An 8-year-old boy presents with lethargy, periorbital and lower extremity edema, and laboratory findings suggestive of acute renal injury, including hyperkalemia and hyponatremia. Which nursing intervention should be prioritized to address the electrolyte imbalance and prevent complications?

A) Administer intravenous calcium gluconate to stabilize cardiac membranes

B) Initiate a high-potassium diet to compensate for renal losses

C) Encourage oral fluid intake to flush out excess potassium

D) Administer a loop diuretic to promote renal excretion of potassium

An 8-year-old boy is admitted with acute renal injury. He presents with lethargy, edema, and electrolyte imbalances, including hyperkalemia and hyponatremia. Considering his recent history of amoxicillin use and penicillin allergy, which nursing intervention is the priority to prevent further renal damage?

B) Discontinue amoxicillin and notify the healthcare provider for an alternative antibiotic.

A) Administer a diuretic to reduce fluid overload and edema.

B) Discontinue amoxicillin and notify the healthcare provider for an alternative antibiotic.

C) Initiate continuous renal replacement therapy (CRRT) immediately.

D) Restrict dietary potassium intake and monitor cardiac function.

An 8-year-old boy with acute renal injury is being treated for hyperkalemia with calcium gluconate and insulin with glucose. The ultrasound shows mild bilateral hydronephrosis. Which of the following is the most appropriate next step in the management of this patient?

C) Consult urology for potential surgical intervention to relieve obstruction.

A) Initiate dialysis to manage persistent hyperkalemia.

B) Perform a voiding cystourethrogram to assess for vesicoureteral reflux.

C) Consult urology for potential surgical intervention to relieve obstruction.

D) Increase fluid intake to promote renal perfusion and function.

An 8-year-old boy with acute renal injury and persistent hyperkalemia is receiving treatment with calcium gluconate and insulin with glucose. An ultrasound reveals mild bilateral hydronephrosis. Which nursing intervention is most important to prioritize in managing this child's condition?

A) Monitor cardiac rhythm continuously.

B) Encourage increased oral fluid intake.

C) Prepare the child for immediate dialysis.

D) Educate the parents on low-potassium diet.

An 8-year-old boy with worsening kidney function, fluid overload, and severe electrolyte imbalances is being considered for continuous renal replacement therapy (CRRT). As the nurse caring for this patient, which of the following interventions is most important to prioritize before initiating CRRT?

B) Ensure vascular access is adequate and functioning properly for CRRT.

A) Administer a dose of antihypertensive medication to manage fluctuating blood pressure.

B) Ensure vascular access is adequate and functioning properly for CRRT.

C) Educate the family about the CRRT procedure and obtain informed consent.

D) Prepare equipment for bedside hemodialysis as an alternative to CRRT.

An 8-year-old boy is experiencing complications related to acute kidney injury, as evidenced by low urine output, hypertension, and respiratory distress. The healthcare team is considering initiating continuous renal replacement therapy (CRRT). What is the most critical nursing assessment to prioritize before the initiation of CRRT?

C) Evaluating the child's vascular access site for patency and signs of infection.

A) Assessing the child's nutritional status and recent dietary intake.

B) Monitoring the child's neurological status and level of consciousness.

C) Evaluating the child's vascular access site for patency and signs of infection.

D) Checking the child's developmental milestones and cognitive function.

A pediatric patient undergoing continuous renal replacement therapy (CRRT) is showing signs of increased intracranial pressure, including headache, irritability, and confusion. Considering the current clinical scenario, what is the most appropriate nursing intervention to address this complication?

C) Elevate the head of the bed to 30 degrees to promote venous drainage

A) Increase the rate of CRRT to enhance toxin clearance

B) Administer a bolus of hypertonic saline to reduce intracranial pressure

C) Elevate the head of the bed to 30 degrees to promote venous drainage

D) Restrict fluid intake to prevent further fluid overload

A nurse is caring for a pediatric patient undergoing continuous renal replacement therapy (CRRT) who is exhibiting signs of increased intracranial pressure. Which action should the nurse prioritize to address the patient's neurological status?

B) Position the patient with the head of the bed elevated to 30 degrees.

A) Increase the rate of CRRT to enhance toxin removal.

B) Position the patient with the head of the bed elevated to 30 degrees.

C) Administer a diuretic to promote additional fluid removal.

D) Request an immediate neurological consult for potential intervention.

A pediatric patient with mild cerebral edema and unstable hemodynamics is being managed with CRRT and vasopressors. Which nursing intervention is most critical to prioritize in this clinical scenario to prevent further neurological deterioration?

B) Closely monitor intracranial pressure and adjust fluid management accordingly.

A) Administer scheduled doses of mannitol to reduce cerebral edema.

B) Closely monitor intracranial pressure and adjust fluid management accordingly.

C) Increase the rate of CRRT to enhance clearance of uremic toxins.

D) Titrate vasopressor dosage to maintain stable blood pressure.

