Care of deteriorating patient

Joel Johnson

Joel is a 72 year-old retired architect. He continues to work informally as a consultant on some projects in addition to having had a number of books of poetry published in recent years. Joel has been married to Sylvia for 49 years, and they have been planning a cruise to celebrate their golden wedding next year. They have four grown up children, and nine grandchildren, who they see regularly and often assist their parents by providing child care. In addition, Joel and Sylvia also care for Sylvia’s 94 year-old mother who is increasingly frail.

Joel attended the practice nurse at his GP surgery with a painful and inflamed injury to his left fore-arm sustained whilst clearing his garden shed last week, he believes he caught it on a rusty bow saw that was hanging on the shed wall. Concerned about the state of the wound and his observations the nurse called an ambulance for Joel to be transferred to the accident and emergency unit for potential admission.

Joel has mild osteoarthritis for which he takes over-the-counter NSAIDs and is prescribed Ramipril 5mg od for hypertension. Joel was a heavy smoker until giving up twenty years ago.

 

OBSERVATIONS ON ARRIVAL AT ACCIDENT AND EMERGENCY

AIRWAY: Unable to talk in full sentences as needs to catch his breath.

BREATHING: RR: 28pm, SpO2 93% on air. Some sounds of gurgling as he breathes.

CIRCULATION: HR: 112bpm, regular but thready, BP: 72/58 – Joel complains of feeling dizzy. Joel seems to think he has been passing less urine in the last couple of days.

DISABILITY: AVPU: Alert but seems a little muddled and shows signs of slurred speech

EXPOSURE: Temperature: 38.4C. Joel has an inflamed wound on his left arm and his skin feels clammy to the touch. Joel also admits to feeling nauseous.

Blood Results:

  • Sodium 142mmol/L
  • Potassium 5.1mmol/L
  • Urea  39 mmol/L
  • Creatinine 259 µmol/L
  • FBC Hb 100.2g/L, WCC 16.2×109/L
  • Lactate 4.1mmol/L
  • CRP 136mg/L

 

 Problem 1:

Using the A-E approach what are the nursing priorities for Joel’s immediate care including any further tests that may be required?

Problem 2:

Provide the rationale for the care you have suggested in problem 1 .

  • Make use of appropriate pathophysiology
  • Include relevant pharmacology
  • Use appropriate national guidelines.

Developing Scenario

After three days on the ward Joel’s condition has deteriorated and he is now confirmed as having stage 3 acute kidney injury (AKI) with serum creatinine of  403µmol/L and no urine output for 18 hours. He needs renal replacement therapy.

 

Problem 3: What evidence-based treatment options may be employed to maintain Joel whilst he is in the ICU. Assuming Joel recovers from this acute episode discuss the ongoing care he may need to help him rehabilitate and in relation to the management of potential ongoing chronic kidney disease, including any multi-disciplinary team involvement.