A patient with a history of recurrent urinary tract infections presents with elevated serum creatinine and BUN levels, leukocytosis, significant hematuria, and pyuria. Ultrasound shows bilateral hydronephrosis and a post-void residual of 350 mL. Which nursing intervention should be prioritized to address the immediate risk of acute kidney injury in this patient?

C) Insert an indwelling urinary catheter to relieve bladder outlet obstruction.

A) Initiate a low-protein diet to reduce renal workload.

B) Administer broad-spectrum antibiotics to treat the urinary tract infection.

C) Insert an indwelling urinary catheter to relieve bladder outlet obstruction.

D) Monitor blood pressure closely to manage hypertension.

A patient presents with elevated serum creatinine and blood urea nitrogen levels, leukocytosis, and ultrasound findings of significant post-void residual urine and bilateral hydronephrosis. Given these diagnostic results, what is the nurse's priority intervention to prevent further renal damage and potential complications?

B) Inserting an indwelling urinary catheter to relieve bladder outlet obstruction and reduce hydronephrosis.

A) Administering broad-spectrum antibiotics immediately to address the suspected infection.

B) Inserting an indwelling urinary catheter to relieve bladder outlet obstruction and reduce hydronephrosis.

C) Initiating intravenous fluids to improve renal perfusion and support kidney function.

D) Consulting with the nephrology team for further assessment and management of kidney function.

A patient with a background of diabetes and penicillin allergy is suspected of urosepsis and is experiencing ongoing renal stress despite decompression. Considering the patient's hemodynamic instability and risk factors, what is the most critical nursing intervention to prioritize at this time?

A) Administering broad-spectrum antibiotics to address the suspected gram-negative bacteremia.

B) Initiating an aggressive fluid resuscitation plan to improve renal perfusion and stabilize blood pressure.

C) Closely monitoring blood glucose levels and adjusting the insulin regimen to manage potential changes in insulin sensitivity.

D) Collaborating with the pharmacist to ensure the chosen antimicrobial therapy is effective and safe considering the patient's penicillin allergy.

A patient presenting with signs of urosepsis and ongoing renal stress despite decompression efforts is under your care. The healthcare team has initiated broad-spectrum antibiotics, IV fluids, and is monitoring renal function closely. Given his current clinical condition and history, which nursing intervention should be prioritized to address the most immediate threat to the patient's health?

C) Continuously monitor neurological status and report any changes.

A) Increase the rate of intravenous fluids to improve renal perfusion.

B) Administer antihypertensives to stabilize blood pressure.

C) Continuously monitor neurological status and report any changes.

D) Adjust the antibiotic regimen based on preliminary culture results.

A patient with suspected urosepsis and atrial fibrillation shows signs of hemodynamic instability. Despite antibiotic treatment, the patient's fever persists and white blood cell count remains elevated. Considering the patient's renal impairment and ongoing treatment, which of the following nursing interventions is most critical in this scenario?

D) Monitor and adjust anticoagulation therapy based on bleeding risk and INR levels.

A) Administer an antipyretic to manage the patient's fever.

B) Initiate fluid restriction to prevent further renal impairment.

C) Collaborate with the healthcare team to adjust the antibiotic regimen.

D) Monitor and adjust anticoagulation therapy based on bleeding risk and INR levels.

A 68-year-old male patient with a history of benign prostatic hyperplasia, suspected urosepsis, and new onset atrial fibrillation is being managed for mild hydronephrosis, elevated serum creatinine, and a persistent fever. The healthcare team is considering various interventions. As the primary nurse, which of the following interventions should you prioritize to address the patient's current condition and prevent further complications?

D) Propose the adjustment of the antibiotic regimen based on the sensitivity report to ensure effective treatment of the E. coli infection.

A) Advocate for the initiation of anticoagulation therapy to prevent thromboembolic events due to atrial fibrillation.

B) Recommend the immediate initiation of corticosteroid therapy to suppress the inflammatory response associated with suspected urosepsis.

C) Suggest the urgent scheduling of a transurethral resection of the prostate (TURP) to relieve urinary obstruction and prevent further renal damage.

D) Propose the adjustment of the antibiotic regimen based on the sensitivity report to ensure effective treatment of the E. coli infection.

