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NUR440 Case Study 5 Acute Renal Failure

Case study focusing on the management of acute renal failure.

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    NUR440 Case Study 5 NUR440 Case Study Five: Acute Renal Failure ML is a 32 - year - old African - American woman who was involved in a motor vehicle crash (MVC) 3 days ago. She was driving the vehicle when she lost control of the car and slid off the side of the road hitting the embankment. Her history is significant for diabetes. Her medication regimen includes insulin 70/30 for which she takes 12 units in the morning and evening. On admission, her weight was 125 pounds. Her skin was pale and cold. Her vital signs were as follows: BP = 78/40 mm Hg; P = 140 bpm; RR = 42/min and shallow. She was disoriented and confused. Bony deformities were obvious in the left and right shins. She was diffusely tender to touch, more so over her right chest. During the course of her first 3 days, the following findings and treatments occurred. The insertion of a Foley catheter was difficult and revealed gross hematuria. Her lab results revealed: Hgb = 12.2; Hct = 36; WBC = 11,200; blood glucose = 180. Urinalysis revealed a pH of 6, a specific gravity of 1.018, 4+ occult blood, 1+ protein, and RBCs too numerous to count. Chest x - ray films showed multiple faint rib fractures on the right side. Heart size was normal, and there were no other remarkable findings on the x - ray film or ECG. Initial serum electrolytes and amylase were normal, as was her ABG. Her fractures were confirmed to the shaft of the right femur and left tibia and fibula. She was treated with warmed blankets, 2 units of PRBCs, and 4 L of saline. Her blood pressure came up to 116/78. Urine output was 55 ml over the next 90 minutes. A CT scan of her head with contrast infusion was normal. A CT scan of her abdomen showed some ascitic fluid and a probable hematoma of the spleen. The abdomen was explored and a lacerated spleen was removed. ML required an additional 4 units of blood during the surgery. For the last 3 days, ML's urine output has averaged 40 to 50 ml/hr, and her mean arterial pressure (MAP) was 60 to 80. The patient was alert and communicative. The color of her urine became gradually lighter; however, the BUN rose to 75 mg/dl with a serum creatinine value of 4.5 mg/dl. Other lab tests revealed: calcium = 6.2; phosphorous = 8.2; uric acid = 13.2; LDH = 473; CPK = 12,000; urine osmolality = 370; urine creatinine = 52. During this period, the patient underwent internal fixation of the lower extremity fractures. ML was diagnosed with acute renal failure (ARF) 1. Define acute renal failure and its cause in the case of ML. ARF occurs quickly, over a few day or weeks with a sudden reduction in the glomerular filtration rate (GFR), resulting in elevation of blood urea nitrogen (BUN), plasma creatinine and cystatin C levels. The retention of these products in the blood disrupts the electrolyte, acid - base homeostasis, and fluid volume equilibrium. ARF is usually associated with oliguria (less than 30 ml/hr or less than 400 ml/day) and is caused by any condition that reduces blood flow, blood pressure or kidney perfusion. ML’s ARF was most likely caused from hypovolemia and crush injuries. The hypovolemia caused her blood pressure to drop, consequently, reducing the flow of blood to her kidneys, producing ischemic damage from inadequate tissue perfusion impairing tubular endothelial function; perfusion pressures decrease and eventually equal GFR. Due to ML’s

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