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PIAT ( Renal)

Renal Case study questions and answers (Nursing 321)
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Nursing (231)

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Academic year: 2021/2022
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Community College of Philadelphia

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Case Study 1 Acute Renal Failure (ARF)

Scenario You are working on a med/surg floor of an acute care hospital and assume the care of E., a 78-year-old woman who is 3 days post inferior wall MI. E. had been healthy before admission except for a longstanding history of osteoarthritis treated for years with celecoxib 100 mg daily and long standing hypertension treated with atenolol 50 mg daily. On presentation to the ED, E. had severe hypertension (210/122 mm Hg). An IV was started with D5W at KVO and she was taken directly to the cardiac catheterization lab for acute PTCA (percutaneous transluminal coronary angioplasty). Her angioplasty was successful, and she has been pain-free since the PTCA 3 days ago.

You are reviewing E.’s lab work and note the following values: Na 142 mEq/L, K 5. mEq/L, Cl 104 mEq/L, CO2 26 mEq/L, glucose 158 mg/dL, BUN 60 mg/dL, creatinine 3 mg/dL. You have also noted her urine output for the past 8 hours is 160 mL.

  1. From your notes, describe general prerenal, intrarenal, and postrenal causes of acute renal failure (ARF).

Prerenal: Sudden & severe drop in BP (shock) or interruption of blood flow to the kidneys from severe injury or illness; also called prerenal azotemia (causes: Severe volume depletion, Shock, HF, Sepsis) Intrarenal: direct damage to kidneys by inflammation, toxins, drugs, infection, or reduced blood supply; called Acute Tubular Necrosis (causes: infections, drugs like antibiotics or NSAIDs, contrast dyes, Glomerulonephritis) Postrenal: sudden obstruction of urine flow due to enlarged prostate, kidney stones, bladder tumor, or injury; called postrenal azotemia (causes: Urethral or bladder cancer, Kidney stones, Urethral structures)

  1. From the above case study, what factors are present in E. B.’s medical history that predispose her to development of acute renal failure? Note whether each factor is related to prerenal, intrarenal or post renal failure.

Interruption of blood flow (MI) → Prerenal

Years of NSAID treatment (celecoxib) / Atenolol daily → Intrarenal

Contrast dye during angiogram → Intrarenal

  1. What might be possible explanations for E.’s increase in BUN and creatinine and decreased urine output following her MI and PTCA?

Acute Renal Failure: During the initiation/onset phase of acute renal failure then BUN & creatinine begin to rise. Then, during the oliguric phase, Urine output is at about 100 – 400 ml/24 hours that does not respond to fluid changes or diuretics.

  1. From your notes, briefly describe the stages (or phases) of acute renal failure (pay particular attention to what happens to the BUN, creatinine and urine output in each stage).

Onset phase: BUN and creatinine (nitrogenous wastes) begin to rise Oliguric phase: Urine output of 100 – 400 ml/24 hours that does not respond to fluid changes or diuretics;lasts 8-15 days Diuretic phase: May diurese up to 10 liters/day of dilute urine as the kidney begins to recover; Occurs 2-6 weeks after the onset of the oliguric phase and continues until the BUN level reaches normal limits Recovery phase: Lasts up to a year; Renal function may continue to improve; Client returns to normal level of activity

  1. What stage of acute renal failure is E. B. most likely in?

Oliguric phase

  1. Describe some of the medical treatments that might be used for prerenal and intrarenal failure (Hint: refer to treatments for ARF in your Powerpoint).

Prerenal: Dehydration and Low Blood Pressure: IV fluids or vasopressors Congestive Heart Failure: diuretics or ACE inhibitors Live Cirrhosis: liver transplant, Transjugular intrahepatic portosystemic shunt (TIPS), hemodialysis, liver dialysis, vasopressors Intrarenal: Glomerulonephritis: termination of suspected drug, corticosteroids, lasix, Kayexalate, plasmapheresis, salt/protein/potassium restriction Acute Tubular Necrosis: Termination of suspected nephrotoxic drug, Lasix, Vasopressors, Potassium-reducing drugs, Restriction of protein/salt/potassium, Hemodialysis in severe cases Acute Interstitial Nephritis: termination of the suspected drug, restriction of potassium/salt/protein, Corticosteroids

  1. What are your nursing interventions and priorities for a patient in ARF?

Monitor F&E; Reduce Metabolic Rate (bedrest); Promote Pulmonary Function; Prevent Infection; Provide Skin Care; Provide Psychosocial Support;

E. is started on peritoneal dialysis (PD). (Know that PD can be used in acute or chronic renal failure however).

  1. Based on K. B.’s assessment and lab values, determine the most likely cause of K. B.’s dehydration? (This is a critical thinking question not found in your notes).

