A nurse is caring for a patient with acute renal insufficiency exhibiting worsening lethargy, disorientation, and hyperkalemia. Which intervention should the nurse anticipate to address the patient's hyperkalemia and stabilize the cardiac membrane?

A) Administer insulin with glucose

B) Provide oral calcium carbonate

C) Increase dietary potassium intake

A patient with acute kidney injury presents with lethargy, disorientation, worsening shortness of breath, and elevated blood pressure. Lab results indicate hyperkalemia and metabolic acidosis. What is the priority nursing intervention to address the patient's condition?

B) Prepare the patient for urgent dialysis to manage fluid overload and correct electrolyte imbalances.

A) Administer a potassium-wasting diuretic to decrease serum potassium levels.

B) Prepare the patient for urgent dialysis to manage fluid overload and correct electrolyte imbalances.

C) Increase the patient's supplemental oxygen to improve oxygen saturation levels.

D) Administer sodium bicarbonate to correct metabolic acidosis.

A patient with fluid overload and hyperkalemia is being treated with diuretics, insulin, dextrose, and calcium gluconate. Despite these interventions, the patient's blood pressure remains elevated, and heart rate is increased. Which intervention should the nurse prioritize next to address the patient's cardiovascular status?

B) Administer a beta-blocker to control heart rate and reduce cardiac workload

A) Initiate a continuous intravenous infusion of a vasodilator

B) Administer a beta-blocker to control heart rate and reduce cardiac workload

C) Increase the dose of diuretics to further manage fluid overload

D) Provide supplemental oxygen to improve respiratory status

A patient with fluid overload and renal impairment is receiving diuretics and insulin-dextrose infusion to manage hyperkalemia. The patient is also experiencing persistent hypertension and elevated heart rate. Which of the following interventions should the nurse prioritize to address the cardiovascular complications while ensuring patient safety?

C) Initiate a beta-blocker to control heart rate and hypertension

A) Increase the dose of diuretics to further reduce fluid overload

B) Administer the calcium gluconate and closely monitor the ECG

C) Initiate a beta-blocker to control heart rate and hypertension

D) Increase the rate of insulin infusion to rapidly correct hyperkalemia

A patient with a suspected paralytic ileus presents with abdominal distension, decreased bowel sounds, and metabolic acidosis. After the administration of calcium gluconate, the patient's calcium levels are elevated, and potassium levels have decreased. Which nursing intervention is most appropriate to address the current electrolyte imbalances while considering the patient's condition?

C) Hold calcium gluconate and monitor potassium levels closely.

A) Increase the rate of insulin infusion to lower calcium levels.

B) Administer sodium bicarbonate to correct the metabolic acidosis.

C) Hold calcium gluconate and monitor potassium levels closely.

D) Administer an additional dose of calcium gluconate to stabilize the patient.

A patient has developed a paralytic ileus likely due to electrolyte imbalances and current pharmacological therapy. The healthcare team has decided to hold opioids to prevent exacerbation of the ileus. Which additional nursing intervention is most appropriate to address the patient's current condition?

C) Implement a nasogastric tube to decompress the stomach and intestines.

A) Increase the patient's oral fluid intake to promote bowel motility.

B) Administer a high-fiber diet to stimulate gastrointestinal function.

C) Implement a nasogastric tube to decompress the stomach and intestines.

D) Encourage early ambulation to enhance bowel motility.

A patient with kidney failure presents with worsening respiratory distress, bilateral pleural effusions, pulmonary edema, and metabolic acidosis. Which intervention should the nurse prioritize to address the patient's respiratory status and fluid overload?

A) Administer a loop diuretic to decrease fluid volume.

B) Increase the oxygen flow rate to improve oxygen saturation.

C) Prepare the patient for intubation and mechanical ventilation.

D) Initiate continuous renal replacement therapy (CRRT) to manage fluid and electrolyte balance.

A patient with kidney failure presents with increased respiratory distress, elevated blood pressure, and decreased oxygen saturation. The healthcare team has identified pulmonary edema and metabolic acidosis as contributing factors to the patient's condition. Which of the following interventions should the nurse prioritize to address fluid overload while monitoring the patient's electrolyte and acid-base balance?

C) Administer a diuretic as prescribed and monitor electrolyte levels closely.

A) Administer a rapid intravenous infusion of normal saline.

B) Initiate an infusion of sodium bicarbonate to correct metabolic acidosis.

C) Administer a diuretic as prescribed and monitor electrolyte levels closely.

D) Increase oxygen flow rate to improve hypoxemia.

A patient with advanced kidney failure is experiencing confusion and restlessness after diuretic therapy, and their BUN and creatinine levels are elevated. The healthcare team is considering initiating hemodialysis. Which nursing intervention is most critical to perform prior to starting dialysis in this patient?

A) Monitor the patient's electrolyte levels specifically focusing on potassium.

B) Educate the patient about the hemodialysis procedure to reduce anxiety.

C) Assess the patient's respiratory status and oxygen saturation.

D) Ensure the patient has fasted for at least 8 hours prior to the procedure.

