Renal GU Progressive case study The nurse is admitting a 74-year-old female, KB, to the emergency department. She has a 4-day-long history of non-localized abdominal pain, incontinence, new-onset mental confusion, and lethargy.

Her most current vital signs are BP 82/38, HR 118 and irregular, RR 28, Temp 100.9 degrees, room air oxygen saturation 89%.

 

PMH: Renal calculi CHF with an EF of 28% s/p MI with stent in 5/2020 Afib HTN DM 2 Height: 5’8″ Weight: 220 lbs Allergies: Sulfa drugs, Codeine

Serum Lab review: Bun 38 mg/dL Creat 4.2 mg/dL GFR: 25 ml/min/1.73m2 Sodium: 114 mEq/L Potassium: 7.1 mEq/L Glucose: 320 mg/dL   White Blood Cells: 15,000/mm3 Hct: 48% Hgb: 18g/dL Platelet: 180,000/mm3

Urinalysis: Appearance: dark amber, cloudy with sediment Ph 6.9 Specific Gravity: 1.026 Protein: Moderate Nitrates: Positive WBC’s: many RBC’s: many

Current Medications: Aspirin, 81mg PO, QD Plavix, 75mg PO QD Eliquis, 5mg, PO, QD Digoxin, 0.25mg PO, QD Atenolol, 100mg PO, BID Lisinopril, 20mg PO, QD Aldactone, 100mg PO, QD Metformin, 500mg PO, BID Sliding scale Regular Insulin AC

 

1. What are some medical problems that could be going on with KB, and what is the rationale?
2. What is your interpretation of the serum lab values, and why?
3. What is your interpretation of the urinalysis, and why?
4. Why do you think she is taking her current medication and why? Are there any medication you would expect to be changed at this time, on admission, why?

 

The health care provider (HCP) orders are as follows:

The health care provider (HCP) orders are as follows:	What is the rationale for this order and is it appropriate/safe?	Which are the top 3 priorities
Titrate O2 via NC to maintain O2 saturation greater than 92%
Morphine, 2mg IV push x1
NS @ 200ml/hr x 8 hours
Heparin IV drip: 850 units/hour
EKG
Regular insulin, 12 units, SC

 

KB had all orders implemented. She is admitted to the ICU. A KUB and CT scan were performed and a 4.5mm stone was located in the left kidney, a ECSL was performed. An indwelling Foley catheter was placed. Her BP continued to decline, and she was placed on blood pressure support medicine, intravenously.

Her BUN/Creat continued to increase (BUN 48, Creat 4.9) and GFR continued to decrease (GFR 12). A decision was made to place temporary dialysis catheters in the subclavian.

1. What do you think is happening?
2. How do you know?
3. What other nursing interventions would be implemented, and why?

 

Forty-eight hours later, KB’s status is unchanged.  She continues to feel lethargic and has been receiving hemodialysis daily. Below is the current report from the night shift, items in red are new results.

 

PMH: Renal calculi CHF with an EF of 28% s/p MI with stent in 5/2020 Afib HTN DM 2 Height: 5’8″ AdmissionWeight: 220 lbs Current weight: 250lbs Allergies: Sulfa drugs, Codeine

Serum Lab review: Bun 52 mg/dL Creat 5.2 mg/dL GFR: 18 ml/min/1.73m2 Sodium: 114 mEq/L Potassium: 6.1 mEq/L Glucose: 120 mg/dL   White Blood Cells: 8,000/mm3 Hct: 28% Hgb: 8 g/dL Platelet: 180,000/mm3

Urinalysis: Appearance: yellow with slight sediment Ph 5.9 Specific Gravity: 1.013 Protein: Moderate Nitrates: negative WBC’s: none RBC’s: none

Current Medications: Aspirin, 81mg PO, QD Plavix, 75mg PO QD Eliquis, 5mg, PO, QD Digoxin, 0.25mg PO, QD Atenolol, 100mg PO, BID Lisinopril, 20mg PO, QD Aldactone, 100mg PO, QD Metformin, 500mg PO, BID Sliding scale Regular Insulin AC Heparin, IV drip, titrate per PTT sliding scale Procrit 3,000 units/ml three times/week Lasix, 40mg PO, BID Aluminum hydroxide (Amphojel), 25mg PO, AC NS @ 75ml/hr Vancomycin, 1g, IV QD Coumadin, 5mg, PO QD

 

1. Why are the lab values and current weight important?
2. Why do you think changes were made in the client’s medications?

 

KB remained in the hospital and slowly her status improved.  Unfortunately, her kidneys will not recover. You are providing discharge teaching with the client and her daughter. You prepared a discharge teaching packet, knowing renal failure is a new diagnosis for her.

1. What do you include, and why?
2. Below are the discharge medications. Provide brief patient education on the 4 new medications.

 

Dischage Medications:

Aspirin, 81mg PO, QD

Plavix, 75mg PO QD

Digoxin, 0.25mg PO, QD

Atenolol, 100mg PO, BID

Metformin, 500mg PO, BID

Sliding scale Regular Insulin AC

Procrit 3,000 units/ml three times/week during dialysis

Lasix, 40mg PO, BID

Aluminum hydroxide (Amphojel), 25mg PO, AC

Coumadin, 5mg, PO QD