Question

Patient Profile W.A. is a 70-year-old African American female who presented to the emergency department with fever, severe nausea, vomiting, and diarrhea. She is admitted to the intensive care unit (ICU) with a diagnosis of kidney failure and septicemia. Her previous medical history includes glaucoma, chromic kidncy failure, hypertension, and insulin-dependent diabetes mellitus She had a left above-the-knee amputation 1 year ago. Subjective Data W.A.'s daughter states she was able to do her daily chores at home independently, but for the last few days it was getting difficult for her to get around and that she needed to take frequent breaks because of shortness of breath and no energy. Her daughler also reports that W.A had been complaining of headaches with nausea and dizziness for the past few days. Goes to hemodialysis 3 days a weck Objective Data Physical Examination Blood pressure 178/96, pulse 110, temperature 101.5°F respirations 28 -Oxygen saturation 86% on 15 LPM via mask Oriented to name only Crackles in bilateral lower lobes 2+ edema bilateral lower extremities and hands Abdomen is distended with hypoactive bowel sounds x4 quadrants Diagnostic Studies -CBC: Hernoglo bin 7 gdL, hematocrit 23.8%, RBC 2.57 million/mm, WBC 14.8 m Chemistry Panel: Serum sodium 132 mEq L, serum 6.0 mEqL, calcium 9.3 mg'dl, phosphorus 6.0 mg/dL, glucose 197 mg/dL, albumin 24 UL, serum blood urea nitrogen 77 mg/dL, serum creatinine 7.30 mg dL eGFR African American 10, BNP 182 pgiml Urinalysis: Dark yellow and cloudy, protein 28 mg dL positive for casts, positive for red blood cells and white blood cells, positive for glucose and ketones Blood cultures pending Discussion Questions 1. What is MODS? After reviewing WA.'s presentation, what organ systems do you suspect are involved and why? 2. What do you think is the origin of WA's septicemia? 3. What additional tests would you anticipate for W.A.? 4. What are the interprofessional care goals for WA.? 5. Describe interprofessional care that would be appropriate for WA 6. W.A.'s urine output over the past 4 hours is 20 mLs and her latest potassium level is 7 meq/L. The provider is ordering a continuous renal replacement therapy machine (CRRT) Why would a CRRT be ordered for WA.? 7. Outline a care plan for W.A., describing nursing interventions that would be appropriate for promoting oxygenation, maintaining fluid volume, and promoting tissue perfusion.

Answer 1

1. MODS: Multiple Organ Dysfunction Syndrome or multi-organ failure, multiple systems organ failure,

Is the development of physiologic derangement and involves two or more organ systems. This may result in a potentially life-threatening physiologic insult.

More than two organ systems will be dysfunctioning.

Systems involved in case of W.A. :

Lung: evident by breathing difficulty, bilateral crackles, respiratory rate of 28/ minute, oxygen saturation of 86% on 15 LPM via mask

Kidney: evident by electrolyte imbalance-

High blood urea nitrogen – 77 mg/dl (normal is 7-20 mg/dl)

Raised creatinine level – 7.3 mg per dl (normal is 0.8-1.3 mg/dL.)

Slightly low Serum sodium: 132 mEq/L(normal is135 – 145 mEq/L.)

High BNP : 182 pg/ml (normal -125 pg/mL for patients aged 0-74 years)

eGFR African American of 10, which is significantly less

Heart and the cardiovascular system: Evident by oedema on lower extremities and hands, a pulse of 110bpm, BP 178/96 mm Hg

Gastrointestinal/hepatic: distended abdomen and hypoactive bowel sounds on all four quadrants

Neurologic: the patient is oriented to name only

Hematologic: Hb is 7 mg/dl – mild anemia , hematocrit 23 .8% - low , RBC 2.5 7 million/ mm² - low, WBC of 14.8 mm^{2 ­­}- elevated

Immunologic: septicemia

Endocrine/metabolic: Hyperglycemia 197 mg/dl

2. Underlying chronic renal failure is the septicemia in W.A. The in End-stage renal failure itself is a risk factor of septicemia.

A patient could have acquired infection from the hemodialysis procedure also.

3. Blood culture, ABG analysis, ECG, chest radiograph to analyze the extent of lung involvement or ARDS

4. Inter-professional care goals:

Diagnose the cause of septicemia

Provide appropriate medical treatment to eliminate infection

Minimize the damage to organs

Restore the highest possible level of functioning

5. Collaborative care: medical management, nursing care, physiotherapy, effective diagnosis

The health care team must provide collaborative care.

Medical diagnosis and treatment plan by physicians.

Proper nursing care plan by nursing professional.

Physical therapy by physiotherapists

Efficient diagnostic measures

6. CRRT

CRRT can support the patient's kidney function and will clear the toxins from the body effectively, as the patient has hemodynamic instability.