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 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

Labs/Diagnostic Results: Basic Metabolic Panel Most RecentCURRENT Potassium Creatinine0.93.2

What’s the Big Deal? What is the medical problem? 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… 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) You call the cardiologist due to clinical concern over his urine output and receive the following orders:

Nursing Diagnoses & Goals Nursing DiagnosisGoals 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 InterventionRationale/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.

Interventions continued InterventionsRationale/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 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... AssessmentRationale 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 InterventionEvaluation 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).

Interventions continued InterventionsRationale/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 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.

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. 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