A patient with advanced kidney failure presents with confusion, restlessness, elevated blood urea nitrogen (BUN), and creatinine levels, alongside hypertension and tachypnea. Which nursing intervention is the most critical to implement at this time?

C) Prepare the patient for initiation of renal replacement therapy, such as hemodialysis.

A) Administer a sedative to manage restlessness and confusion.

B) Increase the dose of intravenous furosemide to enhance diuresis.

C) Prepare the patient for initiation of renal replacement therapy, such as hemodialysis.

D) Initiate oxygen therapy to improve respiratory status.

Kidney Failure - Nursing Case Study

Pathophysiology

• Primary mechanism: Reduced Glomerular Filtration Rate (GFR) - The kidneys lose their ability to filter blood efficiently due to damage or disease, leading to waste accumulation and electrolyte imbalances. This is often caused by conditions like diabetes or hypertension that damage the delicate structures within the kidneys.

• Secondary mechanism: Tubular Dysfunction - Damage to the renal tubules impairs their ability to reabsorb essential substances and excrete waste, exacerbating fluid overload, electrolyte disturbances, and acid-base imbalances. This dysfunction can be a result of toxin exposure or chronic injury from underlying diseases.

• Key complication: Fluid Overload and Electrolyte Imbalance - These mechanisms lead to complications such as edema, hyperkalemia, and metabolic acidosis, which increase the risk of cardiovascular events and require careful management to prevent further systemic complications.

Patient Profile

Demographics:

58-year-old male, retired factory worker

History:

• Key past medical history: Type 2 diabetes, hypertension, and chronic kidney disease

• Current medications: Metformin, lisinopril, atorvastatin, and furosemide

• Allergies: Penicillin

Current Presentation:

• Chief complaint: Increasing fatigue and swelling in legs

• Key symptoms: Shortness of breath, decreased urine output, nausea, and confusion

• Vital signs: Blood pressure 165/95 mmHg, heart rate 92 bpm, respiratory rate 22 breaths per minute, temperature 37.1°C, oxygen saturation 92% on room air

Section 1

Change in Patient Status:

As the nurse continues monitoring the patient, there is a noticeable change in his condition. Over the next 24 hours, the patient becomes increasingly lethargic and disoriented, with intermittent confusion that complicates communication. His shortness of breath worsens, now requiring supplemental oxygen to maintain an oxygen saturation of 90%. Physical examination reveals pronounced pitting edema in the lower extremities, extending to the mid-calf, and jugular venous distention, suggesting significant fluid retention.

The patient's vital signs indicate further deterioration: blood pressure has risen to 175/100 mmHg, and his heart rate has increased to 105 bpm. Repeat blood tests reveal worsening renal function with a serum creatinine level of 5.8 mg/dL and blood urea nitrogen (BUN) of 65 mg/dL. Electrolyte imbalances are evident, with potassium levels elevated at 6.2 mEq/L, indicating hyperkalemia, and a bicarbonate level of 16 mEq/L, suggesting metabolic acidosis. These lab results confirm the progression of kidney failure and highlight the urgent need for intervention to address the fluid overload and electrolyte imbalances.

In response to these changes, the healthcare team adjusts the treatment plan, considering the potential need for renal replacement therapy, such as dialysis, to manage the patient's acute renal insufficiency and prevent further complications. Additionally, they prioritize stabilization of the patient's cardiovascular status and aim to optimize fluid balance through cautious diuretic therapy and electrolyte management. The team also considers modifying the antihypertensive regimen to better control the patient's blood pressure and reduce further kidney damage. This evolving situation requires close monitoring and coordination of care to ensure the patient's stability and prevent further decline.

Section 2

The healthcare team swiftly implements the revised treatment plan to address the patient's deteriorating condition. Diuretics are administered cautiously to manage the fluid overload, and the patient's electrolyte levels are closely monitored. Within hours, there is a moderate reduction in the pitting edema, and the jugular venous distention shows slight improvement. However, despite these efforts, the patient continues to experience intermittent confusion, and his shortness of breath persists, requiring ongoing supplemental oxygen.

Repeat laboratory tests reveal that while the serum creatinine level has stabilized at 5.6 mg/dL, indicating some response to treatment, the hyperkalemia remains a concern with potassium levels at 5.9 mEq/L. The bicarbonate level has improved slightly to 18 mEq/L, yet metabolic acidosis is still present. The medical team decides to initiate a low-dose insulin infusion, coupled with dextrose, to help drive potassium back into the cells and reduce the risk of cardiac complications. Additionally, calcium gluconate is administered to protect the myocardium from the effects of elevated potassium.

Despite these interventions, new complications arise. The patient's blood pressure remains elevated at 170/95 mmHg, and his heart rate has increased slightly to 110 bpm. This persistent hypertension suggests an inadequate response to the current antihypertensive regimen, prompting the healthcare team to reassess and adjust the medications. They consider adding a beta-blocker to better control the heart rate and reduce the cardiac workload. As the team navigates these evolving challenges, they emphasize the need for continuous monitoring and timely adjustments to the treatment plan, recognizing the critical balance required to stabilize the patient's complex condition.

