Case Study 101

Abdominal Aortic Aneurysm with Acute Kidney

Injury

1. T.A. has questions about his surgery. He asks you, “I was fine before surgery.
I'd still be fine now if I hadn't been operated on, wouldn't I?” Based on your
knowledge of AAA, what will your response be?

My response to T.A would be although he did not feel the symptoms or did not
feel ill before the surgery, any type of aneurysm have a very high risk of mortality
rate. The one T.A is suffering is the most dangerous type of aneurysm. T.A’s AAA
measured at 8cm diameter, the risk of rupture greatly increases which is
recommended for surgery. Without the procedure, chances of survival would be
very slim.

2. Why are you concerned about the weakness in T.A.'s legs?

I am concerned about the weakness in T.A’s legs because lower extremity

weakness can indicate several conditions, such as nerve damage or decreased
perfusion. If nerve damage has occurred it is important to identify what is causing
it and trying to reverse the damage. Early identification leads to a higher
prognosis.

3. You are performing your initial assessment of T.A.'s legs. What should you
include?

In performing initial assessment for T.A’s legs, the following should be included:

· Extremity texture (Clammy, dry, hairless)

· Color
· Extremity temperature (cool=decrease perfusion, warm=
DVT)
· Capillary refill (Sound be less than 2 seconds)
· Presence of edema (should be absent)
· Reflexes (Patellar, Babinski)
· Extremity Strength (Push against my hand with the bottom
of foot, push against my hand on top of foot)
 · Presence of pulses (quality, rate, rhythm)
4. In addition to ongoing assessment, describe specific nursing interventions to
place in T.A.’s plan of care that are part of patient safety initiatives aimed at
minimizing his risk of developing a deep vein thrombosis (DVT).

• Make T.A wear compression stockings to prevent potential dislodgment of a

formed thrombus
• Make sure the stockings are in the correct size
• Administer anticoagulant medication such as low-molecular-weight heparin to
inhibit the number of coagulation proteins within the blood
• Initiate early ambulation or gait training
• Administer sequential compression device

5. Four hours after his admission to your floor, you note that T.A. has had a total
urinary output of 75mL of dark amber urine. Why are you concerned?

I am concerned about this because having a total urinary output of 75mL of dark
amber urine means the kidneys are failing to produce adequate amounts of urine.
The perfusion to the kidneys could be compromised. With an inadequate amount
of urine being produced, the toxins within the body could begin to build up
leading to more issues, or the kidneys could be retaining urine.

6. You examine the urinary catheter and tubing for obstructions, and find none.
What other assessments do you need to gather?

Assessments that I need to gather are the following:

• Bladder scan for urine retention

• BUN - if within normal range
• Creatinine - if within normal range
• Urine Analysis - check urine specific gravity and osmolarity
Case Study Progress
Laboratory Test Results
Potassium 5.8 mEq/L
Sodium 132 mEq/L
Glucose 224 mEq/L
BUN 66 mg/dL
Creatinine 3.4 mg/dL

7. Interpret T.A.'s laboratory results.

T.A has an increased level of potassium, glucose, BUN, creatinine. While sodium
level has increased. T.A is at high risk for cardiac dysrhythmias due to the increase
in potassium. The increased result of BUN and creatinine indicates that there is a
current kidney injury, but it does not identify if it is a chronic or an acute problem
that is occurring. An increased glucose result within the urine indicates that the
kidneys are failing to absorb the blood sugar back into the blood vessel as it
passes through them.

8. Indicate the expected outcome for T.A. that is associated with each of the
medications he is receiving. Be specific. Include the type of medication it is,
class, etc.

Lantus (insulin glargine) 30 units subcut daily

· Class: Long Acting insulin
· Expected Action: Decrease serum glucose by increasing
glucose reuptake in the muscle and fat. Lantus can provide
coverage for up to 24 hours and takes approximately 1-2
hours for the onset of the medication.
· Adverse Effect: Hypoglycemia, injection site irritation

NovoLog (insulin aspart) subcut per sliding scale ac/hs

· Class: Fast Acting Insulin
· Expected Action: Decrease blood glucose level by increasing
the reuptake into the muscle and fat. Additionally, NovoLog
can decrease the amount of glucose produced by the liver.
· Adverse Effect: Hypoglycemia, injection site irritation
Imipenem–cilastatin sodium (Primaxin) 1 g IV piggyback (IVPB) q8h
· Class: Carbapenem / Anti-bacterial
· Expected Action: treat bacterial infection by binding to
infectious cell walls and destroy them. Decrease in infection
would be evidenced by a decrease in malaise, fever, and
normal LOC.
· Adverse Effect: Allergic reaction

Dopamine IV infusion at 2 mcg/kg/hr

· Class: Vasodilator/Neurotransmitter
· Expected Action: Due to the widening of the blood vessels,
the goal is to increase the blood flow to the kidney to
prevent further damage. The way that the kidneys receive
an increase in blood flow is the increase in cardiac output.
· Adverse Effect: Hypotension

Furosemide (Lasix) 20 mg IV push q8h

· Class: Loop Diuretic
· Expected Action: Increase urine output, increase potassium
excretion, and decrease fluid retention.
· Adverse Effect: Hypokalemia, electrolyte disturbances, and
hypotension

Sevelamer hydrochloride (Renagel) 800 mg PO with meals

· Class: Phosphate Binder
· Expected Action: Decrease phosphate by binding to the
consumed phosphate within the gastrointestinal track and
excreting it out within the feces.
· Adverse Effect: GI upset such as stomach pain, vomiting, and
nausea

Sodium polystyrene sulfonate (Kayexalate) 1 g PO bid

· Class: Potassium Binder
· Expected Action: decrease potassium levels by increasing
fecal excretion through binding potassium to the lumen of
the GI tract.
· Adverse Effect: nausea, vomiting, constipation
9. The dialysis catheter is inserted into T.A.'s left subclavian vein. You are
preparing to administer the IV antibiotic and find that his only other IV access, a
peripheral line, is the site of the dopamine infusion. What are your options?

