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Acute Renal Failure

Mr. Jamison is a 30 year old male patient admitted to the ED after a severe motorcycle accident. He sustained a fx of the pelvis and left tibia and a lacerated spleen. He is restless, irritable and drowsy. VS: HR 120 and irregular, BP 80/50, RR 22, Temp 96.7 tympanic, urine output is decreased.

What do you think is happening to Mr. Jamison?

What would you expect in terms of laboratory results (electrolytes and fluids)?

What interventions (in order of priority) need to be implemented for Mr. Jamison?

List Nursing Diagnosis for this patient

Several days later Mr. Jamison is in the ICU recovering from surgical repair of his fractured pelvis, tibia and spleen. The evening assessment revealed VSS as well as diagnostic reports. Morning assessment reveals the following: change in mental status, as he is drowsy and difficult to arouse and irritable, increasing pain, H&H 9.7 and 24, K+ 6.8, u/o less than 30ml/hr. BP 90/60, HR 116, RR 22 and shallow, WBC 14.3,

Tº 101.4

What do you suspect is happening to Mr. Jamison?

What would you plan for this patient?

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 Acute Renal Failure 

NURS 240 CASE STUDY ARF

Mr. Jamison is a 30 year old male patient admitted to the ED after a severe motorcycle accident. He sustained a fx of the pelvis and left tibia and a lacerated spleen. He is restless, irritable and drowsy. VS: HR 120 and irregular, BP 80/50, RR 22, Temp 96.7 tympanic, urine output is decreased.

What do you think is happening to Mr. Jamison?

Mr. Jamison’s is in severe hypovolemic shock due to the trauma after the accident. The resultant dehydration- fluid loss in the body causes reduced total blood volume, low venous return and hypotension (Kimmoun et al., 2016). His symptoms are consistent with the body’s catecholamine release as a compensatory mechanism to maintain vital organ perfusion.

What would you expect in terms of laboratory results (electrolytes and fluids)?

Sodium is the abundant cation in extracellular fluid with a normal serum level of 135 to 145 mEq/L. It is the primary determinant of extracellular osmolality, control of water distribution and fluid balance in the body (Cranshaw & Nolan, 2006). Water follows sodium and in hypovolemic shock, there is a deficiency of total body water and total body sodium due to massive blood loss. Hypovolemic hyponatremia causes reduced serum osmolality and anti-diuretic hormone release to maintain blood volume. Consequently, there will be increased water retention and hyponatremia.

Laboratory tests to confirm hypovolemia include a renal profile test, random urine urea, creatinine and sodium measurements (Cranshaw & Nolan, 2006). Expected results for Mr. Jamison include; a plasma creatinine ratio less than 1:10, urine sodium concentration less than 20 mmol/L, fractional sodium excretion less than 1%, and fractional urea excretion less than 35%.

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What interventions (in order of priority) need to be implemented for Mr. Jamison?

ABC-

Airway- Protect the airway by checking for potency. If not potent, open and clear airway through Jaw thrust, chin lift, head tilt.

-Provide airways adjuncts as required.

-Initiate measures to control the c-spine as needed.

Breathing- Administer high flow oxygen.

-Place the patient in a modified Trendelenburg position (feet at 45’ and head flat) to promote fluid redistribution (Mandal, 2016).

Circulation- Secure venous access using two large bore cannulas at both hands. Consider intraosseous or central access if venous access is not rapidly established.

- Collect blood for x-match, FBC, EUC’s, Creatinine, ABG’s, and Blood ETOH.

-Start IV fluids using isotonic crystalloid solutions e.g. Saline (0.9% NaCl) to restore the intravascular blood volume (Mandal, 2016). Give 2 liters as a bolus in the first hour.

- Do catheterization and continuously monitor the vital signs. A urine output of more than 30 mLs/hr. is the best indication of improved perfusion.

- Follow any other instructions from the physician.

- Prepare the patient for emergency abdominal laparotomy.

 List Nursing Diagnosis for this patient.

- Deficient fluid volume/hypovolemia related to active fluid loss as evidenced by hypotension, low body temperature, and decreased urine output.

- Decreased cardiac output related to 30% loss of total blood volume AEB by decreased urine output.

-  Impaired gas exchange related to interference with oxygen delivery.

- Ineffective tissue perfusion related to severe blood loss AEB a weak pulse.

- Risk for metabolic acidosis related to a decrease in the amount of blood in the capillaries.

-Risk for infection related to compromised circulation

Several days later Mr. Jamison is in the ICU recovering from surgical repair of his fractured pelvis, tibia and spleen. The evening assessment revealed VSS as well as diagnostic reports. Morning assessment reveals the following: change in mental status, as he is drowsy and difficult to arouse and irritable, increasing pain, H&H 9.7 and 24, K+ 6.8, u/o less than 30ml/hr. BP 90/60, HR 116, RR 22 and shallow, WBC 14.3,

Tº 101.4

What do you suspect is happening to Mr. Jamison?

Mr. Jamison is showing symptoms of septic shock and organ dysfunction.  He has the classical symptoms of a systemic infection- fever, tachypnea, tachycardia, and high blood cell count (Edman-Wailer et al., 2016). The severity is evident in his altered mental status, hypotension, and decreased urine output.  A white blood cell count is a confirmation of his sepsis (normal level is 4,000 to 10,000).

What would you plan for this patient?

-Consider oxygen administration with deteriorating consciousness.

-Practice infection control for all invasive procedures and proper hand-hygiene.

- Administer fluids to correct tissue hypoperfusion. Ionotropic agents are the best choice if there is myocardium contractility compromise (Edman-Wailer et al., 2016).

-Collaborate with other health care staff to identify the specific organism responsible for the infection.

-Administer prescribed medications- antibiotics, antipyretics, and vasopressors.

- Monitor blood levels for antibiotic toxicity, creatinine, WBC, hemoglobin, hematocrit, platelets, and coagulation levels.

- Monitor for complications like hyperkalemia through cardiac results.

- Assess the patient’s physiologic status, fluid intake/output, and nutritional requirements.

-Evaluate effectiveness of interventions for proper wound healing, verbalization of the disease process and hemodynamic stability.

 

 

References

Cranshaw, J., & Nolan, J. (2006). Airway management after major trauma. Continuing Education in Anaesthesia, Critical Care & Pain, 6(3), 124-127. https://academic.oup.com/bjaed/article/6/3/124/375420

Edman-Wallér, J., Ljungström, L., Jacobsson, G., Andersson, R., & Werner, M. (2016). Systemic symptoms predict presence or development of severe sepsis and septic shock. Infectious Diseases, 48(3), 209-214.

Kimmoun, A., Novy, E., Auchet, T., Ducrocq, N., & Levy, B. (2016). Hemodynamic consequences of severe lactic acidosis in shock states: from bench to bedside. Critical Care, 19(1), 1-13.

Mandal, M. (2016). Ideal resuscitation fluid in hypovolemia: The quest is on and miles to go! International journal of critical illness and injury science, 6(2), 54.

Turkey, F. S. (2019). Hemorrhagic shock. Clinical Management of Shock—The Science and Art of Physiological Restoration. DOI: 10.5772/intechopen.82358

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