Fluid is restricted when the person is on dialysis; therefore, the hemodialysis could be the cause of her dehydration.

  1. Describe the stages of chronic renal failure. Pay particular attention to the areas where renal insufficiency differs from end stage renal disease (ESRD).

1: below normal to mild loss of kidney function; often no symptoms; GFR >/= 90 2: mild-moderate loss of kidney function; high BP, protein in urine; GFR 60- 3: mod-severe loss of kidney function; anemia, early bone dx; GFR 30- 4: severe loss of kidney function; fatigue, swelling, n/v; GFR 15- 5: kidney failure; GFR <15 or dialysis

  1. What factor in K. B.’s medical history has led to her development of chronic renal failure?

Diabetes

  1. Because K. B. is on hemodialysis, what stage of chronic renal failure would she be in?

5 (kidney failure): GFR <15 or dialysis

  1. Renal failure causes severe alterations in many substances in the body. Using your notes, indicate whether the levels of each of the following values are increased or decreased in a patient with renal failure.

Glomerular Filtration Rate: decreased Systemic fluid volume: increased Urine output (for most people with renal failure): decreased Hemoglobin and Hematocrit: decreased BUN: increased Creatinine: increased Magnesium: increased Potassium: increased Sodium: decreased or normal Phosphorus: increased Calcium: decreased Bicarbonate: decreased

Bonus question—Which acid/base imbalance can occur in the person with renal failure? Metabolic acidosis

K.’s CBC (complete blood cell count) yields the following results: WBC 7,600, RBC 3, Hgb 8, Hct 24%, and platelets 333,000.

  1. K.’s physician notes that the anemia is the most likely cause of K. B.’s increasing fatigue. Why is K. anemic.

Patient RBC and Hgb and Hct are all low. Patient has not been eating and getting a source of Iron. K is also in end stage renal failure. Her kidneys are unable to release the hormone Erythropoietin which singles the bone marrow to make more red blood cells. The kidneys are unable to send out the hormone as much as she would need them too.

  1. List at least one clinical finding for each of the following systems that may be noted by the nurse when performing physical assessment on the patient with chronic renal disease. For each clinical finding, briefly identify its pathophysiologic cause(s).

System Clinical finding Pathophysiologic cause(s) Cardiac Angina or SOB r/t Uremic pericarditis

Pericardial sac becomes inflamed by uremic toxins or infection

Vascular HTN Damaged kidneys may release too much renin, which can lead to high blood pressure.

GI Anorexia Alterations in appetite regulation, such as amino acid imbalance, which increases the transport of free tryptophan across the blood-brain barrier. This creates a hyper serotoninergic state that is prone to low appetite.

Integumen t

Uremic frost When the blood urea nitrogen is high, the concentration of urea in sweat is increased greatly. Evaporation results in the deposition of urea crystals on the skin. Skeletal Osteodystrophy Due to elevated phosphorus levels and decreased action of vitamin D.

  1. Based on the definitions you completed in part 1 of the study guide, the table above, and K. B.’s case study, which term would be used to describe her renal failure signs and symptoms, azotemia or uremia? Briefly explain.

Uremia : Classical signs of uremia are: progressive weakness and easy fatigue, loss of appetite due to nausea and vomiting, muscle atrophy, tremors, abnormal mental function, frequent shallow respiration, and metabolic acidosis.

After K. is discharged, she will resume hemodialysis (HD) 3 days per week at the outpatient dialysis center. (Know that HD can be used for both acute and chronic renal failure). K. B. has an AV (arteriovenous) fistula in her left arm.

  1. Explain the difference between an AV fistula and an AV graft.

An AV fistula is a direct connection between the patient’s artery and one of their nearby veins. This is the absolute BEST access a patient can have because it is all their own tissue. The fistula resists clotting and infection.

An AV graft (sometimes called a bridge graft) is an indirect connection between the artery and vein, most commonly a plastic tube is used, but donated cadaver arteries or veins can also be used.

  1. On assessment of an AV fistula or graft, what physical findings would you expect during auscultation and palpation? What do these findings mean?