A patient with acute kidney injury and respiratory distress has developed hyperkalemia with a potassium level of 5.9 mEq/L. The healthcare team plans to initiate renal replacement therapy. As a nurse, what is the most critical immediate action to address the patient's hyperkalemia and prevent cardiac complications before starting dialysis?

B) Administer intravenous calcium gluconate

A) Administer sodium polystyrene sulfonate (Kayexalate) orally

B) Administer intravenous calcium gluconate

C) Initiate a low-potassium diet

D) Prepare the patient for hemodialysis immediately

A patient with acute kidney injury and respiratory distress is exhibiting hyperkalemia with a serum potassium level of 5.9 mEq/L. The healthcare team is considering immediate interventions to prevent cardiac complications. Which nursing intervention should the nurse prioritize to address the hyperkalemia in this patient, considering the potential for hemodynamic instability?

A) Administer intravenous calcium gluconate to stabilize cardiac membranes.

B) Initiate hemodialysis immediately to remove excess potassium.

C) Administer intravenous insulin and dextrose to facilitate intracellular potassium shift.

D) Restrict dietary potassium intake and monitor serum levels closely.

A patient undergoing continuous venovenous hemofiltration (CVVH) develops hypotension, altered mental status, and is receiving norepinephrine to maintain mean arterial pressure. Which nursing intervention is most appropriate to address the altered mental status considering the patient's current hemodynamic condition?

C) Assess for potential metabolic disturbances and adjust dialysis settings accordingly.

A) Increase the norepinephrine dose to further stabilize blood pressure and improve cerebral perfusion.

B) Administer a fluid bolus to improve blood pressure and cerebral perfusion.

C) Assess for potential metabolic disturbances and adjust dialysis settings accordingly.

D) Initiate sedative therapy to manage the patient's confusion and disorientation.

A patient with acute kidney injury has developed hypotension and altered mental status after initiating continuous venovenous hemofiltration (CVVH). Despite the introduction of norepinephrine, the patient remains hemodynamically unstable. Which nursing intervention should be prioritized to address the underlying cause and stabilize the patient?

C) Reassess the CVVH settings to ensure appropriate fluid removal rates and prevent fluid deficit.

A) Increase the norepinephrine dose to achieve a higher mean arterial pressure.

B) Administer a fluid bolus to increase circulating volume and improve perfusion.

C) Reassess the CVVH settings to ensure appropriate fluid removal rates and prevent fluid deficit.

D) Initiate continuous electrocardiogram monitoring to detect potential arrhythmias.

bph - Nursing Case Study

Pathophysiology

• Primary mechanism: Hormonal imbalances, particularly increased dihydrotestosterone (DHT), stimulate prostatic cell proliferation, leading to prostate gland enlargement and urethral compression.

• Secondary mechanism: Altered stromal-epithelial interactions within the prostate further promote hyperplasia through autocrine and paracrine signaling, exacerbating glandular growth and urinary obstruction.

• Key complication: Progressive bladder outlet obstruction can result in severe complications such as acute urinary retention, recurrent urinary tract infections, and, if untreated, kidney damage due to increased bladder pressure and backflow.

Patient Profile

Demographics:

68-year-old male, retired construction worker

History:

• Key past medical history: Benign Prostatic Hyperplasia (BPH) diagnosed 10 years ago, recurrent urinary tract infections, hypertension, type 2 diabetes mellitus

• Current medications: Tamsulosin, Finasteride, Metformin, Lisinopril, Aspirin

• Allergies: Penicillin

Current Presentation:

• Chief complaint: Severe difficulty urinating and abdominal pain

• Key symptoms: Urinary retention, nocturia, hematuria, lower abdominal pain, fever, fatigue

• Vital signs: Blood pressure 160/95 mmHg, heart rate 112 bpm, respiratory rate 24 breaths/min, temperature 101.3°F, oxygen saturation 88% on room air

Section 1

New Diagnostic Results:

Following the initial assessment, the healthcare team ordered a series of diagnostic tests to clarify the extent of the patient's condition and to guide further treatment. Blood tests revealed a marked elevation in serum creatinine at 2.5 mg/dL, indicating compromised renal function, likely due to prolonged increased bladder pressure and potential backflow. Blood urea nitrogen (BUN) was elevated at 45 mg/dL, further suggesting renal impairment. A complete blood count showed leukocytosis with a white blood cell count of 15,000/µL, consistent with an ongoing infection, correlating with the patient's fever and fatigue.

