Page 413 - Critical Care Nursing Demystified

398 CRITICAL CARE NURSING DeMYSTIFIED

ANSWERS

CASE STUDY

1. When you palpate the right forearm fistula site, you should feel a thrill (rushing of blood
pulsating under your fingers) and auscultate a bruit (swishing noise), which will deter-
mine patency. Do not forget to use a Doppler if you do not hear anything.
2. Hyperkalemia is confirmed by tall, tented T waves; widening of the QRS; and flattening of
the P wave. Confirmation is done by the laboratory value of 7.2 mEq/L.
3. Her findings are indicative of a patient in CRF who has not been dialyzed. She is retaining
sodium, potassium, and phosphate, which are seen as the kidneys cannot excrete these
and they cannot be dialyzed due to her clotting AV fistula. Since calcium is opposite of
phosphate in CRF, her levels are low, causing this level to rise.
ABGs indicate a metabolic acidosis because the pH is 7.25 with an HCO level of less
3
than 22. She is partially compensating for this as her low pCO indicates she is blowing
2
off her CO (creating a respiratory alkalosis). But the acidosis is her primary problem as
2
indicated by the pH, which will always tell you the primary acid-base disturbance. This is
confirmed by her respiratory rate in the 30s; she probably has Kussmaul’s respirations if
she is breathing fast and deep.

Her low Hgb and Hct tell you to ask the husband or patient if she has been taking her 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.
Procrit, folic acid, and iron to help compensate for the lack of kidney production of native
erythropoietin.
4. The priority treatment is to give this patient calcium gluconate IV to help stimulate the
heart to contract and prevent death by dysrhythmias (ventricular fibrillation or asystole).
A solution of glucose and insulin should be given to help drive the potassium back into
the cell. This can also reverse the hyperkalemia.
She will need blood later due to her low Hct and Hbg. She cannot wait for Epogen
to work.
5. Decreased cardiac output related to hyperkalemia as noted by ECG changes, hypoten-
sion, and dysrhythmias. Fluid volume excess related to lack of dialysis treatments as
manifested by elevated serum sodium and peripheral edema.