When you place your ear or fingers over your fistula, you should be able to hear a consistent swoosh or feel a slight vibration. The sound you hear may change from a swooshing noise to a whistle-like sound.

  1. Describe care of the patient with an AV fistula or graft.

Use sound and touch to check the blood flow through your fistula daily; Sterile technique with bag changes and catheter care; Bags must be warmed prior to instillation (no Microwaving); Normal outflow should be clear and pale yellow; Measure amount of outflow after each exchange (Fill, dwell and drain make up one exchange)

  1. Using your notes, fill in the blanks for the following description of HD:

HD system consists of: Dialyzer (artificial kidney), Dialysate, Vascular access routes, and Dialysis machine. Blood and dialysate flow in opposite directions across an enclosed semipermeable membrane. Dialysate contains a balanced mix of electrolytes and water that closely resembles human plasma. On the other side of the membrane is the client’s blood. Processes of diffusion and osmosis are used to draw excess fluids and wastes out of the blood, across the membrane and into the dialysate solution to be discarded.

  1. Describe the complications of HD and the HD-related nursing care.

Comp: Hypertriglyceridemia, Anemia, SOB, Hypotension, Bleeding, Muscle cramps, HA, Fatigue, Infection, Sleep problems

Nursing Care: check before giving meds; baseline weight & BP prior; monitor for hypotension post op (IV fluids to rehydrate); monitor for bleeding post op 6 hrs

  1. Explain how K. B.’s hemodialysis might have made her dehydration worse.

Removal of fluid by ultrafiltration during haemodialysis frequently leads to dehydration along with fluid restrictions.

Case Study 3

Urinary Tract Infection (UTI)

Scenario

You are working in the ED when M.’s daughter brings her mother in. M. is an 89- year-old widow with a 4-day history of dysuria, back pain, incontinency, and severe mental confusion. M. Z. had been discharged from the hospital two weeks earlier after having a total hip replacement. You note that M. Z. had a foley catheter during her previous hospital stay. M. Z.’s most current VS are 118/60, 88, 18, 99° F. The medical director ordered several lab tests on admission. The results were as follows: WBC 11,000, CMP (complete metabolic profile) WNL (within normal limits). Post Void catheterization for residual urine yielded 100 ml, and UA (urinalysis) showed WBC’s present, RBC small, bacteria many. The urinary C&S (culture and sensitivity) results were as follows: E. coli (Escherichia coli) > 100,000 colonies, sensitive to ciprofloxacin, trimethoprim/sulfamethoxazole, and nitrofurantoin.

Do you think M. Z. has cystitis or pyelonephritis? Why?

Pyelonephritis (mainly due to the back pain that accompanies the other symptoms of a UTI such as a low grade fever, incontinency, dysuria, and the urinary C&S results that are described above)

What physical assessment technique might the physician or nurse perform to assess M. Z. for possible pyelonephritis?

On physical examination, the key finding is tenderness to palpation of the costovertebral angle.

Explain the new onset of M. Z.’s mental confusion.

A change in mental status is a common assessment finding in elderly adults with UTI’s.

Is M. Z. 's postvoid residual urine normal? What should normal postvoid residual be?

No, a postvoid residual of 100 mL or more indicates urinary retention. Normal residual is 30-50 mL.

What specific findings in a urinalysis indicate the presence of a urinary tract infection?

Bacteria count ≥ 100,000 colonies per ml = UTI.

Based on the information in the above case study, what are the factors that may have predisposed S. to formation of kidney stones?

Dehydration and Positive family history

Identify the various methods that can be used to treat a patient with a kidney stone. (Hint: refer to nursing considerations and other treatments in your notes).

Pain Medication

Retrograde Ureteroscopy: Ureteroscope is passed through urethra and bladder into the Ureter. Once stone is visualized, it can be grasped and removed or lithotripsy can be done.

Stenting: Small tube placed in ureter by ureteroscopy. Stent dilates the ureter to enlarge the passageway for

S. R. is discharged home with instructions to strain all urine and return if she experiences pain unrelieved by the pain medication or increased N/V (nausea and vomiting). What specific instructions will you give S. about her urine, fluid intake, medications, and activity?

•Check urine pH daily.

•Patient should walk as often as possible to promote

passage of stones.

•Patient should drink at least 3 L of fluid a day unless

contraindicated.