My options are to use the subclavian vein, or other line. However, these two are
not compatible. I would probably start a new line to infuse the antibiotic, this is to
continue dopamine infusion.

10. T.A. is placed on a fluid restriction and a renal diet. T.A. asks how much he is
going to be able to drink. What is your reply?

The more the severe the condition, the less fluids that T.A should intake. This
depends on the severity of the stage of the complication. I will tell T.A that it will
depend on how much fluid T.A is releasing from the body. Common range for
restrictions would be 300-700 ounces of fluid/day.

11. Briefly describe a renal diet. What referral may be needed and why?

A renal diet typically consists of a high carbohydrate and low protein diet. Foods
such as quinoa, oats, bananas, and sweet potatoes examples of foods that are
high in carbs. Meat, poultry, and fish are a few examples of foods that are high in
protein so they should be avoided by any pt. on a renal diet. A nutritionist should
be able to help the T.A. identify the foods that he would enjoy eating but still
remains within the category of a renal diet. T.A should receive all the proper
information and gets all his questions answered.

12. What are some interventions you can use to help T.A. be more comfortable
while on a fluid restriction?

Some interventions I can use to help T.A be more comfortable while on a fluid
restriction are the following:
• Let T.A take small sips of water to stretch out the amount of water throughout
the day instead of drinking an entire amount at once
• Let T.A suck on sugar free candy help with dry mouth
• Give T.A frequent oral care to prevent dry mouth
13. As you plan your care of T.A. for the remainder of the shift, identify which
aspects of his care you can delegate to the UAP? Select all that apply.

a. Measure vital signs every 2 hours

b. Assist him with oral hygiene as needed
e. Obtain and record an accurate daily weight

14. You note that T.A.'s blood glucose levels have ranged from 62 to 387mg/dL
over the past 3 days. He comments, “That's funny, you're giving me almost
twice the amount of insulin that I give myself at home. I don't understand why
it's not working.” How should you respond?

I would respond by telling T.A that currently his body is experiencing a lot of
stress from both the surgery and the kidney injury. When the human body is
experiences a lot of stress, the glucose levels tend to rise which is what is
happening in your body right now. Additionally, his kidneys are not
processing/filtering your bodies waste properly, leading to an increase in glucose
as well.

15. Explain the relationship between his blood glucose readings and wound
healing.

I would explain to T.A that the time it takes for wounds to heal is greatly extended
because the nutrients in the body such as oxygen and proteins are being used to
break down the protein, rather than healing wounds. The higher the glucose
levels remain, the longer it takes for wounds to heal.

Case Study Progress

The next morning, T.A. goes for his first dialysis treatment. Shortly after his
return, T.A. complains of headache and severe nausea. He is restless and
slightly confused, and he has an elevated blood pressure.
16. What is the significance of these findings?

Due to this being T.A. first dialysis treatment, it is vital to monitor for any adverse
reactions to the treatment. Although headaches and nausea are fairly common
side effects of dialysis, the restlessness and acute confusion is what beings to
worry me. Additionally, hypotension is the common reaction to dialysis not
hypertension like T.A. is experiencing. With this mixture of symptoms, T.A. is most
likely experiencing dialysis disequilibrium syndrome. This syndrome is classified by
the presentation neurological signs shortly after receiving dialysis. The neurologic
symptoms are attributed to cerebral edema and increased intracranial pressure,
although the precise cause remains unknown.

17. You page the physician. What will you do while waiting for the physician to
return your call?

I will maintain calm. I would not allow visitors. But if there are family members
around, I would kindly ask them to leave the patient to let him rest and let them
go the waiting area to ensure that T.A is not bothered. Also, I would anticipate
infusing hypertonic decrease solution to the patient, and make sure that I have
patient IV access to start infusion as soon as possible and administer medication
to decrease ICP.

18. While waiting for the physician, T.A. begins to vomit severely. During the
episode, he complains of something “not feeling right” in his abdomen. What is
your immediate concern and why?

My immediate concern would be the increased pressure on the abdomen during

vomiting episodes because of wound separation. When people vomit, the
abdomen muscles contract which can cause the fresh sutures to pull apart. This is
because a separation of the sutures would expose T.A’s abdomen and internal
organs to infectious organisms. In such, internal organs such as the intestines may
fall out of the abdominal cavity which is a top tier emergency.
19. You remove his abdominal dressing and immediately see a few loops of
intestine. You have another staff member page the physician. What care will
you render before the physician’s arrival?

The care that I would render would be to dawn sterile gloves and apply a wet
sterile saline dressing directly on the tissue. It is beyond important to make sure
that the dressing is moist because you want the intestine tissue to remain as
moist as possible. It is important to cover the tissue as soon as possible to
decrease the exposure to harmful organisms. I would not leave T.A’s side because
deterioration of his condition can occur rapidly.