Section 3

As the team continues to monitor the patient's condition, a new complication presents itself. Overnight, the patient develops acute abdominal pain with associated nausea and vomiting, raising concern for a possible gastrointestinal issue. Upon examination, the abdomen is moderately distended with decreased bowel sounds, suggesting a paralytic ileus potentially secondary to electrolyte imbalances and the current pharmacological therapy. The patient's blood pressure remains elevated at 168/92 mmHg, and his heart rate has increased further to 115 bpm. Oxygen saturation holds steady at 92% on supplemental oxygen.

The healthcare team quickly orders abdominal imaging and a comprehensive metabolic panel to further investigate the cause of the abdominal symptoms. The imaging reveals dilated bowel loops without evidence of perforation, aligning with the suspicion of an ileus. The metabolic panel indicates a mild increase in serum calcium level to 10.8 mg/dL, likely due to the recent administration of calcium gluconate, and a slight decrease in potassium to 5.7 mEq/L. Despite these findings, the patient's metabolic acidosis persists, with bicarbonate now at 17 mEq/L.

In response to these developments, the team deliberates on modifying the treatment plan. They decide to temporarily hold medications that could exacerbate the ileus, such as opioids. They also consider adjusting the insulin and dextrose infusion to maintain potassium levels while ensuring that calcium levels do not rise further. Recognizing the complexity of managing multiple issues concurrently, the team emphasizes the importance of regular reassessment and interdisciplinary collaboration to address the interconnected challenges faced by the patient. This careful, dynamic approach aims to prevent further complications and optimizes the patient's chances for recovery.

Section 4

As the team continues to monitor the patient, a change in status becomes evident the following morning. The patient, who had been experiencing acute abdominal pain and nausea, now reports increased discomfort and a new onset of shortness of breath. Upon assessment, the patient's respiratory rate has increased to 28 breaths per minute, and auscultation reveals diminished breath sounds at the lung bases with crackles heard bilaterally, suggesting the development of pulmonary congestion or edema. The patient's blood pressure remains elevated at 170/94 mmHg, and his heart rate is now 118 bpm, indicating persistent tachycardia. Oxygen saturation has decreased to 89% despite being on supplemental oxygen, warranting further investigation and intervention.

In light of these changes, the healthcare team orders a chest X-ray and an arterial blood gas (ABG) analysis to evaluate the patient's respiratory status and potential fluid overload. The chest X-ray confirms bilateral pleural effusions and pulmonary edema, likely secondary to fluid retention and hypertension exacerbated by the patient's compromised renal function. The ABG reveals worsening metabolic acidosis with a pH of 7.28 and a bicarbonate level of 15 mEq/L, alongside mild hypoxemia. Given these findings, the team recognizes the need to adjust the fluid management strategy, potentially incorporating diuretics cautiously, while balancing the patient's electrolyte and acid-base status.

These developments underscore the complexity of managing a patient with kidney failure and emerging complications and highlight the need for vigilant reassessment and timely interventions. The team discusses the possibility of initiating renal replacement therapy to address fluid overload and metabolic derangements, weighing the risks and benefits in the context of the patient's overall condition. Interdisciplinary collaboration remains crucial as they strive to stabilize the patient's status and prevent further deterioration, emphasizing the interconnectedness of the patient's respiratory, cardiovascular, and renal systems in this critical phase of care.

Section 5

In response to the concerning findings from the chest X-ray and ABG analysis, the healthcare team initiates a cautious approach with diuretic therapy to manage the patient's fluid overload, opting for a low-dose intravenous furosemide. Over the next several hours, the team closely monitors the patient's urine output, vital signs, and electrolyte levels to assess the effectiveness of the intervention and to prevent potential complications such as electrolyte imbalances. The patient's urine output begins to improve slightly, indicating a positive response to the diuretic, yet it is clear that renal function remains significantly impaired.

However, as the team re-evaluates the patient, they notice a new onset of confusion and restlessness, suggesting possible encephalopathy due to the accumulating toxins in the blood, a common issue in advanced kidney failure. The patient's blood urea nitrogen (BUN) and creatinine levels are markedly elevated at 85 mg/dL and 5.2 mg/dL, respectively, reinforcing the need for more aggressive management of the accumulated waste products. The patient's blood pressure remains elevated at 168/92 mmHg, and despite slight improvements in oxygen saturation, now at 91%, his respiratory rate continues to be high at 26 breaths per minute.

Given the inadequate response to conservative management and the development of neurological symptoms, the team deliberates the urgency of initiating renal replacement therapy, such as hemodialysis, to address both fluid overload and the critical metabolic imbalances. This decision is complicated by the challenge of maintaining hemodynamic stability and managing potential dialysis-related complications. The interdisciplinary team, including nephrology, nursing, and respiratory therapy, collaborates to devise a comprehensive care plan that addresses the multi-system impact of the patient's condition, aiming to stabilize his status and prevent further deterioration. This pivotal decision represents a critical juncture in the patient's treatment, requiring careful clinical reasoning and continuous reassessment of his response to the evolving therapeutic interventions.