
with dinner, he has had only 50 ml urine output.
• We decide to do a bladder scan and found there
is no residual urine in the bladder…
Past Medical HX
Past Medical HX:
• CAD
• HTN
• DM II
• Neuropathy (lower extremities)
• Hyperlipidemia
• COPD/Asthma
Assessment Data
Nursing Assessment DataRESP- breath sounds clear with
equal aeration bilateral, non
labored
Cardiac- pink, warm, dry. S1S2,
no edema, pulses 3+ ALL.
Neuro- A & O x4
GI/GU- active BS in all quads,
abdominal soft/non-tender,
voiding without difficulty
Misc- Appears to be resting
comfortably in no acute distress
VS:
• T: 98.9
• P: 88 reg
• R: 20
• BP: 138/88
• O2 sats: 92% RA
Labs/Diagnostic Results:
Basic Metabolic
Panel
Most Recent
CURRENT
Potassium
4.1
5.9
Creatinine
0.9
3.2
What’s the Big Deal?
What is the medical problem?
http://www.youtube.com/watch/?
v=UbgZW9EzQmo
What is the underlying
cause/pathophysiology of this
concern?
What is your primary concern?
• The medical problem▫ Acute Renal Failure
• What is the underlying cause?
▫ Acute intra-renal failure caused by
nephrotoxicity related to the radioactive dye
used in the angiogram.
• What is the primary concern?
▫ Decreased urine output, Increased K+ & Cr lab
levels, Correcting the issue before furthering
kidney damage.
What is Relevant?
• Data relevant:
• VS??
▫ No indication of pre-renal
failure due to hypoperfusion
• Labs
▫ Increased K+
▫ Increased Creatinine
• Assessment▫ Physical assessment reveals
patient is physically stable
• Output▫ The last 8 hours, 50 mL UO
• Blood pressure is slightly
elevated but could be related
to HTN
• Respirations are normal –
COPD/asthma so Sats look
good related to medical HX
• Potassium/Creatinine increase
related to acute renal failure
• Stable status indicative that
acute renal failure is not at a
critical point and pt. is
tolerating well.
SBAR…
You call the cardiologist
due to clinical concern
over his urine output and
receive the following
orders:
Physician OrdersFoley Catheter
Furosemide (Lasix) 80 mg
IVP… Start Furosemide IV
gtt at 10 mg/hour if <250
mL u/o in response to IVP
after 2 hours.
Regular Insulin 10 units IVP
D50 (50 mL) 25 gm IVP
Sodium Bicarbonate (50 mL)
1 amp IVP
Calcium Chloride 1 gm IV
D/C Lisinopril (home med
that he continues to
receive for HTN)
D/C Ibuprofen (prn for Pain)
Nursing Diagnoses & Goals
Nursing Diagnosis
Goals
• Acute renal failure R/T nephrotoxic
effects of radio active dye AEB 50
mL urine output in 8 hours.
• Risk for altered cardiac perfusion
secondary to hyperkalemia
• Electrolyte imbalance R/T renal
dysfunction AEB potassium level of
5.9
• Deficient knowledge R/T
medications and Tx plan AEB
patient stating “why are you
stopping my home meds and why
the heck do I need these new ones,
and a foley what??? That goes
where???”
• Patient will have increased
urine output of at least 30
mL/hour.
• Patient will maintain adequate
perfusion and remain free
from cardiac complications
R/T hyperkalemia.
• Patient will return to normal
electrolyte values.
• Patient will verbalize a clear
understanding of medications
and Tx options.
Interventions & Rationale
Intervention
• Insert foley catheter.
• Administer Furosemide.
• Administer 10 units of regular
insulin.
• Administer D50 50mL/25g
IVP.
• Administer 50mL sodium
bicarbonate.
• Administer calcium chloride 1g
IV.
• D/C Lisinopril, his home med.
• D/C Ibuprofen
Rationale/patient education
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Allow easy tracking of urine out put,
availability to draw labs, and ease for the
patient if the furosemide works.
Increase urine out put, decrease K+, wash
out nephrotoxins, save kidney Steve 1 and
Steve 2.
Insulin cause K+ to enter the cells
decreasing your serum K+ level.
Maintains blood glucose level after insulin
administration and causes osmotic diuresis.
Lowers serum K+ by causing a shift in
hydrogen ions for K+ in the cells.
Stabilizes cardiac cells and prevents
negative effects of elevated K+ by raising
threshold potential.
Lisinopril has the potential to decrease renal
perfusion by decreasing BP and glomerular
filtration pressure.