A urinalysis confirmed the presence of significant hematuria and pyuria, with a positive nitrite test and high leukocyte esterase, indicative of a urinary tract infection. Given his history of recurrent UTIs, this suggests a severe ongoing infection, possibly complicated by urinary stasis from bladder outlet obstruction. An ultrasound of the kidneys and bladder revealed significant post-void residual urine volume of 350 mL and bilateral hydronephrosis, suggesting urine backflow and pressure affecting the upper urinary tract, which could potentially lead to kidney damage if not addressed promptly.

These findings necessitate immediate clinical interventions to relieve the obstruction and address the infection. The healthcare team must consider the risks of acute kidney injury and sepsis, given the patient's vital signs and lab results. This scenario requires advanced clinical reasoning to prioritize interventions that will stabilize the patient, such as catheterization for urinary decompression, initiation of broad-spectrum antibiotics tailored to his penicillin allergy, and careful monitoring of renal function. The team must also address his hypertension and diabetes management in the context of acute illness, necessitating a multidisciplinary approach to optimize the patient's recovery trajectory.

Section 2

As the healthcare team initiated the intervention plan, the patient underwent urinary catheterization to relieve bladder obstruction and reduce pressure on the kidneys. Within hours, there was a significant improvement in urine output, with the catheter draining an initial 800 mL of urine, indicating substantial bladder distention. Alongside this, the patient was started on a broad-spectrum antibiotic regimen, adjusted to avoid cross-reactivity with his penicillin allergy. Despite these measures, the patient’s condition remained precarious; his blood pressure was recorded at 160/95 mmHg, and his heart rate was elevated at 110 bpm, suggestive of underlying hemodynamic instability potentially exacerbated by systemic infection.

The following day, the patient’s condition took a concerning turn. He exhibited increased confusion and disorientation, which raised suspicions of urosepsis given his elevated white blood cell count and persistent fever of 102°F. Blood cultures were drawn, and the preliminary results pointed towards a gram-negative bacteremia, necessitating an adjustment in antimicrobial therapy pending specific culture sensitivities. Concurrently, renal function showed no significant improvement, with serum creatinine creeping to 2.8 mg/dL, indicating ongoing renal stress despite decompression efforts. The team decided to initiate intravenous fluids cautiously, balancing the risk of fluid overload due to underlying cardiac issues.

This evolving clinical picture required a reassessment of priorities. The focus shifted towards aggressive management of the suspected sepsis, careful titration of antihypertensives considering his labile blood pressure, and a reassessment of his diabetic regimen in light of potential alterations in insulin sensitivity during severe infection. The multidisciplinary team, including nephrology, infectious disease, and endocrinology, convened to formulate a more comprehensive plan to stabilize his renal function and systemic condition, recognizing the delicate interplay of his comorbidities and acute illness.

Section 3

As the healthcare team continued to manage the patient’s complex condition, new diagnostic results were integrated into the evolving clinical picture. A repeat ultrasound of the kidneys and bladder revealed mild hydronephrosis, which suggested that the bladder decompression had not completely alleviated the pressure on the renal system. The team considered this finding in conjunction with the patient’s persistently elevated serum creatinine level. Additionally, a CT scan of the abdomen and pelvis highlighted an enlarged prostate with significant post-void residual urine, further complicating the urinary obstruction scenario. This prompted discussions regarding potential interventions such as transurethral resection of the prostate (TURP) versus medical management with alpha-blockers or 5-alpha-reductase inhibitors, taking into account the patient’s hemodynamic instability and infection status.

Simultaneously, the blood culture sensitivities confirmed the presence of Escherichia coli sensitive to the current antibiotic regimen, but with intermediate resistance to several other common antibiotics. This necessitated a continued rigorous approach to antimicrobial stewardship to prevent further resistance. The patient’s white blood cell count remained elevated at 15,000/mm³, and his fever persisted despite ongoing antibiotic treatment. This prompted the infectious disease team to consider adjunctive therapies such as corticosteroids to modulate the inflammatory response associated with the suspected urosepsis.