A child with mild cerebral edema and potential uremic encephalopathy is receiving continuous renal replacement therapy (CRRT) and requires careful neurological and hemodynamic management. Which nursing intervention is most critical to prioritize at this time?

D) Performing frequent neurological assessments for changes in consciousness and pupil response.

A) Administering a low-dose vasopressor to stabilize blood pressure.

B) Increasing supplemental oxygen to maintain saturation above 95%.

C) Adjusting CRRT settings to optimize uremic toxin clearance.

D) Performing frequent neurological assessments for changes in consciousness and pupil response.

Acute Renal Injury in Kids - Nursing Case Study

Pathophysiology

• Primary mechanism: Hemodynamic changes lead to reduced renal perfusion, often due to dehydration or septic shock, causing inadequate delivery of oxygen and nutrients to kidney tissues, resulting in acute tubular necrosis.

• Secondary mechanism: Nephrotoxic injury from medications or infections damages renal tubular cells directly, impairing their function and leading to accumulation of waste products in the blood.

• Key complication: Impaired urine output and electrolyte imbalances can progress to fluid overload and metabolic acidosis, necessitating prompt intervention to prevent long-term kidney damage.

Patient Profile

Demographics:

8-year-old male, student

History:

• Key past medical history: History of recurrent urinary tract infections

• Current medications: Amoxicillin (for recent UTI), multivitamins

• Allergies: Penicillin

Current Presentation:

• Chief complaint: Decreased urine output and swelling in legs

• Key symptoms: Fatigue, nausea, flank pain, mild confusion

• Vital signs: Temperature - 99.1°F, Heart rate - 110 bpm, Blood pressure - 140/90 mmHg, Respiratory rate - 24 breaths per minute, Oxygen saturation - 96% on room air

Section 1

As the healthcare team conducted the initial assessment of the 8-year-old boy, they noted several critical findings that warranted further investigation. Upon physical examination, the patient appeared lethargic, with periorbital and lower extremity edema. Auscultation of the lungs revealed bilateral crackles, suggesting fluid accumulation. The abdominal examination indicated tenderness over the flanks, consistent with the reported flank pain. Despite the patient's mild confusion, he was still able to follow simple commands, although his responses were slower than expected for his age.

Laboratory results soon confirmed the severity of the situation. The complete blood count showed a mildly elevated white blood cell count, suggesting a possible infectious or inflammatory process. Serum chemistry tests revealed a marked increase in blood urea nitrogen (BUN) and creatinine levels, indicating significant renal impairment. Electrolyte imbalances were evident, with hyperkalemia and hyponatremia posing immediate risks. Additionally, a urinalysis demonstrated hematuria and proteinuria, further supporting the diagnosis of acute renal injury.

The combination of clinical and laboratory findings led the team to suspect that the acute renal injury was progressing towards a more severe state, potentially transitioning into acute kidney failure. Immediate interventions, including fluid management and electrolyte stabilization, were initiated to mitigate further complications. The team also considered the possibility of nephrotoxic effects from the recent amoxicillin use, given the patient's penicillin allergy and history of recurrent UTIs. This introduced a new layer of complexity to the case, necessitating careful review of the medication regimen and consideration of alternative treatments to prevent worsening of renal function. The focus remained on monitoring the patient's response to the interventions and adjusting the treatment plan accordingly to prevent long-term renal damage.

Section 2

As the healthcare team closely monitored the 8-year-old boy's condition, a new set of diagnostic results provided both insight and concern regarding his status. Repeat laboratory tests showed a slight improvement in blood urea nitrogen (BUN) and creatinine levels, suggesting a partial response to the fluid management and electrolyte stabilization efforts. However, the hyperkalemia persisted, with potassium levels still dangerously elevated at 6.5 mmol/L. This prompted the team to initiate additional interventions, including the administration of calcium gluconate to protect cardiac function and insulin with glucose to facilitate the intracellular shift of potassium.

Concurrently, an ultrasound of the kidneys was performed to assess for any structural abnormalities or obstructions contributing to the acute renal injury. The imaging revealed mild bilateral hydronephrosis, raising the possibility of obstructive uropathy as a complicating factor. This finding necessitated further investigation to determine the underlying cause, such as a possible ureteral obstruction or severe bladder dysfunction. The presence of hydronephrosis, combined with the clinical signs of fluid overload and persistent electrolyte imbalances, indicated that the acute renal injury might be more complex than initially anticipated.

The team recognized the importance of addressing these complications promptly to prevent progression to acute kidney failure. A multidisciplinary approach was adopted, involving pediatric nephrology and urology consultations to explore potential surgical or procedural interventions. The focus was on maintaining renal perfusion and function while managing the fluid and electrolyte disturbances. By integrating the new diagnostic findings with the patient's clinical presentation, the healthcare team aimed to refine the treatment strategy and support the child's recovery, aware that the next steps would be crucial in determining the trajectory of his renal health.