Ibuprofen inhibits renal perfusion by
Inhibiting COX1-2 decreasing the kidneys
ability dilate the renal arteries.
Interventions continued
Interventions
Rationale/Pt. Education
• Elevate HOB.
• Cardiac monitoring.
• Room supplies/safety- O2,
suctioning, ambubag,
compression board, call light,
and bed in low position.
• Promote respiratory function
& decrease risk for aspiration
(supposing hyponatremia
developed/other N/V causes).
• Evaluation for ECG changes.
• Supplies ready for rapid
response to possible
complications and general
safety.
Worst Possible Complications
Complications
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Irreversible kidney damage
Tetany
Seizures
Coma
Respiratory Failure
Bleeding
Infection
Sepsis/septic shock
Cardiogenic Shock
MODS
Heart Block
V-Fib
Cardiac Arrest
Pine box six feet deep AKA DEATH.
Acute Renal Failure
Assessments needed to quickly respond
to Complications...
Assessment
Rationale
• Respiratory- RR, Effort, lung
sounds, pulse OX, muscle
strength, & presence of nausea.
• Cardiac (tele)- Rate, rhythm,
pulses in the extremities, pulse
deficits, & any ECG changes.
• Neuro- LOC, lethargy,
confusion, seizures, paresthesia,
or coma.
• I’s & O’S
• Labs- BMP, ABG, CBC, and UA.
Maybe Lactate, BNP, blood
culture, albumin/pre albumin,
cardiac biomarkers, and LFT’s
• Detection of fluid volume
overload, cardiac abnormalities,
decreasing muscle
strength/ability maintain
adequate breathing pattern, and
risk for aspiration.
• Monitor for arrhythmias, fluid
volume status, and tissue
perfusion.
• Early detection in electrolyte
imbalance and perfusion status.
• Evaluation of kidney function to
determine if interventions are
working and risks for other
complications.
Evaluation of Interventions
Intervention
• Insert foley catheter.
• Administer Furosemide.
• Administration of 10 units of
regular insulin, D50
50mL/25g IVP, and 50mL
sodium bicarbonate.
• Administer calcium chloride 1g
IV.
• D/C Lisinopril, his home med.
• D/C Ibuprofen
Evaluation
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Showed increased urine output within 15
minutes of administration of furosemide,
allowed continual monitoring, and patient
stated it was amazing not to have to get up
to pee.
Initial dose of furosemide successfully
increased urine output to 450 mL within 2
hours of administration, second order of
furosemide was not necessary.
Successfully lowered K+ to 4.2 by 2000
(next lab draw), and did not compromise
serum glucose level or acid base balance.
Patient remained free from cardiac
complications R/T hyperkalemia.
No identifiable way to measure the success
of discontinuing medications other than the
return of renal function (it’s multifaceted).
Interventions continued
Interventions
Rationale/Pt. Education
• Elevate HOB.
• Cardiac monitoring.
• Room supplies/safety- O2,
suctioning, ambubag,
compression board, call light,
and bed in low position.
• Patient maintained good
respiratory function.
• Patient maintained normal
rate, rhythm, and experienced
no ECG changes.
• Patient maintained safety and
had a peachy mood all night.
Final Assessment Data
Nursing Assessment DataRESP- breath sounds clear with
equal aeration bilateral, non
labored
Cardiac- pink, warm, dry. S1S2,
no edema, pulses 3+ ALL.
Neuro- A & O x4
GI/GU- active BS in all quads,
abdominal soft/non-tender,
voiding without difficulty. Urine
output maintained above 70
mL/hour.
Misc- Appears to be resting
comfortably in no acute distress.
VS:
• T: 98.6
• P: 70 reg
• R: 18
• BP: 120/70
• O2 sats: 93% RA
LABS:
• K+ 4.2
• Cr 0.7
• We did a web event because
the lab only looked at K+ and
Cr on this patient since
admission.
Dr. assessed in the AM
Okayed the Patient for discharge and to continue home meds
Wrote orders for D/C teaching
Discharge Teaching
• Follow up with primary care
physician in 1-2 weeks
• Keep track of blood pressure
and blood glucose levels in diary
• Bring diary to appointments
• New medications- Plavix &
Nitro.
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Contact physician ifIf blood glucose >400 or
Blood pressure >150/90
Increased edema...notice
swelling/puffiness in extremities
• Decreased urinary ouput
• Weigh yourself daily and report
more than 2.2 lbs in one day or
5 lbs in one week.
• Go to emergency department
if...
▫ Excessive bleeding at insertion
site or anywhere
▫ Chest pain
▫ Shortness of breath
▫ Urinary Retention
▫ DEATH