•Teach s/s of UTI.

•Kidney stones increases a client risk for infection which

can lead to sepsis and eventually shock.

•Strain urine to monitor for stone passage.

•Send any stone to the lab for analysis to determine its composition.

S. returns to the ED that night with pain unrelieved by the pain medication, nausea and vomiting and increased blood in her urine. Lab studies show the following abnormal results: BUN 30 mg/dL and creatinine 3 mg/dL. She is being held in the ED.

A large kidney stone can cause chronic infection and urine flow obstruction. What may be the impact of this problem on her long-term kidney function?

Increases the risk of developing chronic kidney disease.

Since S. R. is unable to pass the stone, it is decided to schedule her for lithotripsy in the morning. Describe lithotripsy, and pre and post procedure care and teaching.

•Also known as extracorporeal shock wave lithotripsy.

•Uses sound waves to break the stone into small fragments to be passed.

•Client receives conscious sedation and has an EKG.

•The lithotriptor is aimed at the stone which is visualized with Fluoroscopy.

•Pain medication is given and the lithotripter delivers 500 – 1500 shocks over 30 – 45 minutes.

•Strain urine for stones afterward.

•Extensive bruising may occur on the flank of the affected side.

•It is normal to have blood in urine for several days.

S.’s lithotripsy was successful and she passed many small fragments of stone in the days after the procedure. Pathologic examination of the stone reported it to be calcium oxalate.

Because S.’s stone has been reported as calcium oxalate, what are the main food restrictions that would be recommended?

Spinach, black tea and rhubarb

If S. R.’s stone had been composed of calcium phosphate, struvite, uric acid or cystine, what general type of food would need to be restricted?

Calcium phosphate stones: Limit foods high in animal protein

Struvite stones: Limit high-phosphate foods, dairy, red and organ meats, whole grains

Uric acid stones: Limit intake of purines, organ meats, poultry, fish, red wines, sardines

Cystine stones: Limit animal protein

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PIAT ( Renal)

Course: Nursing (231)

38 Documents
Students shared 38 documents in this course

University: Community College of Philadelphia

Was this document helpful?
Case Study 1
Acute Renal Failure (ARF)
Scenario
You are working on a med/surg floor of an acute care hospital and assume the care of
E.B., a 78-year-old woman who is 3 days post inferior wall MI. E.B. had been healthy
before admission except for a longstanding history of osteoarthritis treated for years
with celecoxib 100 mg daily and long standing hypertension treated with atenolol 50 mg
daily. On presentation to the ED, E.B. had severe hypertension (210/122 mm Hg). An IV
was started with D5W at KVO and she was taken directly to the cardiac catheterization
lab for acute PTCA (percutaneous transluminal coronary angioplasty). Her angioplasty
was successful, and she has been pain-free since the PTCA 3 days ago.
You are reviewing E.B.’s lab work and note the following values: Na 142 mEq/L, K 5.0
mEq/L, Cl 104 mEq/L, CO2 26 mEq/L, glucose 158 mg/dL, BUN 60 mg/dL, creatinine
3.8 mg/dL. You have also noted her urine output for the past 8 hours is 160 mL.
1. From your notes, describe general prerenal, intrarenal, and postrenal causes of
acute renal failure (ARF).
Prerenal: Sudden & severe drop in BP (shock) or interruption of blood flow to the
kidneys from severe injury or illness; also called prerenal azotemia (causes: Severe
volume depletion, Shock, HF, Sepsis)
Intrarenal: direct damage to kidneys by inflammation, toxins, drugs, infection, or
reduced blood supply; called Acute Tubular Necrosis (causes: infections, drugs like
antibiotics or NSAIDs, contrast dyes, Glomerulonephritis)
Postrenal: sudden obstruction of urine flow due to enlarged prostate, kidney stones,
bladder tumor, or injury; called postrenal azotemia (causes: Urethral or bladder cancer,
Kidney stones, Urethral structures)
2. From the above case study, what factors are present in E. B.’s medical history
that predispose her to development of acute renal failure? Note whether each
factor is related to prerenal, intrarenal or post renal failure.
Interruption of blood flow (MI) → Prerenal
Years of NSAID treatment (celecoxib) / Atenolol daily → Intrarenal
Contrast dye during angiogram → Intrarenal
3. What might be possible explanations for E.B.’s increase in BUN and creatinine
and decreased urine output following her MI and PTCA?

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