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Physical Examination

Mrs. Davies is a 70-year-old white woman who presented to the emergency department because of a 4-day history of increased shortness of breath and generalized weakness. Mrs. Davies stated that she has been 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 she was short of breath and had no energy. She has a long history of heart failure, diabetes mellitus type 2, and hypertension. She is admitted with a tentative diagnosis of acute kidney injury (AKI).

Subjective Data

Has been having headaches on and off, with nausea and dizziness

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Reported that she hadn’t been taking her medications regularly at home because of ‘forgetfulness’

Has not been urinating a lot

Feels ‘puffy’ in her legs and hands

Objective Data

Physical Examination

Blood pressure 178/96, pulse 110, temperature 98.9° F, respirations 24

Alert and oriented to person, place, and time

Mild jugular venous distention

Fine crackles in bilateral lower lobes

Heart rate regular, no murmurs

Bowel sounds normoactive and present in all four quadrants

2+ edema bilateral lower extremities and hands

Diagnostic Studies

Echocardiogram shows decreased left ventricular function

Urinalysis: Urine dark yellow and cloudy, protein 28 mg/dL, negative for glucose and ketones, positive for casts, red blood cells and white blood cells

24-hour urine output = 380 mL

Laboratory Tests:

Hemoglobin 8 g/dL

Hematocrit 23.8%

RBC 2.57 million/mm3

WBC 4.7 mm3

Sodium 132 mEq/L

Potassium 5.2 mEq/L

Calcium 9 mg/dL

BUN 36 mg/dL

Creatinine 4.9 mg/dL

BNP 182 pg/mL

Question 1

Interpret Mrs. Davies’s laboratory test results and describe their significance.

Question 2

What is the most likely cause of Mrs. Davies’s AKI?

Question 3

What additional tests, if needed, could be done to determine the cause of AKI?

Question 4

What are the priority nursing diagnoses to address the concern of fluid retention?

Question 5

What are the priority nursing interventions for these nursing diagnoses?

 

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