Case Analysis: Acute Renal Failure

Ms. Jimenez is a 56-year-old woman who has been having financial difficulties since her divorce
5 years ago. She was recently involved in a motor vehicle crash (MVC) in which she drove over a curb
and hit a telephone pole. She did not sustain any significant injuries in the MVC. 2 days ago, Ms.
Jimenez’s daughter Maria returned home at 8:00 p.m. to find Ms. Jimenez sitting on the floor with a
decreased level of consciousness. Maria was able to shake her mother awake. With slurred speech, Ms.
Jimenez told her daughter that she drank 3 large glasses of antifreeze (ethylene glycol) at around 7:00
p.m. Maria called 911 and emergency medical services transported Ms. Jimenez to the local emergency
department.

Upon arrival at the emergency department, Ms. Jimenez is afebrile with a rectal temperature of
97℉ (36.1℃). Her other vital signs are blood pressure 135/85, pulse 68, and respiratory rate 24. Her
initial arterial blood gasses (ABGs) on a 15 L/min non-rebreather revealed a pH of 7.19, partial pressure
of carbon dioxide (PaCO2) of 13 mmHg, partial pressure of oxygen (PaO2) of 359 mmHg, bicarbonate
(HCO3 2) of 5 mEq/L, and oxygen (O2) saturation of 100%. Ms. Jimenez is sedated in the emergency
department using etomidate. She is intubated and put on a mechanical ventilator. A Foley catheter is
inserted. She receives succinylcholine chloride, lorazepam, and propofol. Her oxygen saturation is 92%
on an FIO2 (fraction of inspired oxygen) of 70%. The health care provider’s physical examination reveals
no abnormal findings. The neurological exam is deferred because Ms. Jimenez is intubated and sedated.
An electrocardiogram (ECG, EKG) shows that Ms. Jimenez is in a normal sinus rhythm. A chest X-ray
(CXR) shows no infiltrate and proper endotracheal tube placement.

A urinalysis shows a specific gravity of 1.010, a small amount of occult blood, 3 to 5 WBC per
high-power field (HPF), a few bacteria per HPF, and a moderate amount of uric acid crystals and urine
calcium oxalate crystals. A urine culture & colony count was negative (no growth). Her blood alcohol
level is less than 10 mg/dL. Her ethylene glycol level is 36 mg/dL. Her complete blood count (CBC) is
within normal limits except for a mean cell volume (MCV) of 79.2 μm3. Troponin level is 0 ng/mL,
creatine kinase (CK) is 182 U/L, and creatine kinase cardiac isoenzyme (CK-MB) is within normal limits
(WNL). Serum osmolality is 392 mOsm/Kg. Her electrolytes are within normal limits except for a serum
bicarbonate of 7 mEq/L. She has an anion gap of 29 mEq/L, BUN of 25 mg/dL, and creatinine of 1.4
mg/dL. Her liver function tests are within normal limits.

Ms. Jimenez is admitted to the intensive care unit (ICU) and prescribed intravenous (IV) fluids of
normal saline with 2 ampules of bicarbonate at 125 mL per hour. The medications prescribed for her
include 4-methylpyrazole IV every 12 hours, thiamine 100 mg IM, and levalbuterol treatments. Lab work
prescribed includes CBC, electrolytes, ethylene glycol levels, basic metabolic panel (BMP), creatinine
level, acetone level, and urinalysis. In the ICU at the bedside, a Quinton dialysis catheter is surgically
inserted in the right internal jugular vein for emergency dialysis and placement of the Quinton catheter is
confirmed by CXR.

It is 48 hours after her arrival in the emergency department. Ms. Jimenez has undergone 12 hours
of emergency dialysis, has been extubated, and is medically stable for transfer to a medical-surgical
nursing unit. A safety sitter remains in Ms. Jimenez’s room at all times. Ms. Jimenez is alert and oriented
but has a flat affect. She is not remorseful for her actions and states, “I had hoped I would be successful
this time.” A psychiatrist sees Ms. Jimenez for a consultation. The psychiatric assessment reveals that she
has been planning the poisoning for a few weeks. She states, “I was hoping I would die quickly and it
would look like an accident.” Ms. Jimenez states that she has made attempts in the past to overdose on
medications. She did not seek care at the hospital when these suicide attempts were not successful. She
has been depressed since divorcing her husband 5 years ago. Since her divorce, she has not paid taxes and
there have been mounting financial bills with the Internal Revenue Service. As a result, her wages are
being garnished (money is withheld from her paycheck and sent to a creditor). She reports, “On the
outside I appear bright and upbeat but on the inside I am so lonely and sad and just don’t want to go on
anymore.” She wonders how she will pay for her medical care now. “I had not planned on the poison not
working and needing dialysis. I bet dialysis is expensive.”

