Name: Erica Meyers Class/Group: NSG 219 Date: 4/10/21

Scenario
You are working on a telemetry unit and have just received a transfer from the ICU. The 70-year-old
male patient, T.A., is postoperative day 2 after three-vessel coronary bypass graft surgery. He has a
history of hypertension, hyperlipidemia, and type 2 diabetes mellitus requiring insulin for the past 6
months to control glucose levels. The ICU nurse tells you that there were complications during surgery
and he received 3 units of blood to treat hypotension. Since surgery, T.A. has experienced intermittent
atrial fibrillation that is under control with amiodarone and metoprolol. The nurse voices concern his
urine output seems to be decreasing.

1. Four hours after his admission to your floor, you note that T.A. has had a total urine output of 75 mL
of dark amber urine. Why are you concerned?
Decreased urine output darken in color could indicate the patient is dehydrated. Decreased renal
function is also a major concern.

2. You check the urinary catheter and tubing for obstructions and find none. What other assessments do
you need to gather?
Assess V/S, Draw labs (BUN, creatinine, electrolytes), past medical history, ultrasound, current
medication list, dietary habits, family history, assess for edema, assess skin turgor, auscultate lung
sounds.

You notify the surgeon of the decreased urine output. The surgeon orders a stat electrolyte panel and
asks you to call with the results.

Chart View: Laboratory Test Results

Potassium 5.8 mEq/L (5.8 mmol/L)

Sodium 132 mEq/L (132 mmol/L)

Glucose 224 mEq/L (12.4 mmol/L)

BUN 86 mg/dL (30.7 mmol/L)

Creatinine 4.4 mg/dL (389 mcmol/L)

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

Potassium and glucose are elevated. BUN and creatine are excessively elevated. Sodium level is
decreased. High potassium and glucose can indicate kidneys are not filtering waste properly and BUN
and creatinine being highly elevated indicates kidney failure and low GFR.

4. What actions do you need to take because of the serum potassium level?
Place patient on a heart monitor and reduce potassium intake. Dialysis may be needed to help filter out
potassium the kidneys are retaining. Monitor potassium levels also (redraw labs).

Chart View: Medication Administration Record

Dopamine IV infusion at 2 mcg/kg/min

Furosemide 80 mg IV push daily

Sodium polystyrene sulfonate (Kayexalate) 1 gram PO twice daily

Sevelamer hydrochloride (Renagel) 800 mg PO with meals

5. The surgeon writes new orders. Identify the expected outcome associated with each medication he
will be receiving.
Dopamine will decrease B/P.
Furosemide is a diuretic that will produce more urine and reduce fluid overload.
Kayexalate will reduce high blood potassium.
Renagel will decrease blood phosphorus.

6. T.A. weighs 164 lbs. The pharmacy-supplied IV bag reads “dopamine 400 mg/250 mL.” Calculate the
hourly rate for the dopamine infusion. Round to the tenth.
5.6 mL/hr

The surgeon determines that T.A. is in the oliguric phase of acute kidney injury (AKI). T.A. is sent to
radiology for placement of a dialysis catheter.

7. What is the likely reason T.A. developed AKI?

Hypotension that occurred during surgery. Hypotension causes patients to develop ATN which can lead
to AKI.

8. The RIFLE criteria delineate the three stages of AKI based on:

A. Glomerular filtration rate (GFR)

B. Serum creatinine and urine output

C. Urine osmolality and specific gravity

D. Blood pressure and BUN/creatinine ratio

9. You decide to assess T.A. for indications of AKI. What do these include?
Urine output, serum creatine level, edema, nausea, fatigue, and shortness of breath.

10. What are your priority nursing problems right now?

Monitoring potassium and creatine levels. Decreased urine output

11. The dialysis catheter is inserted into T.A.’s left subclavian vein. You are preparing to give the IV
furosemide and find that his only other IV access, a peripheral line, is the site of the dopamine infusion.
What are your options?
Start another IV since you cannot administer through dialysis catheter or same line as dopamine.

12. T.A. asks if he is going to be on dialysis for the rest of his life. How would you respond?
Depending on the severity, AKI can be reversible. However, the patient would need to speak to the
doctor to discuss long-term therapy.
13. 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?
Fluid restrictions are based off the severity of the condition which should be discussed with the doctor.

14. Briefly describe a renal diet.

Low in sodium, phosphorus, and protein. Fluid restrictions and limiting potassium and calcium may be
needed as well in some patients.

15. What referral may be needed and why?

Referral to dietitian to select right diet/foods.

16. What are some interventions you can use to help T.A. be more comfortable while on a fluid
restriction?
Keep oral mucous membranes moist by rinsing mouth.
Frequent oral hygiene.
Keep sugar-free hard candy, mints, and gum at bedside.
Space fluid intake evenly throughout the day.

17. As you plan your care of T.A. for the rest 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

C. Obtain T.A.’s glucose level before dinner

D. Monitor T.A.’s lung sounds every 4 hours

E. Obtain and record an accurate daily weight

F. Evaluate T.A.’s I/O trends for the past 48 hours

18. You note that T.A.’s postoperative blood glucose levels range from 62 to 387 mg/dL (3.4 to 21.6
mmol/L). 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?
During critical illness hyperglycemia is common. The kidneys play a major role in glucose and insulin
metabolism.

19. In addition to ongoing assessment, describe nursing interventions to place in T.A.’s plan of care that
are part of patient safety initiatives aimed at minimizing his risk for a VTE developing.
Blood thinners (Lovenox)
Encourage ambulation
SCD’s or stockings

The next morning, T.A. is scheduled for his first dialysis treatment at 0800.

20. What type of assessment data do you need to gather before his dialysis treatment?
History of existing kidney disease/family history
Long-term health problems
Drugs/Herbal preparations
Dietary habits
Support systems

21. Doses of IV amiodarone, metoprolol, and furosemide are scheduled for 0800. What should you do?

A. Give all three medications 1 hour before dialysis

B. Hold all three medications and notify the surgeon

C. Give the amiodarone and hold the metoprolol and furosemide

D. Hold all three medications and give them immediately upon return

22. T.A. is off the unit 4 hours for therapy. When he returns, what assessments do you need to make?
V/S, labs, medication, complications during dialysis

23. Shortly after his return, T.A. tells you he has a headache and severe nausea. He is restless and slightly
confused, and his BP is 180/102 mm Hg. What is the significance of these findings?
Dialysis disequilibrium

24. You page the surgeon. What will you do while waiting for a return call?
Administer hypertonic saline