Case Study Objectives

1. Analyze and interpret clinical data and patient assessments to identify signs and symptoms of acute kidney injury (AKI) in a real-life patient scenario.
2. Apply critical thinking skills to recognize the physiological mechanisms contributing to the development of AKI, considering factors such as dehydration, contrast dye exposure, and prolonged NPO status.
3. Evaluate the appropriate nursing actions and interventions required at various stages of AKI management, including fluid resuscitation, diuretic therapy, and ongoing assessment.
4. Anticipate and suggest potential preventive measures for AKI, emphasizing the importance of pre- and post-contrast scan IV fluid administration in vulnerable patients.
5. Understand the significance of monitoring laboratory values, such as BUN, creatinine, GFR, and electrolytes, to assess kidney function and guide treatment decisions in AKI cases.

By actively engaging with this acute kidney injury case study, nursing students will enhance their clinical reasoning skills and gain valuable insights into the assessment, management, and prevention of AKI in real-world healthcare scenarios.

Kidney Injury Case Study

Ms. Barkley is a thin, frail 64-year-old female presenting from a nursing home for acute abdominal pain, nausea, and vomiting x 2 days. She receives a CT scan with IV contrast. Findings show no acute bleeding, but a possible small bowel obstruction.  She is admitted for bowel rest, with the following written orders from the provider:

• Continuous Telemetry
• Strict I&O measurements
• Keep SpO2 > 92%
• Keep NPO (strict)
• Hydrocodone/Acetaminophen 5-325 mg PO q6h PRN moderate to severe pain
• Ondansetron 4mg PRN nausea

She is admitted to the unit at the beginning of shift, and the UAP reports the following vital signs:
HR 103
RR 16
BP 118/68
SpO2 96%
Pain 6/10

At the end of the 12-hour shift, vital signs are as follows:
HR 96 RR 22

BP 147/80 SpO2 93%

Pain 3/10

The nurse recognizes that the patient has not voided all day and assists the patient to the bathroom. The patient voids 200 mL dark, concentrated urine.

Provider orders a 500 mL bolus of Normal Saline (0.9%) IV over 1 hour and a renal function panel, which is drawn promptly by the nurse. After 6 hours, Ms. Barkley still has had no further urine output. A bladder scan shows approximately 60 mL of urine in the bladder. A head-to-toe assessment now reveals crackles in Ms. Barkley’s lungs and her SpO2 is 89%

The renal function panel has resulted:
BUN 56 mg/dL
Na 132 mg/dL
Cr 3.6 mg/dL
Ca 7.7 mg/dL
GFR 47 mL/min/m2
Phos 4.8 mg/dL
K 5.5 mEq/L
Mg 1.4 mg/dL

The provider orders to give 1L bolus of Normal Saline (0.9%) over 1 hour, then 125 mL/hr of Normal Saline continuously. The provider also orders a one-time dose of 40 mg Furosemide IV push and to re-check the Renal Function Panel in 6 hours.  Ms. Barkley diuresis approximately 600 mL in 2 hours and her lungs now sound clear to auscultation.

Over the next two days, Ms. Barkley’s hourly urine output begins to improve and her BUN, Creatinine, and GFR return to normal ranges.  Her small bowel obstruction resolves on its own and she is able to begin taking PO food and fluids.