Clinical Values Result Impression

Temperature 97 F / 36.1 C Normal

Blood Pressure 135/85 Abnormal (Prehypertension)

Pulse Rate 68 Normal

Respiratory Rate 24 Abnormal (Tachypnea)

Arterial Blood Gas (pH) 7.19 Abnormal (Slightly acidic)

Arterial Blood Gas (PaCO2) 13 mmHg Abnormal (Respiratory

alkalosis)

Arterial Blood Gas (PaO2) 359 mmHg Abnormal (Elevated)

Arterial Blood Gas (HCO3) 5 meq/L Abnormal (Metabolic acidosis)

Arterial Blood Gas (SaO2) 100% Normal

Physical Examination Normal

ECG Normal sinus rhythm

Chest X-ray Normal, no infiltrate, proper ET tube placement

Urinalysis

Urine Specific Gravity 1.010 Normal

Occult Blood Present (Small amount) Abnormal (Hematuria)

White Blood Cells 3 - 5 per HPF Normal

Bacteria Few per HPF Abnormal

Uric Acid Crystals, Urine Present (Moderate amount) Abnormal (Indicative of

 Calcium Oxalate Crystals inflammation, infection, injury)

Blood alcohol level Less than 10mg/dl Abnormal (High)

Ethylene glycol level 36mg/dl Abnormal (High)

Complete blood count (CBC)

Mean cell volume 79.2 um3 Abnormal

Others

Troponin level 0 ng/ml Normal

Creatine kinase 182 U/L Normal

Creatine kinase cardiac Normal Normal

isoenzyme

Serum osmolality 392 mOsm/kg Abnormal (High)

Serum electrolytes Normal Normal

Serum bicarbonate 7 mEq/L Abnormal (Low)

Anion gap 29 mEq/L Abnormal (High - indicative of

metabolic acidosis)

BUN 25 mg/dl Abnormal (High)

Creatinine 1.4 mg/dl Abnormal (High)

Liver function Normal Normal

Risk factors
● Modifiable risk factors
○ Ethylene glycol intoxication - it is uncommon, but can result in life-threatening
metabolic acidosis, kidney failure, and death
○ Admitted to ICU - being hospitalized, especially for a serious condition that requires
intensive care increase your risk of acute kidney failure
○ Medication overdose - there are some medications that can make crystals that don’t
break down which can block the flow of urine and there are some that can damage certain
kidney cells when the kidneys try to filter them out
○ Suicide attempt - her numerous suicide attempt (e.g., ethylene glycol intoxication and
medication overdose) resulted in acute damages to her kidneys causing it to fail
● Non-modifiable risk factors
○ Age (56 y/o) - advanced age increases the risk of acute kidney failure
Pathophysiology
● Substance intoxication - adverse renal effects occur in the 3rd stage of human ethylene glycol
poisoning, which occurs 24–72 hours after acute exposure.
○ Decreased LOC - due to ethylene glycol intoxication and overdose of medication
○ Presence of moderate amount of uric acid crystals and urine calcium oxalate - the
hallmark of renal toxicity is the presence of calcium oxalate monohydrate crystals in the
renal tubules and urine following ingestion of large amounts of ethylene glycol
■ Renal obstruction
■ Azotemia - elevation of BUN and serum creatinine levels. This condition occurs
when your kidneys have been damaged by injury, disease, or medications, and
they're unable to get rid of enough nitrogen waste in your body.
● High BUN - kidneys are not working well or there’s obstruction
● High creatinine - a sign that kidneys are not filtering the blood effectively
because there is damage
■ Metabolic acidosis - build-up of too many acids in the blood which happens
when the kidneys are unable to remove enough acid from the blood
● ABG: HCO3 or bicarbonate of 5 mEq/L
● Anion gap of 29 mEq/L - indicative of the condition
■ Tachypnea can be a symptom of sepsis or acidosis, such as metabolic acidosis
because the buildup of carbon dioxide in the blood makes the blood more acidic
than usual, alerting the brain. In response, the brain signals the respiratory drive
to increase in pace in an attempt to correct the imbalance.

Nursing Diagnosis
● Ineffective breathing pattern related to metabolic acidosis secondary to acute renal failure as
manifested by decreased level in consciousness, kussmaul’s respiration, arterial blood gas pH
level at 7.19 and bicarbonate level at 5 mEq/L, and anion gap of 29mEq/L
○ Perform intubation and place the client in a mechanical ventilator
■ Administer Succinylcholine chloride to facilitate tracheal intubation and provide
muscle relaxation during mechanical ventilation
■ Administer Lorazepam to sustain sedation while on mechanical ventilation
■ Administer Propofol to sustain sedation while on mechanical ventilation
■ Administer Levalbuterol to facilitate bronchodilation
○ Administer 2 ampules of bicarbonate at 125ml/hour for metabolic acidosis
● Altered renal perfusion related to glomerular malfunction as evidenced by the laboratory values
of 36 mg/dl ethylene glycol level, 25 mg/dl BUN, 1.4 mg/dl creatinine, presence of uric acid
crystals and urine calcium oxalate crystals.
○ Place a foley catheter
○ Perform dialysis as ordered
● Acute confusion related to ethylene glycol poisoning as evidenced by decreased level of
consciousness
○ Administer Fomepizole (4 - methylpyrazole) IV every 12 hours to treat ethylene glycol
poisoning
 ○ Administer Thiamine 100mg IM to metabolize glyoxylic acid, that is produced in
ethylene glycol intoxication
● Ineffective coping related to situational crisis of divorce and financial problems as evidenced by
suicidal intent and suicidal attempt of drinking 3 large glasses of ethylene glycol

