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Acute Kidney Injury Case Study (60 min)

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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

Critical Thinking Check
Bloom's Taxonomy: Application

Which order would you question or request clarification for? Why?

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Critical Thinking Check
Bloom's Taxonomy: Application

What additional nursing assessments need to be performed?

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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.

Critical Thinking Check
Bloom's Taxonomy: Application

What nursing action(s) should be implemented at this time? Who should this information be passed on to?

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Critical Thinking Check
Bloom's Taxonomy: Analysis

What diagnostic tests would you expect the provider to order? Why?

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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

Critical Thinking Check
Bloom's Taxonomy: Analysis

What nursing action(s) should be implemented at this time?

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Critical Thinking Check
Bloom's Taxonomy: Analysis

What orders should be anticipated from the provider?

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Critical Thinking Check
Bloom's Taxonomy: Analysis

What is going on physiologically with Ms. Barkley at this time? Explain what contributed to the development of this condition

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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.

 

Critical Thinking Check
Bloom's Taxonomy: Analysis

What could have been done, if anything, to prevent Acute Kidney Injury for Ms. Barkley?

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