Nursing Case Study for Acute Kidney Injury
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Outline
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
Which order would you question or request clarification for? Why?
What additional nursing assessments need to be performed?
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.
What nursing action(s) should be implemented at this time? Who should this information be passed on to?
What nursing action(s) should be implemented at this time? Who should this information be passed on to?
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
What nursing action(s) should be implemented at this time?
What orders should be anticipated from the provider?
What is going on physiologically with Ms. Barkley at this time? Explain what contributed to the development of this condition
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.
What could have been done, if anything, to prevent Acute Kidney Injury for Ms. Barkley?
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Transcript
Hi guys. My name is Abby. We’re going to go through a case study for acute kidney injury together. Let’s get started. In this scenario, our patient is Ms. Barkley. She’s thin and frail, 64 years old and presents from a nursing home for acute abdominal pain as well as nausea and vomiting that she’s been experiencing for the last two days. She receives a CT scan with IV contrast and the findings show no acute bleeding, but a possible small bowel obstruction. She is admitted to the hospital for bowel rest with the following written orders from the provider:
The provider wants continuous telemetry, strict I and O measurements as well as to keep her saturation above 92%. She’s also to be kept under strict NPO. She has some PRN orders for pain medication as well as medication for nausea. As you can see below, she is admitted to the unit at the beginning of the shift and the CNA reports, the following vital signs:
Her blood pressure is 118/68 mmHg with a heart rate of 103 beats/minute, respiratory rate of 16 breaths/minute saturating on room air at 96% and her current pain score is a 6 out of 10. Now that we have some information about this patient, let’s take a look at our critical thinking checks number one and number two below.
Great job. At the end of the 12-hour shift, the vital signs are as follows: her blood pressure is 147 over 80 with a heart rate of 96 beats/minute and shes respirating at 22 times a minute. Her SpO2 is now 93% and her pain score is 3 out of 10. The nurse recognizes that the patient has not voided all day and assists the patient to the restroom. The patient ends up voiding 200 milliliters of really dark concentrated urine. Now that we know that let’s take a look at our critical thinking checks number three and number four below.
Excellent work. The provider orders 500 milliliters of normal saline to be given IV over an hour and a renal function panel needs to be drawn and the nurse does so promptly. After about six hours, Ms. Barkley still has no further urinary output. A bladder scan shows approximately 60 mL of urine in the bladder. A head-to-toe assessment now reveals crackles bilaterally, and she’s only saturating at 89%. The renal function panel has come back. Let’s take a look at those results. The sodium 132, potassium 5.5, a BUN a 56 and a creatinine of 3.6. Let’s take a look at her calcium as well. Calcium resulted at 7.7 and her GFR or the glomerular filtration rate is 47. Phosphorus came back at 4.8 and magnesium at 1.4. Now that we have her lab information and some more about her head to toe, let’s take a look at our critical thinking checks number five, number six and number seven.
Great job. The provider orders to give another bolus this time, a liter of normal saline, again, over an hour, and then a continuous normal saline infusion of 125 milliliters per hour. The provider also orders a one-time dose of 40 milligrams of Furosemide via IV push and to recheck the renal function panel in another six hours. Ms. Barkley diuresis, approximately 600 milliliters in two hours. And her lungs now sound clear to auscultation. Over the next two days, Ms. Barkley’s urinary output begins to improve and her BUN and creatinine, as well as her GFR return to normal limits. Her small bowel obstruction resolves on its own and she’s now able to begin taking food and fluids by mouth. Let’s take a look at our critical thinking check number eight.
Great job guys, that wraps up this case study on acute kidney injury. Please take a look at the attached study tools and test your knowledge with a practice quiz. We love you guys, now go out and be your best self today, and as always, happy nursing!
References:
Overview of the management of acute kidney injury (AKI) in adults Authors:Mark D Okusa, MDMitchell H Rosner, MD updated Dec, 2021;
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Medical surgical 1 (Cardiac and respiratory)
Concepts Covered:
- Cardiac Disorders
- Emergency Care of the Cardiac Patient
- Cardiovascular
- Shock
- Shock
- Noninfectious Respiratory Disorder
- Respiratory
- Acute & Chronic Renal Disorders
- Hematologic Disorders
- Respiratory Emergencies
- Documentation and Communication
- Preoperative Nursing
- Immunological Disorders
- Intraoperative Nursing
- Vascular Disorders
- Renal Disorders
- Disorders of Pancreas
- Newborn Complications
- Medication Administration
- Central Nervous System Disorders – Brain
- Studying
- Emergency Care of the Trauma Patient
- Infectious Respiratory Disorder
- Endocrine
- Disorders of the Adrenal Gland
- Disorders of the Thyroid & Parathyroid Glands
- Musculoskeletal Trauma
- Oncology Disorders
- Integumentary Disorders
- Integumentary Disorders
- Liver & Gallbladder Disorders
- Circulatory System
- Disorders of Thermoregulation
- Multisystem
- Upper GI Disorders
- Neurological Emergencies
- Communication
- Perioperative Nursing Roles
- Sexually Transmitted Infections
- Peripheral Nervous System Disorders
- Disorders of the Posterior Pituitary Gland
- Lower GI Disorders
- Postoperative Nursing
- Emergency Care of the Respiratory Patient
- Emergency Care of the Neurological Patient
- Respiratory Disorders
- Respiratory System
- Infectious Disease Disorders