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Day 1:

Andrew Kelly Ian (A.K.I) is 67 year-old male who was brought into the emergency department by his son Jason. Upon visiting his father, Jason noted mr. Ian was confused, weak, and feverish. Assessment in the ED revealed Mr. Ian was lethargic, oriented x2 with dry mucous membranes, 1+ peripheral pulses, delayed capillary refill, 2+ pitting edema in both lower extremities, bilateral crackles and foley output of 15 mL/hr of dark amber urine. Vital signs were as follows BP 91/60 (MAP 70), HR 120, RR 25, O2 88%, T 100.4F. Mr. Ian has a history of chronic kidney disease stage 2, hypertension, coronary artery disease and congestive heart failure. His surgical history includes CABG in 2012 and a right hip replacement in January 2019. According to Jason, his father had been taking ibuprofen for many months since his hip replacement surgery. Additionally, Mr. Ian recently threw out his back two weeks ago while gardening, which led to an increased use of ibuprofen. Jason stated that he noticed multiple empty bottles of ibuprofen in his fathers kitchen.

Labs revealed diminished renal function (BUN of 55, Cr of 9, and GFR of 29), hyperkalemia (5.8), eosinophilia (3.5%) and metabolic acidosis (pH 7.25, PaCO2 30, HCO3 7). A urine analysis demonstrated a urine sodium of 15, osmolality of 800 and specific gravity of 1.9. A renal biopsy confirmed diagnosis of drug induced-acute interstitial nephritis with 50% interstitial fibrosis and a RIFLE criteria of stage failure. Mr. Ian’s providers decided to treat him by stopping all NSAID medications, administering intravenous normal saline, managing fluid status, correct electrolyte imbalances and metabolic acidosis. Due to hemodynamic instability and acute deterioration in renal function, Mr. Ian was transferred to the ICU.

Day 6:

By day five of care he was transferred to the telemetry floor, as Mr. Ian’s conditions was stable and resolving. Hemodialysis improved renal function as evidenced by Cr 3.6, BUN 33.2, GFR of 40 and urine values as follows: urine sodium 24, urine osmolality of 550 and urine specific gravity of 1.2. He was alert and oriented x3, equal strength in upper and lower extremities, moist mucous membranes, capillary refill <2 seconds, normal skin turgor, NSR on the monitor, 1+ edema in the lower extremities, 2+ peripheral pulses, fine crackles in lower lung bases, 2 L/min of oxygen via nasal cannula and output of 25 ml/hr of amber urine.

Day 10:

By day ten of admission Mr. Ian’s acute interstitial nephritis had resolved, however, this event further injured his kidneys resulting in CKD stage 3. When he received the news he was going to be discharged that day, Mr. Ian expressed to the nurse “I am nervous to go home and have to manage my chronic conditions. I don’t know if I can do it by myself.”

Questions:

1. What are this patient’s risk factors for acute kidney injury?
2. What lab values helped Mr. Ian’s providers determine he had prerenal AKI, versus acute tubular necrosis?
3. What labs should the nurse monitor for an acute kidney injury patient like Mr. Ian?
4. What collaborative interventions and support does Mr. Ian need after discharge?

Answers:

1. Older age (over 65), previous history of renal insufficiency (CKD stage 2), hypertension, coronary artery disease, congestive heart failure and over use of an NSAID
2. Urine sodium concentration, osmolarity and specific gravity
3. Cr, BUN, GFR, electrolytes, urine sodium concentration, osmolality and specific gravity
4. The nurse should evaluate Mr. Ian’s baseline knowledge and provide unrushed, individualized education to enhance the patient’s ability to care for himself. Since the jason, the son, is also involved in Mr. Ian’s care the nurse should include him in the teaching. Lastly, collaboration with case management to provide Mr. Ian with a home health nurse would be beneficial.