1. Background:

Ms. C. is a 53 y/o female with admitted to 2A with complaints of severe right abdominal pain. She is a pleasant lady with a friendly demeanor and asks for very little assistance. Mrs. C is morbidly obese which makes it difficult to get out of bed without assistance but for the most part, she can ambulate and walk around on her own once she is out of the bed with the assistance of a walker. Because of her obesity, Ms. C has several skin folds throughout her body, which make a great medium for fungal infections. The area underneath her skin folds is red and irritated. Ms. C has had oliguria for the past several days and is outputting very little to no urine. A foley catheter has been placed in order to remove any urinary retention. However, very minimal urine seems to be coming out of foley. The doctors have requested labs to be drawn on a regular basis to check her kidney function and to also monitor her electrolytes. Her admitting diagnosis is Acute Renal Failure.

Past Medical History: o Essential Hypertension o Hyperlipidemia o Diabetes Mellitus Type 2 o Stage 3 Diabetic Chronic Kidney Disease o Severe Obesity

Present Medical History: o Severe abdominal pain o Dehydration o Oliguria o Uncontrolled Diabetes o Chronic Kidney Disease o Hypertension o Obesity

Active Orders: o Foley Catheter o Oxygen 2 L NC o Blood Sugar Monitoring AC and HS o Insulin Regular o Insulin NPH 10 units in AM o Insulin NPH 5 units before bed time o Flucanozole 100 mg IV o D5W 1000 mL with Sodium Bicarb 100 mEq IV solution running at 75 ml/hr o Albuterol 2.5 mg/0.5 mL Nebulizer 2.5 mg o Morphine Inj Syg 2mg PRN Q4H o Morphine Inj Syg 4 mg PRN Q4H o Lotrimin Cream o Ondansetron inj 4mg o Levothyroxine tab 175 mcg o Acetaminophen 650 mg o D50W Inj Syg o Glucagon Inj 1 mg o QVAR 80 o Famotidine 20 mg o Albuterol o Lasix

Medication Information: o Humulin R (Regular Insulin): o Indicated as an adjunct to diet and exercise to improve glycemic control in adults and children with type 1 and type 2 diabetes mellitus. o Humulin R (insulin (human recombinant)) U-100, when used subcutaneously, is usually given three or more times daily before meals. The dosage and timing of Humulin R (insulin (human recombinant)) U-100 should be individualized and determined, based on the physician's advice, in accordance with the needs of the patient. Humulin R (insulin (human recombinant)) U-100 may also be used in combination with oral antihyperglycemic agents or longer-acting insulin products to suit the needs of the individual patients with diabetes. The injection of Humulin R (insulin (human recombinant)) U-100 should be followed by a meal within approximately 30 minutes of administration. o The average range of total daily insulin requirement for maintenance therapy in insulin-treated patients without severe insulin resistance lies between 0.5 and 1 unit/kg/day. In situations of insulin resistance, e.g. during puberty or due to obesity, the daily insulin requirement may be substantially higher. Initial dosages for patients with diabetes are often lower, e.g., 0.2 to 0.4 units/kg/day. o Humulin R (insulin (human recombinant)) U-100 may be administered by subcutaneous injection in the abdominal wall, the thigh, the gluteal region or in the upper arm. Subcutaneous injection into the abdominal wall ensures a faster absorption than from other injection sites. Injection into a lifted skin fold minimizes the risk of intramuscular injection. Injection sites should be rotated within the sameregion. As with all insulin, the duration of action will vary according to the dose, injection site, blood flow, temperature, and level of physical activity. o Side Effects: Insulin may cause minor and usually temporary side effects such as rash, irritation or redness at the injection site. To help prevent hypoglycemia, eat meals on a regular schedule. Too much insulin can cause low blood sugar (hypoglycemia). The symptoms include cold sweat, shaking, rapid heart rate, weakness, headache and fainting which, if untreated, may lead to slurred speech and other behaviors that resemble drunkenness. o D5W 1000 mL with Sodium Bicarb 100 mEq IV: o Intravenous Sodium Bicarbonate therapy increases plasma bicarbonate, buffers excess hydrogen ion concentration, raises blood pH and reverses the clinical manifestations of acidosis. o Sodium Bicarbonate is indicated in the treatment of metabolic acidosis which may occur in severe renal disease, uncontrolled diabetes, circulatory insufficiency due to shock or severe dehydration, extracorporeal circulation of blood, cardiac arrest and severe primary lactic acidosis. Sodium Bicarbonate is further indicated in the treatment of certain drug intoxications, including barbiturates (where dissociation of the barbiturate-protein complex is desired), in poisoning by salicylates or methyl alcohol and in hemolytic reactions requiring alkalinization of the urine to diminish nephrotoxicity of hemoglobin and its breakdown products. Sodium Bicarbonate also is indicated in severe diarrhea which is often accompanied by a significant loss of bicarbonate. o Side Effects: Frequent urge to urinate, headache (continuing), loss of appetite (continuing), mood or mental changes, muscle pain or twitching, nausea or vomiting, nervousness or restlessness, slow breathing, swelling of feet or lower legs, unpleasant taste, unusual tiredness or weakness o o Furosemide (Lasix) o Furosemide, a 'water pill,' is used to reduce the swelling and fluid retention caused by various medical problems, including heart or liver disease. It is also used to treat high blood pressure. It causes the kidneys to get rid of unneeded water and salt from the body into the urine. o This medicine is sometimes prescribed for other uses; ask your doctor or pharmacist for more information. o Furosemide comes as a tablet and liquid to take by mouth. It usually is taken once a day in the morning or twice a day in the morning and afternoon. o Furosemide controls high blood pressure but does not cure it. o Side Effects: muscle cramps, weakness, dizziness, confusion, thirst, upset stomach, vomiting, blurred vision, headache, restlessness, constipation.

