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Ignatavicius & Workman: Medical-Surgical Nursing: Critical

Thinking for Collaborative Care, 5th Edition

Answer Guidelines – Critical Thinking Challenges

Chapter 75: Interventions for Clients with Acute and Chronic Renal
Failure

CRITICAL THINKING CHALLENGE 1 (Text page 1739)


The client is a 32-year-old woman who was struck by a car while jogging on a country road
during the afternoon of a very hot day. When she arrives at the emergency department by
ambulance three hours after the accident, she is able to talk, does not have an IV, and is in
extreme pain. She tells you that she had been jogging for an hour when she was hit. Her husband
tells you that she is in great health, working full-time as an aerobics instructor. She is 5 feet 1
inch tall and weighs 110 lb. Her only drugs include oral contraceptives, a multivitamin, and 800
mg per day of ibuprofen. She has a compound fracture of her left femur and considerable
bruising on the left hip and pelvis. Her vital signs are T 99.4, P 116 and thready, R 30, and BP
90/58.
1. For what type(s) of acute renal failure is she at risk? Why?
2. Do any of her usual drugs increase her risk for ARF? Which one(s) and why?
3. Is there any specific assessment data you could obtain without a prescription to evaluate her
risk for acute renal failure?
The physician prescribes the following interventions:
• IV placement with an 18-gauge cannula, NS at 200 mL/hr
• Hematocrit and hemoglobin levels
• Morphine sulfate 2 mg IV push
• Foley catheter placement
• Type and crossmatch for 4 units of packed red blood cells
• X-rays of the left hip and leg and KUB
4. In what order (and why) should you perform these interventions?

Suggested Responses
1. For what type(s) of acute renal failure is she at risk? Why?
She is most at risk for prerenal renal failure (ATN) as a result of prolonged hypovolemia.
She was exercising heavily for an hour in the heat, which probably caused her to be
dehydrated. Her injuries caused some external bleeding and could very well have caused
internal bleeding, both of which increase the degree of hypovolemia. If her injuries also
resulted in muscle damage she could be at risk for intrarenal renal failure from precipitation
of myoglobin in the kidney tubules. She may have sustained some direct damage to her left
kidney as a result of trauma.
2. Do any of her usual drugs increase her risk for ARF? Which one(s) and why?
The drug that increases her risk for ARF is the ibuprofen. This nonsteroidal anti-
inflammatory agent inhibits the synthesis of prostaglandins. The result of this
inhibition is reduced renal blood flow. In addition, the ibuprofen frequently causes a chronic
interstitial nephritis. The decreased blood flow makes any renal hypoperfusion worse, as
does the interstitial nephritis.

Copyright © 2006, 2002 by Elsevier Inc.


3. Is there any specific assessment data you could obtain without a prescription to
evaluate her risk for acute renal failure?
Measure her urine output, compare that to any intake. Examine any urine she does excrete
for color, specific gravity, and the presence of blood or protein (by dipstick). Weigh her
(using a scale that weighs the whole bed or cart rather than moving her). Measure abdominal
girth for determination of internal bleeding.
The physician prescribes the following interventions:
• IV placement with an 18-gauge cannula, NS at 200 mL/hr
• Hematocrit and hemoglobin levels
• Morphine sulfate 2 mg IV push
• Foley catheter placement
• Type and crossmatch for 4 units of packed red blood cells
• X-rays of the left hip and leg and KUB
4. In what order (and why) should you perform these interventions?
First, start the IV and give the morphine. She is hypovolemic and needs fluid replacement.
She also is in severe pain, which could worsen shock and make her even more hypovolemic.
Draw blood for the hematocrit, hemoglobin, and the type and crossmatch. The laboratory
information is needed for baseline and she will need the transfusion therapy as soon as
possible.
Place the Foley catheter to accurately determine output and to prevent more pain from efforts
to use a bedpan. Although the x-rays are important for diagnosis, the other measures are
more important to do or obtain first.

CRITICAL THINKING CHALLENGE 2 (Text page 1745)


The client is a 77-year-old woman admitted to your unit with suspected CRF. She has had type 2
diabetes for 25 years and is also being treated for hypertension. She admits that when her money
is low, she stops buying the blood pressure drugs because she feels that if she has to choose
between the two, it is more important to continue her antidiabetic drugs. She says that she has
noticed that her heartbeat is irregular, her rings and shoes are tight, and that she has gained 8
pounds over the last 10 days.
1. What other assessment data should you obtain?
2. What risk factors for the development of CRF are noted in her past medical history?
Provide a rationale for your choices.
3. What cardiac and respiratory manifestations may you find on physical examination of this
client?