Nursing Interventions
Ineffective breathing pattern:
● Monitor vital signs for the detection of delayed recovery or adverse events.
● Auscultate and percuss chest to evaluate presence/characteristics of breath sounds and secretions.
● Review laboratory data, such as ABGs (determines degree of oxygenation and carbon dioxide
[CO2] retention), drug screens, and pulmonary function studies (determines vital capacity/tidal
volume).
● Promote pulmonary function by assisting the patient to turn, cough, and take deep breaths
frequently to prevent atelectasis and respiratory tract infection.
● Note emotional responses (e.g., gasping, crying, reports of tingling fingers). Anxiety may
contribute or exacerbate acute or chronic hyperventilation.
● Encourage slower/deeper respirations or the use of pursed-lip technique to help client relax.
● Encourage adequate rest periods between activities to limit fatigue.
● Monitor pulse oximetry, as indicated, to verify maintenance/improvement in O2 saturation.

Altered Renal Perfusion:

● Continually assess renal function (urine output, laboratory values).
○ Assess urine output. Urine output varies from scanty to a normal volume.
○ Assess laboratory results. Laboratory results may increase, decrease, or stabilize and
these may indicate each phase of ARF.
● Assess blood in the urine. Hematuria may be present in patients with Acute Renal Failure.
● Reduce metabolic rate by encouraging bed rest to prevent fever and infection.
● Provide adequate hydration/ maintain fluid balance to prevent dehydration; avoiding fluid excess.
● To prevent infections from ascending in the urinary tract, give meticulous care to patients with
indwelling catheters.
● To prevent toxic drug effects, closely monitor dosage, duration of use, and blood levels of all
medications metabolized or excreted by the kidneys.
● Provide renal replacement therapy as indicated.
● Weigh the client daily; If the patient gains or does not lose weight or develops hypertension, fluid
retention should be suspected.
● Assess the patient’s progress and response to treatment, and provide physical and emotional
support.

Acute confusion:
● Assess the patient’s attention span and level of distractibility in making decisions or
problem-solving
● Orient the patient as necessary
● Implement safety measures
● Treat the underlying physiological condition
 ● Limit stimuli or avoid sensory extremes
● Allow adequate time for sleep by following a normal sleep-wake cycle
● Ensure appropriate support
● Assist with treatment regimen prescribed to address the underlying condition
● Work with the patient for possible solutions regarding specific conflicts that remain unsolved
● Educate the patient in interventional techniques for episodes of irrational or negative thoughts

Ineffective coping:
● Observe for causes of ineffective coping such as grief, lack of support, or recent changes in life
situation
● Monitor risk of harming self or others and intervene as appropriate. Refer for mental health care
immediately if indicated
● Evaluate resources and support systems available to the patient
● Set a working relationship with the patient through continuity of care
● Assist the patient in setting realistic goals and identify personal skills and knowledge
● Provide chances to express concerns, fears, feelings and expectations
● Utilize empathetic or therapeutic communication
● Convey feelings of acceptance and understanding. Avoid false reassurances
● Encourage the patient to recognize her own strengths and abilities
● Consider mental and physical activities within the patient’s ability

Pharmacologic Interventions
● Administer Succinylcholine chloride for relaxation of the muscle
○ Nursing Considerations:
■ Monitor Symptoms hyperkalemia such as, fatigue, weakness, tingling, and
bradycardia
■ Assess respiratory status
■ Monitor vital signs
● Administer Lorazepam to sustain sedation while on mechanical ventilator
○ Nursing Considerations
■ Assess respiratory status
■ Check for hypersensitivity
■ Do not abruptly stop
● Administer Propofol to sustain sedation while on mechanical ventilator
○ Nursing Considerations
■ Assess level of consciousness
■ Do not leave the patient unattended
■ Monitor vital signs
● Administer 2 ampules of bicarbonate for metabolic acidosis
○ Nursing Considerations
■ Monitor vital signs
■ Watch out for decreasing level of consciousness
■ Record intake and output
● Administer 4-methylpyrazole also known as fomepizole to block metabolism of ethylene glycol
and methanol to their toxic metabolites
○ Nursing Considerations
■ Monitor vital signs: blood pressure, respiratory rate and pulse rate.
■ Assess for any pain, bruising, skin rash, numbness or weakness.
■ Check intake and output and advice to avoid strenuous activities.
● Administer Thiamine to metabolize glyoxylic acid, that is produced in ethylene glycol
intoxication
○ Nursing Considerations:
■ Monitor vital signs: blood pressure, respiratory rate and pulse rate
■ Assess for chest pain and shortness of breath.
■ Monitor intake and output, advise the client to avoid greasy food and encourage
to drink plenty of water.
● Administer Levalbuterol to increase airflow to the lungs
○ Nursing Considerations:
■ Assess heart rate, ECG and heart sounds
■ Monitor signs of CNS toxicity such as tremor, anxiety and nervousness
■ Assess level of consciousness