NURS 123Multiple Organ Dysfunction Syndrome student Case study

Multiple Organ Dysfunction Syndrome (MODS) Patient Profile W.A. is a 70-year-old African American female who presented to the emergency department with fever, severe nausea, vomiting, and diarrhea. She is being admitted to the intensive care unit (ICU) with a diagnosis of kidney failure and septicemia. Her previous medical history includes glaucoma, chronic kidney failure, hypertension, and insulin-dependent diabetes mellitus. She had a left above-the-knee amputation 1 year ago. Subjective Data  W.A.’s daughter states she was able to do her daily chores at home independently, but for the last few days it was getting difficult for her to get around and that she needed to take frequent breaks because of shortness of breath and no energy. Her daughter also reports that W.A. had been complaining of headaches with nausea and dizziness for the past few days.  Goes to hemodialysis 3 days a week Objective Data Physical Examination  Blood pressure 178/96, pulse 110, temperature 101.5° F , respirations 28  Oxygen saturation 86% on 15 LPM via mask  Oriented to name only  Crackles in bilateral lower lobes  2+ edema bilateral lower extremities and hands  Abdomen is distended with hypoactive bowel sounds x4 quadrants Diagnostic Studies  CBC: Hemoglobin 7 g/dL, hematocrit 23.8%, RBC 2.57 million/mm3 , WBC 14.8 mm3  Chemistry Panel: Serum sodium 132 mEq/L, serum potassium 6.0 mEq/L, calcium 9.3 mg/dL, phosphorus 6.0 mg/dL, glucose 197 mg/dL, albumin 2.4 U/L, serum blood urea nitrogen 77 mg/dL, serum creatinine 7.30 mg/dL, eGFR African American 10, BNP 182 pg/mL  Urinalysis: Dark yellow and cloudy, protein 28 mg/dL, positive for casts, positive for red blood cells and white blood cells, positive for glucose and ketones  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? This study source was downloaded by from CourseH on :57:45 GMT -05:00 MODS is multiple organ dysfunction syndrome. Renal because she goes to hemodialysis 3x/week (kidney failure). Endocrine d/t being insulin dependent. Cardiovascular d/t fluid being retained (AEB 2+ edema, BP is high); Pulmonary AEB O2 stats at 86%, RR is elevated (she was having SOB), crackles in lower lobes, dyspnea. Neurological AEB orientation only to name (change in LOC). GI AEB diarrhea. Lymphatic possibly it is not replacing fluid extravascularly back into the intravascular spaces. 2. What do you think is the origin of W.A.’s septicemia? Hemodialysis- since the procedure is invasive, there is the risk for transmission of bacteria to body system. It could possibly be related to a UTI AEB positive U/A for casts (indicating possible glomerular disease & pyelonephritis). WBC’s elevated indicative of possible infection; RBC’s- infection, trauma. 3. What additional tests would you anticipate for W.A.? ABG’s, CXR to rule out fluid in chest or abdomen, ultrasound for kidneys, Accucheck’s every 4 hours, PT/PTT/INR 4. What are the collaborative care goals for W.A.? Prevention of decompensation (respiratory, cardio, renal), Locate and eradicate the source of infection, stress reduction and anxiety-with patient & family, establish a plan of care for the patient’s future health, maintenance of oxygen and perfusion, nutritional and metabolic support, patient education on infection prevention and reduction in risk of HAI’s. 5. Describe collaborative care that would be appropriate for W.A.- Fluid balance to replace F/E losses and volume management, strict I &O (Foley), daily weights, possible TPN for nutrition with sodium restriction, vasodilate to reduce blood pressure, diuretics (Spironolactone-easier on kidneys than Lasix), CVP for monitoring hemodynamics, insulin drip to drop glucose down and reduce risk of infectious processes escalating, antibiotic therapy, pain management, EKG monitoring for dysrhythmias electrolyte imbalance, administer antidysrhythmic if needed. Watch for s/s of potential DIC. Intubate and ventilate to increase perfusion and oxygenation (to reduce risk of acquiring ARDS and decrease BP by reducing stress on the heart). 6. W.A.’s urine output over the past 4 hours is 20 mLs and her latest potassium level is 7 meq/L. The physician is ordering a continuous renal replacement therapy machine (CRRT). Why would a CRRT be ordered for W.A.? This machine allows for continuous removal of fluid from plasma. The MD may order this to remove a larger fluid volume from W.A. Since the pt is almost in renal failure, it is important to control the removal of fluid while maintaining hemodynamic stability. It is indicated in patients with MODS and may be used for patients who are hypovolemic or edematous (in which W.A. is) and unresponsive to diuretics. The medications may become toxic to her because she is unable to effectively excrete them from the kidneys, and by not being able to excrete them, renal failure will be more imminent. 7. Outline a care plan for W.A., describing nursing interventions that would be appropriate for promoting oxygenation, maintaining fluid volume, and promoting tissue perfusion. Monitor respiratory status (oxygenation) while pt is intubated and on ventilator. Make sure rate, mode, and tidal volume, PEEP, FiO2 are correctly set on machine. Provide oral care to decrease risk of acquiring VAP. Comfort measures such as positioning and analgesics for decrease fever and for pain. Fluid restrictions to help decrease risk of fluid overload. Decrease invasive procedures, decrease amount of blood loss/draws, continuous monitoring of vitals,