W.A. is a 70-year-old African American female who presented tothe emergency department with fever, severe nausea, vomiting, anddiarrhea. She is being admitted to the intensive care unit (ICU)with a diagnosis of kidney failure and septicemia. Her previousmedical history includes glaucoma, chronic kidney failure,hypertension, and insulin-dependent diabetes mellitus. She had aleft above-the-knee amputation 1 year ago. B. Subjective Data •W.A.’s daughter states she was able to do her daily chores at homeindependently, but for the last few days it was getting difficultfor her to get around and that she needed to take frequent breaksbecause of shortness of breath and no energy. Her daughter alsoreports that W.A. had been complaining of headaches with nausea anddizziness for the past few days. • Goes to hemodialysis 3 days aweek C. Objective Data Physical Examination • Blood pressure178/96, pulse 110, temperature 101.5° F , respirations 28 • Oxygensaturation 86% on 15 LPM via mask • Oriented to name only •Crackles in bilateral lower lobes • 2+ edema bilateral lowerextremities and hands • Abdomen is distended with hypoactive bowelsounds x4 quadrants Diagnostic Studies • CBC: Hemoglobin 7 g/dL,hematocrit 23.8%, RBC 2.57 million/mm3, WBC 14.8 mm3 • ChemistryPanel: Serum sodium 132 mEq/L, serum potassium 6.0 mEq/L, calcium9.3 mg/dL, phosphorus 6.0 mg/dL, glucose 197 mg/dL, albumin 2.4U/L, serum blood urea nitrogen 77 mg/dL, serum creatinine 7.30mg/dL, eGFR African American 10, BNP 182 pg/mL • Urinalysis: Darkyellow and cloudy, protein 28 mg/dL, positive for casts, positivefor red blood cells and white blood cells, positive for glucose andketones • Blood cultures pending Discussion
Questions 1. What is MODS? After reviewing W.A.’s presentation,what organ systems do you suspect are involved and why? 2. What doyou think is the origin of W.A.’s septicemia? 3. What additionaltests would you anticipate for W.A.? 4. What are the collaborativecare goals for W.A.? 5. Describe collaborative care that would beappropriate for W.A. (Be extensive, specific and thorough in youranswer. Please give rationale for answer). 6. W.A.’s urine outputover the past 4 hours is 20 mLs and her latest potassium level is 7meq/L. The physician is ordering a continuous renal replacementtherapy machine (CRRT). Why would a CRRT be ordered for W.A.?Explain what CRRT is and how it is performed. 7. Outline a careplan for W.A., describing nursing interventions that would beappropriate for promoting oxygenation, maintaining fluid volume,and promoting tissue perfusion.
