NUR440 Case Study 5 Acute Renal Failure

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NUR440 Case Study 5NUR440Case Study Five: Acute Renal FailureML is a 32-year-old African-American woman who was involved in a motor vehiclecrash (MVC) 3 days ago. She was driving the vehicle when she lost control of the car andslid off the side of the road hitting the embankment. Her history is significant fordiabetes. Her medication regimen includes insulin 70/30 for which she takes 12 units inthe morning and evening.On admission, her weight was 125 pounds. Her skin was pale and cold. Her vitalsigns were as follows: BP = 78/40 mm Hg; P = 140 bpm; RR = 42/min and shallow. Shewas disoriented and confused. Bony deformities were obvious in the left and right shins.She was diffusely tender to touch, more so over her right chest.During the course of her first 3 days, the following findings and treatmentsoccurred. The insertion of a Foley catheter was difficult and revealed gross hematuria.Her lab results revealed: Hgb = 12.2; Hct = 36; WBC = 11,200; blood glucose = 180.Urinalysis revealed a pH of 6, a specific gravity of 1.018, 4+ occult blood, 1+ protein,and RBCs too numerous to count.Chest x-ray films showed multiple faint rib fractures on the right side. Heart sizewas normal, and there were no other remarkable findings on the x-ray film or ECG.Initial serum electrolytes and amylase were normal, as was her ABG. Her fractures wereconfirmed to the shaft of the right femur and left tibia and fibula. She was treated withwarmed blankets, 2 units of PRBCs, and 4 L of saline. Her blood pressure came up to116/78. Urine output was 55 ml over the next 90 minutes. A CT scan of her head withcontrast infusion was normal. A CT scan of her abdomen showed some ascitic fluid and aprobable hematoma of the spleen. The abdomen was explored and a lacerated spleen wasremoved. ML required an additional 4 units of blood during the surgery.For the last 3 days, ML's urine output has averaged 40 to 50 ml/hr, and her meanarterial pressure (MAP) was 60 to 80. The patient was alert and communicative. Thecolor of her urine became gradually lighter; however, the BUN rose to 75 mg/dl with aserum creatinine value of 4.5 mg/dl. Other lab tests revealed: calcium = 6.2; phosphorous= 8.2; uric acid = 13.2; LDH = 473; CPK = 12,000; urine osmolality = 370; urinecreatinine = 52. During this period, the patient underwent internal fixation of the lowerextremity fractures. ML was diagnosed with acute renal failure (ARF)1.Define acute renal failure and its cause in the case of ML.ARF occurs quickly, over a few day or weeks with a sudden reduction in theglomerular filtration rate (GFR), resulting in elevation of blood urea nitrogen(BUN), plasma creatinine and cystatin C levels. The retention of these products inthe blood disrupts the electrolyte, acid-base homeostasis, and fluid volumeequilibrium. ARF is usually associated with oliguria (less than 30 ml/hr or lessthan 400 ml/day) and is caused by any condition that reduces blood flow, bloodpressure or kidney perfusion. ML’s ARFwas most likely caused fromhypovolemia and crush injuries. The hypovolemia caused her blood pressure todrop, consequently, reducing the flow of blood to her kidneys, producingischemic damage from inadequate tissue perfusion impairing tubular endothelialfunction; perfusion pressures decrease and eventually equal GFR. Due to ML’s

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