Despite these interventions, the patient’s condition worsened with new onset of atrial fibrillation, likely precipitated by the systemic stress and electrolyte imbalances due to renal impairment. His heart rate fluctuated between 110 and 140 bpm, further complicating blood pressure management and increasing the risk of thromboembolic events. The cardiology team was consulted to evaluate the necessity of anticoagulation therapy, carefully weighing the risk of bleeding against the risk of stroke. This new complication underscored the need for comprehensive monitoring and swift adaptation of the treatment plan to address the multifaceted challenges presented by the patient’s acute illness and chronic comorbidities.

Section 4

As the healthcare team continued to navigate the complexities of the patient's condition, a change in the patient’s status became evident. The patient developed increasing respiratory distress, marked by a respiratory rate of 28 breaths per minute, oxygen saturation dropping to 88% on room air, and the onset of bilateral crackles upon auscultation. These findings suggested the possibility of fluid overload, potentially secondary to acute kidney injury exacerbated by the persistent hydronephrosis and urinary obstruction. Arterial blood gases revealed a pH of 7.32, PaCO2 of 48 mmHg, and HCO3 of 22 mEq/L, indicating a mixed respiratory and metabolic acidosis. This respiratory compromise required the immediate attention of the critical care team to address the potential for acute respiratory failure.

Upon further evaluation, the patient exhibited signs of worsening renal function with serum creatinine escalating to 3.2 mg/dL and blood urea nitrogen (BUN) rising to 48 mg/dL. Electrolyte imbalances were also noted, with hyperkalemia registering at 5.9 mEq/L, necessitating urgent intervention to prevent cardiac complications. The nephrology team recommended initiating renal replacement therapy to manage the acute kidney injury and hyperkalemia, while carefully considering the patient's hemodynamic instability. The decision to proceed with dialysis was complicated by the need to balance fluid removal with maintaining adequate blood pressure, as the patient’s mean arterial pressure hovered precariously at 65 mmHg.

These developments prompted a reevaluation of the overall treatment strategy, considering the patient’s deteriorating respiratory and renal function alongside the persistent cardiac arrhythmia. The interdisciplinary team, including intensivists, nephrologists, and cardiologists, convened to reassess the therapeutic priorities, emphasizing the need for an integrated approach to manage the interdependent organ systems. This adjustment in the treatment plan aimed to stabilize the patient while preventing further deterioration, illustrating the intricate interplay between acute interventions and chronic management strategies in the context of a multifaceted clinical challenge.

Section 5

As the clinical team proceeded with the patient's management, they implemented renal replacement therapy cautiously, initiating continuous venovenous hemofiltration (CVVH) to address the hyperkalemia and fluid overload while minimizing hemodynamic instability. Despite these efforts, a new complication emerged: the patient developed hypotension, with systolic blood pressure dropping to 88 mmHg and diastolic at 50 mmHg. The heart rate increased to 112 beats per minute, indicating a compensatory response to maintain cardiac output. Furthermore, the patient began exhibiting altered mental status, with confusion and disorientation noted during neurological assessment, raising concerns about cerebral perfusion.

In response to the hypotensive episode, the team initiated vasopressor support with norepinephrine, titrating the dose to achieve a mean arterial pressure of 70 mmHg. The patient's oxygen therapy was escalated to high-flow nasal cannula, delivering an FiO2 of 60%, to address the persistent hypoxemia and reduce the work of breathing. However, the increased respiratory support and inotropic therapy prompted a reevaluation of the patient's cardiac status, given the history of arrhythmias and the potential for acute decompensation of heart failure.

To further investigate the etiology of the altered mental status and cardiovascular instability, a comprehensive set of diagnostic tests was ordered, including brain imaging to rule out cerebrovascular events, an echocardiogram to assess cardiac function, and serial troponin levels to monitor for myocardial injury. Meanwhile, the patient’s fluid balance was meticulously tracked, with input and output closely monitored to guide ongoing fluid management strategies. This intricate balance of interventions and diagnostics underscored the complexity of managing the patient’s multifaceted condition, demanding advanced clinical reasoning to navigate the interrelated challenges and optimize outcomes.