NRNP 6566 WK 10 Knowledge Check

NRNP 6566 WK 10 Knowledge Check A 57 year old female is admitted to the oncology unit for chemotherapy related to her to acute leukemia. Her initial dose of chemo was 2 days ago. While rounding today, the patients tells the NP that she feels so weak. The NP notes her heart rate is 44 today (down from 68 2 days ago). She has had less than 100 cc of urine out over the last 24 hours. Labs from this morning include: LAB DATA: -Sodium 131 -Potassium 7.8 -Chloride 105 -Bicarbonate 17 -BUN 67 -Creatinine 5.8 -Glucose 83 -Calcium 7.6 -Phosphorus 6.8 -Uric acid 16.3 What is your working diagnosis for this patient? How would you treat her? Correct Answer: Diagnosis is hyperkalmeia probably from tumor lysis syndrome. Chemotherapy has cause cells to die releasing potassium into the circulation. The elevated uric acid, phsophorus, low calcium, and acute renal failure all stem from tumor lysis. Treatment Check a 12 lead EKG Give calcium gluconate to stabilize cardiac function Begin insulin and dextrose to shift potassium into the intracellular space. Aggressively administer fluids to treat potential pre-renal azotemia Consider Kayexalate to remove potassium. Response Feedback: [None Given] Using the Cockcroft and Gault formula, calculate the estimated GFR for the following patient. 52 year old female weighting 177 pounds. Plasma creatinine is 3.3 Correct Answer: The formula is: For this patient Response Feedback: In women you would multiple the result by 0.85 to reflect the lower muscle mass in women. 30 x .85 = 25 ml/min Medication doses in this patient would need to be altered due to the low GFR [None Given] How would you calculate the fractional excretion of sodium? What does this calculation tell you about the patient’s acute kidney injury? Correct Answer: Calculating the fractional excretion of sodium in patient’s with oliguria is helpful in distinguishing prerenal from intrinsic renal causes of acute kidney injury. The formula is: Respons e Feedbac k: A result of less than 1% indicates a prerenal cause of acute kidney injury. A vale greater than 2 percent indicates an intrinsic renal cause. This formula is less reliable in patients on diuretic therapy. [None Given] A 44 year old female is NPO following surgery for a bowel obstruction. She weighs 166 pounds. How would you calculate her daily maintenance IV fluid need while she is NPO? Correct Answer: For patients weighing more than 20 kg utilize this formula 1500 ml + {weight (kg) x 20 ml/kg/day} = 1500 ml + (75 kg x 20ml/kg) - 1500 ml + 1500 ml = 3000 ml /day or 125 cc / hour Response Feedback: This number accounts for insensible loss, urine output, and basic fluid needs. Patients with fever, NG or GI drainage, or fluid loss from another source will need more than the baseline amount. [None Given] A 65 year old man is admitted with left lobar pneumonia. His symptoms on admission included productive cough, fever, dyspnea, confusion, nausea vomiting, constipation, and weakness. He has a 45 pack year history of smoking. He admits to losing 35 pounds over the past 4 months but his wife says he thought that was because of his poor appetite, feeling bad, and no energy. Medications include Advair, an albuterol rescue inhaler, Lisinopril, and HCTZ. The physical examination shows a somewhat emaciated man with a blood pressure of 123/72. There are decreased breath sound throughout the left lung field and normal cardiovascular, abdominal, and extremity examinations. His sputum is green with some blood streaks. Review of his chest x-ray shows lower lobe consolidation. There are also some white spots in the lower lobe which are concerning. He has been started on antibiotics and seems better but is still confused, weak, and complaining of nausea. His repeat labs from today show: -Sodium 133 -Potassium 4.4 -Chloride 98 -Bicarbonate 31 -BUN 15 -Creatinine 1.0 -Glucose 112 -Calcium 17.7 -What is the most likely diagnosis and how would you treat it? Correct Answer: Initial treatment for left sided pneumonia is appropriate. The review of his labs shows significant hypercalcemia which can also produce some of the symptoms present in this patient. Treatment of hypercalcemia includes administration of fluids, calcionin, furosemide, and possible bispohponate therapy. Response Feedback: [None Given] A 70 year old man is 4 hours post right heme-colectomy for a tumor. The NP is called due to falling urine output since surgery. Past medical history - hypertension, type 2 diabetes, gout Medications - lisinopril, allopurinol, and spironolactone (all last given this morning). Physical exam - BP 100/60. HR 110 regular weight 60 kg Lungs are clear, abdominal wound is clean with no drainage, No JVD Urine output 1700 hr. 35 ml 1800 hr 22 ml 1900 hr 15 ml 2000 hr. 8 ml Urine dipstick is normal How would you classify his renal status? How would you treat it? Correct Answer: This is probably pre-renal acute kidney injury. The presence of hypotension, tachycardia, and decreased urine output suggest hypovolemia. The absence of blood and protein supports pre-renal kidney injury. Initial treatment would be to administer a fluid challenge of 500mls Normal (0.9%) Saline over 1 hour to see if his urine output and blood pressure improve. The volume and rate of fluid will depend on the degree of dehydration and degree of compromise (indicated by hypotension) suffered by the patient. A history of or signs consistent with cardiac failure would lead to more cautious fluid replacement. Response Feedback: [None Given] An 87 year male is brought to the emergency department from a nursing home by his family with concerns about his functional status. They state that over the past week he is very somnolent and not participating in his own care very much. The family is worried that he has had a stroke or is overmedicated by the nursing home staff. Medical record from the nursing home shows that he is disruptive and has daily wrist restraints ordered. The patient is arousable but somnolent when no one is speaking with him. His past medical history is unremarkable. He was placed in the nursing home due to