Page 410 - Critical Care Nursing Demystified

Chapter 8 CARE OF THE PATIENT WITH CRITICAL RENAL NEEDS 395

CASE STUDY

8 R.R. is a 32-year-old female with juvenile onset DM, HTN, and CRF who has been
admitted to the intensive care unit for severe hyperkalemia and clotting of a right
forearm AV fistula. R.R.’s CRF is a result of an aspirin overdose with the diagnosis of

CRF less than 3 months ago.
RR has been extremely depressed according to her husband and not taking
care of herself or going to her dialysis treatments for the past week. He is afraid she
has “given up” and “wants to end it all.”
You perform vital signs (TPR = 100.1°F-120-34, BP 80/40, SaO 90% on 4 L nasal
2
cannula) and attach R.R. to the cardiac monitor. You call for a 12-lead ECG because
you see changes indicative of hyperkalemia and premature ventricular contrac-
tions on the bedside cardiac monitor. You identify her abnormal laboratory
values: Na 155, K 7.2, Ca 5, and phosphate 7; Hct and Hgb 8 g/dL and 25%. ABGs
are pH 7.25, pO 100, pCO 30, HCO 15. She has an S3 and crackles at both bases
2 2 3
with pitting edema bilaterally below the knees.

QUESTIONS

1. What essential assessment finding will alert you to a blocked AV fi stula?
2. What symptoms confirm that this patient has hyperkalemia? Downloaded by [ Faculty of Nursing, Chiangmai University 5.62.158.117] at [07/18/16]. Copyright © McGraw-Hill Global Education Holdings, LLC. Not to be redistributed or modified in any way without permission.

3. Why are her laboratory values so abnormal?
4. What treatment would you anticipate R.R. will be receiving?

After stabilizing R.R.’s collaborative needs (laboratory levels and vital signs,
especially the potassium level and hypotension) you have time to formulate
other less life-threatening nursing diagnoses.

QUESTIONS
5. What nursing diagnostic statements take priority in this scenario?
Once stabilized, R.R. says she just cannot stand the way she is living and is over-

whelmed with the dialysis treatments, the complex medication regime, and
dietary restrictions. You notify the nephrologist about this and contact former
patients who volunteer to talk to patients about adjusting to dialysis. You also
tell her that depression might be induced by uremic poisoning due to an infec-

tion she might have. A dietary consult might be beneficial in this case and you
continue to monitor the patient while making plans to discuss the blocked AV

fistula and a new site replacement with the surgeon.
She stays on your unit with 1:1 surveillance until feeling much better; she
gives permission to insert a central line for HD continuation until a new AV

fistula can be placed.