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Case Study 10

Case Study 10. Carli Prisbrey , Barlow Bird, Kim Coats, Bree Rebman. Chief Complaint/HX of Present Illness.

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Case Study 10

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  1. Case Study 10 Carli Prisbrey, Barlow Bird, Kim Coats, Bree Rebman

  2. 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.

  3. 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…

  4. Past Medical HX Past Medical HX: • CAD • HTN • DM II • Neuropathy (lower extremities) • Hyperlipidemia • COPD/Asthma

  5. Assessment Data Nursing Assessment Data- RESP- 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

  6. Labs/Diagnostic Results:

  7. 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?

  8. 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.

  9. 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.

  10. You call the cardiologist due to clinical concern over his urine output and receive the following orders: SBAR… Physician Orders- Foley 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)

  11. 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.

  12. Interventions & Rationale Intervention Rationale/patient education • 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 • 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.

  13. 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.

  14. Worst Possible Complications Complications Acute Renal Failure • 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.

  15. 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.

  16. Evaluation of Interventions Intervention Evaluation • 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 • 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).

  17. 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.

  18. Final Assessment Data Nursing Assessment Data- RESP- 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.

  19. Re-Assessment By Dr. MJ Dr. assessed in the AM Okayed the Patient for discharge and to continue home meds Wrote orders for D/C teaching

  20. 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. • Contact physician if- • If 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

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