Suggested Responses
1. What other assessment data should you obtain?
Take her blood pressure and other vital signs, especially heart rate. If possible, obtain an
ECG strip. Listen to her lungs. Do a "spot" check of her blood glucose level. Weigh her. Ask
her to show you her prescription bottles or name the drugs she is taking. Ask her when she
last took her antidiabetic drug. Assess her for the presence of pitting or nonpitting edema.
Ask her how much fluid and what types of fluid she usually drinks in a typical day. If she
urinates, measure the volume and examine the urine for color, specific gravity, and the
presence of blood or protein.
2. What risk factors for the development of CRF are noted in her past medical history?
Provide a rationale for your choices.

Copyright © 2006, 2002 by Elsevier Inc.


Diabetes mellitus has many microvascular and macrovascular consequences. This disease
changes the blood vessels in the kidney over time, reducing tissue oxygenation. The
nephrons are damaged and the remaining nephrons must work harder to maintain water,
electrolyte, and acid-base balance. In addition, some oral antidiabetic agents have renal toxic
effects.
Hypertension, if untreated or inadequately treated, damages the capillaries of the glomerulus,
reducing the efficiency of kidney function over time. For this client, the fact that she does
not always take her antihypertensive drugs as prescribed dramatically increases her risk for
hypertensive nephropathy.
3. What cardiac and respiratory manifestations may you find on physical examination of
this client?
She would be expected to have an elevated blood pressure as a result of hypertension and as
a result of water retention (gaining 8 pounds in 10 days). If she has retained potassium, her
heart rate could be irregular and of poor quality. The fluid retention could have causes some
degree of vascular overload and pulmonary edema. This would increase her respiratory rate,
although the breaths may be shallow. If she has pulmonary edema, she may have crackles at
the bases of her lungs. She may be shorter of breath in the supine position.

CRITICAL THINKING CHALLENGE 3 (Text page 1757)


Your client (described earlier on page 1745) has been diagnosed as having ESRD. The health
care provider has prescribed dietary teaching and outpatient HD three times per week. She asks
if she can eventually have a kidney transplant.
1. What instructions should you provide regarding the dietary and fluid needs for this client?
2. How will you explain to the client and her family that HD, rather than transplantation, is the
best choice of renal replacement therapy for her?
3. What changes, if any, will need to be made in her therapy for diabetes and hypertension?
4. What complications should you monitor the client for during and immediately following
dialysis?

Suggested Responses
1. What instructions should you provide regarding the dietary and fluid needs for this
client?
This client will have to follow significant fluid, protein, sodium and potassium restrictions
on the days between dialysis. Fluid limits are usually placed at whatever her output for a
given day is plus an additional 500 to 700 mL. She will need between 1.0 and 1.5 g/kg body
weight of protein each day. For example, a woman who weighs 150 pounds should have
between 70 and 100 g of protein daily (280 to 400 calories of protein). Sodium is restricted
to 2 to 4 g/day and potassium is restricted to 70 mEq/day. (See Chapter 14 for charts
showing sodium and potassium content of various foods.) Often the client is permitted to
have foods rich in sodium or potassium during the first 1 hour of dialysis.
2. How will you explain to the client and her family that HD, rather than transplantation,
is the best choice of renal replacement therapy for her?
Renal transplantation is governed by availability of transplantable kidneys and meeting
specific criteria for being a recipient. In addition, there is a lengthy waiting list for
transplantation. Even if this client qualified for a renal transplant, she would need regularly
scheduled dialysis for months to years. It is unlikely that this client would qualify as a renal
transplant recipient in any state. First, she has two major chronic diseases that in themselves

Copyright © 2006, 2002 by Elsevier Inc.


would be damaging to a transplanted kidney. Second, she is well past 70 years old, the upper
limit of transplant criteria. The medications used to prevent transplant rejection, particularly
the prednisone and the cyclosporine, would have adverse effects on both her hypertension
and her diabetes. Hemodialysis at a dialysis center requires less involvement on her part and
her family's part than would peritoneal dialysis.
3. What changes, if any, will need to be made in her therapy for diabetes and
hypertension?
Her therapy for diabetes may not need adjusting; however, she will need more frequent
monitoring to ensure that her diabetes is under control. She should not take her
antihypertensive drugs until after dialysis on the days she is being dialyzed. Taking them
before dialysis can contribute to hypotension and dialysis disequilibrium syndrome during
and immediately following dialysis by decreasing vascular resistance.
4. What complications should you monitor the client for during and immediately
following dialysis?
At her age and with her other health problems, she would be most at risk for disequilibrium
syndrome during and after dialysis. Closely monitor her during, immediately following
dialysis, and for several hours after dialysis for hypotension, headache, nausea, malaise,
vomiting, dizziness, and muscle cramps. She may need a bolus of fluid (usually normal
saline) if disequilibrium syndrome develops. Her dialysis may need to take place more
slowly over a longer period of time to prevent rapid changes in plasma volume.

Copyright © 2006, 2002 by Elsevier Inc.