2. Acute Renal Failure Pathophysiology:

The interaction of tubular and vascular events result in ARF. The primary cause of ATN is ischemia. Ischemia for more than two hours results in severe and irreversible damage to the kidney tubules. Significant reduction in glomular filtration rate (GFR) is a result of (1) ischemia, (2) activation of the renin-angiotensin system , and (3) tubular obstruction by cellular debris. As nephrotoxins damage the tubular cells and these cells are lost through necrosis, the tubules become more permeable. This results in filtrate absorption and a reduction in the nephrons ability to eliminate waste.

The clinical course of ARF is characterized by the following three phases:

Phase 1. Onset

ARF begins with the underlying clinical condition leading to tubular necrosis, for example hemorrhage, which reduces blood volume and renal perfusion. If adequate treatment is provided in this phase then the individual's prognosis is good.

Phase 2. Maintenance

A persistent decrease in GFR and tubular necrosis characterizes this phase. Endothelial cell necrosis and sloughing lead to tubular obstruction and increased tubular permeability. Because of this, oliguria is often present during the beginning of this phase. Efficient elimination of metabolic waste, water, electrolytes, and acids from the body cannot be performed by the kidney during this phase. Therefore, azotemia, fluid retention, electrolyte imbalance and metabolic acidosis occurs. The patient is at risk for heart failure and pulmonary edema during this phase because of the salt and water retention. Immune function is impaired and the patient may be anemic because of the suppressed erythropoietin secretion by the kidney and toxin-related shorter RBC life.

Phase 3. Recovery
Renal function of the kidney improves quickly the first five to twenty-five days of this phase. It begins with the recovery of the GFR and tubular function to such an extent that BUN and serum creatinine stabilize. Improvement in renal function may continue for up to a year as more and more nephrons regain function. (KU Medical Center, 2011)

Signs and Symptoms of Acute Renal Failure:

o Decreased urine output, although occasionally urine output remains normal o Fluid retention, causing swelling in your legs, ankles or feet o Drowsiness o Shortness of breath o Fatigue o Confusion o Nausea o Seizures or coma in severe cases o Chest pain or pressure (Mayo Clinic, 2010)

3. Nursing Process:
a. Assessment o Objective Data: o VS: T-97.3 P-86 R – 22 BP 141/76 O2: 92% on 2L NC o Pain 8/10 o 100 mL UO in 24 hours o Edema and swelling on both ankles. o K – 5.3 o Expiratory wheezing upon auscultation. o Skin folds red and irritated o Poor ability to transfer o Adequate ability to ambulate o Participates willingly in plan of care o Subjective Data o States pain is an aching sensation on right lower abdomen that is continuous and is occasionally relieved by medicine. o States SOB and difficulty breathing. o States she feels weakness that is generalized. o Lack of appetite. o Has the urge to void occasionally.
b. Identification of problem/Nursing Diagnosis: o Fluid volume overload related to patient diagnosis of acute renal failure as evidenced by low urine output, and edema/swelling of the lower extremities.
c. Plan of action: o Administer order of Lasix to promote duiresis. o Monitor location and extent of edema. o Monitor daily weights. o Monitor lung sounds for crackles and respirations for effort. o Elevate HOB 30-45 degrees to maximize respirations. o Monitor relevant lab values such as electrolytes. o Monitor I&O’s frequently to check for increased/decreased output. o Follow MD’s order to stop infusion of fluid because pt is not excreting fluid in urine.
d. Evaluation: o Over a 24 hour period, the patient’s urine output has increased to 300 mL. This was after the Lasix was given. The patient’s fluids were stopped and her IV was saline locked. The patient’s Potassium levels dropped from 5.3 to 4.7. However, the patient’s kidney function tests were still high and the MD is keeping the patient longer until her lab values have become balanced. The patient still has wheezing upon expiration and the edema on her bilateral ankles are still present. The patient’s I&O’s will continue to be monitored closely.

4. METHOD: o M- Patient will probably be discharged home with new orders of insulin to help control her Diabetes. She will also probably continue to take her QVAR to help with her respiratory issues and also the Lotrimin cream to apply to areas with rashes and fungal infection. The patient suffes from Thyroid problems and will also be sent home with Levothyroxine. In terms of her diagnosis, she may be sent home with an order of Lasix which will promote diuresis and prevent fluid volume excess. o E – The lives in an environment where there are little hazards. o T – The patient needs to recognize signs and symptoms of her disorder. She also needs to recognize the importance of maintaining her diabetic regimen which may have contributed to her acute renal failure. o H - The patient will be sent home with family. They live in a 1 story house. o O- At this time, there have been no arrangements for an office visit. o D- The patient is on a diabetic, car-controlled diet.
References
Pathophysiology. (n.d.). Continuing Education for Respiratory Care. Retrieved
September 15, 2011, from http://classes.kumc.edu/cahe/respcared/cybercas/dialysis/portpath.html

Staff, M. C. (n.d.). Kidney failure, acute - MayoClinic.com. Mayo Clinic. Retrieved
September 15, 2011, from
http://www.mayoclinic.com/health/kidney-failure/DS00280