Critical care case study - Acute kidney injury: Nursing

Nurse. Greta works in the intensive care unit or ICU and is caring for Reggie.

A 47 year old diagnosed with acute kidney injury or AK I. Nurse.

Greta goes through the steps of the clinical judgment measurement model to make clinical decisions about Reggie's care by recognizing and analyzing cues, prioritizing hypotheses, generating solutions taking action and evaluating outcomes.

First, nurse, Greta recognizes important cues including Reggie's vital signs which are temperature 98.9 °F or 37.1 °C, heart rate, 100 BPM, respirations, 26 breaths per minute BP, 154/78 millimeters of mercury and oxygen saturation, 92% on 2 L of oxygen per nasal cannula upon assessment.

Nurse, Greta notes Reggie's urine output from his indwelling catheter was 25 mL in the last hour and has a dark amber color.

He also has a two plus pitting edema in his bilateral lower extremities and crackles upon auscultation to his lung bases.

Next, nurse, Greta analyzes these cues. She reviews the electronic health record or E hr and notes Reggie's admitting diagnosis was glomerulonephritis and his most recent labs show a bun of 31 mg per deciliter creatinine of 2.6 mg per deciliter.

An estimated glomerular filtration rate or egfr of 65 mL per minute. Additionally, his potassium is 5.8 mill equivalent per liter.

His urinalysis shows protein in blood and his arterial blood gas results indicate metabolic acidosis. Nurse Greta knows AK I is a sudden decline in kidney function that occurs over hours or days and can be reversible if identified and treated promptly.

She knows it can occur following glomerulonephritis, which is an inflammation of the network of capillaries in the kidneys that filter blood called the glomeruli.

This can cause intrarenal AK I where part of the kidney itself like the glomeruli is damaged when glomeruli are damaged, their permeability increases allowing large molecules and cells like protein and blood to pass through into the urine resulting in proteinuria and hematuria.

Additionally, glomeruli are unable to maintain a normal G fr. This can lead to hypervolemia edema, weight gain, hypertension and pulmonary crackles as GFR decreases waste products like creatinine and urea accumulate in the blood.

Leading to azotemia a condition where there are high levels of nitrogen containing substances in the blood, which can manifest as anorexia, nausea, vomiting, weakness and altered mental status.

Serum electrolyte balance is also disrupted, leading to the possibility of arrhythmias related to hyperkalemia. These kidneys are also unable to excrete hydrogen ions and reabsorb bicarbonate resulting in metabolic acidosis, nurse Greta knows AK I can progress to permanent kidney damage if left untreated.

She realizes Reggie needs immediate management of his AK I. Now using the information she's gathered.

Nurse Greta chooses a priority hypothesis of impaired fluid balance. She then generates solutions to address Reggie's impaired fluid balance, including pharmacologic and nonpharmacologic interventions.

And she establishes the expected outcome that after intervening Reggie's urine output will increase within an hour. Then nurse Greta takes action to implement these solutions.

First, she reviews orders placed by the health care provider. She notes orders for an IV loop diuretic to induce urinary output, decrease excess fluid and lower potassium and to redraw Reggie's labs every 12 hours.

She also notes standing orders for hourly intake and output measurement and daily weights and to titrate oxygen as needed to maintain oxygen saturation.

Above 94%. Nurse Greta collects her supplies and discusses the plan of care with Reggie.

She increases his oxygen from 2 L to 4 L. Then she administers the IV diuretic according to safe medication administration principles.

Nurse Greta then ensures Reggie's cardiac monitor is applied correctly and that his vital sign monitor is attached and programmed to record his BP every five minutes.

Then she gives Reggie the call bell and tells him that she'll be closely monitoring him. One hour later, Nurse Greta evaluates the outcomes of her actions.

She notes Reggie's vital signs which are BP 130/65 millimeters of mercury, heart rate, 99 BPM respirations, 20 breaths per minute and oxygen saturation.

95% on 4 L per nasal cannula. She notes his urine output for the last hour has increased and is lighter in color.

Nurse, Greta also notes the crackles in Reggie's lungs have diminished. All right.

It's a quick recap. Nurse, Greta recognized and analyzed cues related to Reggie's impaired fluid balance and prioritized hypotheses and generated solutions to address this problem.

Nurse Greta then implemented pharmacologic and non pharmacologic measures to manage Reggie's AK I and evaluated the outcomes compared with the expected outcomes.

Since Reggie's urine output improved within the hour. Nurse Greta determined the plan of care was successful.