Section 3

As the healthcare team continued to monitor the 8-year-old boy's response to the interventions, they observed a notable change in his clinical status. Over the next 24 hours, his urine output remained low, despite the administration of diuretics, which raised concerns about the potential worsening of kidney function. The child's blood pressure began to fluctuate, with episodes of hypertension alternating with hypotension, suggesting instability in his fluid and hemodynamic status. His heart rate increased to 110 bpm, and he exhibited signs of mild respiratory distress, with a respiratory rate of 28 breaths per minute and low oxygen saturation levels of 90% on room air, indicating potential fluid overload and cardiac stress.

New laboratory results revealed persistent hyperkalemia, with potassium levels remaining elevated at 6.3 mmol/L, despite the initial treatments. Additionally, a rising trend in the BUN and creatinine levels was noted, with BUN at 38 mg/dL and creatinine at 2.1 mg/dL, suggesting a further decline in renal function. The metabolic acidosis worsened, with a blood pH of 7.28 and bicarbonate levels dropping to 16 mmol/L. These findings indicated a failure of the kidneys to adequately excrete waste products and maintain acid-base balance, necessitating urgent intervention.

Given these developments, the healthcare team decided to escalate their approach by considering renal replacement therapy options, such as continuous renal replacement therapy (CRRT), to address the fluid overload and severe electrolyte imbalances while providing renal support. The multidisciplinary team, including nephrology and critical care specialists, convened to evaluate the risks and benefits of initiating CRRT in such a young patient. This decision marked a critical juncture in the child's treatment plan, as the team aimed to stabilize his condition and prevent the progression to irreversible kidney damage. The next steps would involve close monitoring of his response to this advanced intervention and ongoing reassessment of his clinical needs.

Section 4

As the healthcare team initiated continuous renal replacement therapy (CRRT) for the young patient, they closely monitored his physiological parameters and laboratory values to assess his response to the intervention. Over the initial 12 hours of CRRT, the team observed a modest increase in urine output, indicating some relief in renal function. However, the child's blood pressure remained labile, with systolic readings fluctuating between 90 and 130 mmHg. The respiratory distress persisted, albeit with slight improvement, as his respiratory rate decreased to 24 breaths per minute and oxygen saturation improved to 93% on supplemental oxygen.

The laboratory results provided mixed insights into the child's response. Potassium levels decreased to 5.5 mmol/L, reflecting partial correction of the hyperkalemia, yet the metabolic acidosis persisted with only a slight improvement in pH to 7.30 and bicarbonate levels rising marginally to 18 mmol/L. Despite these adjustments, BUN and creatinine levels showed only minimal improvement, with creatinine still elevated at 2.0 mg/dL, suggesting ongoing renal impairment.

The team faced a new complication as the child began to exhibit signs of increased intracranial pressure, with episodes of headache, irritability, and a brief episode of confusion. These neurological symptoms raised concerns about the potential for uremic encephalopathy or other central nervous system involvement due to the accumulating toxins. The multidisciplinary team convened once more to deliberate on further interventions, considering the need for additional neuroimaging and possible adjustments in CRRT settings to better manage the child's fluid and metabolic status. The next steps would involve not only addressing the renal issues but also ensuring neurological stability, guiding the team to a comprehensive approach in managing this complex case.

Section 5

As the team prepared to address the child's escalating neurological symptoms, they initiated a thorough neurological assessment and ordered an urgent CT scan of the brain. The initial findings from the CT scan revealed mild cerebral edema, raising concerns about possible uremic encephalopathy exacerbating the child's condition. In light of these findings, the team adjusted the CRRT settings to optimize clearance of uremic toxins while ensuring careful fluid management to prevent further increases in intracranial pressure. Close monitoring of the child's neurological status became a priority, with frequent assessments for changes in consciousness, pupil response, and vital signs.

Despite these interventions, the child's hemodynamic status remained unstable. His blood pressure continued to fluctuate, with episodes of hypertension interspersed with hypotension, suggesting potential autonomic dysregulation or fluid imbalances. The team decided to introduce a low-dose vasopressor to stabilize his blood pressure while ensuring that fluid overload and electrolyte imbalances were meticulously managed. Concurrently, the respiratory team increased the child's supplemental oxygen to maintain adequate oxygenation, keeping his saturation levels above 95%.

As the hours passed, the child's condition required continuous reassessment and adaptation of the treatment plan. The multidisciplinary team prioritized the need for dynamic adjustments in therapy, focusing on the interplay between renal and neurological health. They deliberated on the potential benefits of adding therapeutic interventions, such as mannitol or hypertonic saline, to manage cerebral edema and considered the role of adjunctive therapies in mitigating the systemic effects of renal dysfunction. This ongoing evaluation underscored the complexity of the case, driving home the necessity of an integrative approach to care that could anticipate and address the multifaceted challenges this young patient faced.