Question

Brief Patient History: Mr. X is a 64-year-old male admitted to the unit with acute myocardial infarction (AMI) after emergent left (L)- sided heart catheterization/percutaneous coronary intervention (PCI). Past history includes diabetes mellitus type 2, heart failure, hypertension, and osteoarthritis. Home medications include furosemide Lasix), digoxin (Lanoxin), captopril (Capoten), carvedilol (Coreg), Byetta (exenatide), Glucophage (metformin), and Motrin (ibuprofen). Clinical Assessment: Twenty-four hours after admission to the unit, Mr. X is alert; oriented to person, place, and time; and pain free. His only complaint is shortness of breath and swelling in his ankles, feet, and hands. Physical assessment reveals bilateral breath sounds with basilar crackles; dressing at catheter site; right femoral clean, dry, and intact; peripheral pulses 2+ bilaterally; and 2+ edema noted in lower extremities. Mr. X has a body mass index (BMI) of 35 kg/m2 and weighs 100 kg. IV fluids have been discontinued and saline lock is in place in preparation for transfer to the telemetry unit. Diagnostic Procedures: Admission diagnostic studies: Electrocardiogram (ECG) with ST segment elevation in V1-V4; elevated cardiac enzymes; electrolytes and glucose within normal limits; blood urea nitrogen (BUN), 26 mg/dL; serum creatinine, 1.8 mg/dL; cholesterol, 250 mg/dL; and serum B-type natriuretic peptide (BNP), 300 pg/mL. Current vital signs are as follows: blood pressure of 138/80 mm Hg, heart rate of 108 beats/min (sinus tachycardia), respiratory rate of 28 breaths/min, temperature of 99F, and O2 saturation of 92% on oxygen at 2 L per nasal cannula. Urine output for the past 6 hours is 100 mL. The health care provider is notified of Mr. X’s urine output, and repeat diagnostic studies are ordered that reveal the following: BUN, 56 mg/dL; serum creatinine, 5.6 mg/dL; and potassium, 5.8 mEq/L. Medical Diagnosis Acute anteroseptal myocardial infarction STEMI (ST elevation myocardial infarction) Contrast-induced nephropathy (CIN) Major Outcomes Expected for Patient: Prevention of complications from contrast agent, nephrotoxic agents, and acute kidney injury. Fluid and electrolyte Balance Body weight and vital signs are stable and consistent with baseline Patient and family can participate in informed decision making related to patient care Increase knowledge base related to prevented of chronic kidney disease.

Questions 1. Describe three problems or risks must be managed to achieve these outcomes?

2. What interventions must be initiated to monitor, prevent, manage, or eliminate the three problems and risks identified in question #1?

Answer 1

Contrast induced renal injury Is more common complications occurs after contrast based diagnostic and interventional procedure . Studies proved initiating administration of isotonic solutions 3-4 hours before procedure and following the contrast based procedure . This facilitates more urine output there by excreting the contrast medium rapidly.

Monitoring electrolyte panel like sodium potassium,bicarbonate is done for early detection of renal impairment

Contrast medium administered patient based on the patients body weight.

Metabolic abnormalities like hyperphosphatemia and Hyperkalemia is monitored as it peaks suddenly after contrast administration.

Dietary restrictions like sodium restriction, potassium restriction an be done to prevent further renal injury.

Temporary dialysis is advisable to manage contrast induced renal injury to reverse the condition.

Answer 2

What problems or risk must be managed to achieve these outcomes