Case Study # 2

ST. ANTHONY COLLEGE OF ROXAS CITY, INC.
San Roque Extension, Roxas City, Capiz, Philippines 5800

Member, DC-SLMES Philippines
Empowering Communities, Building Futures
+
COLLEGE OF NURSING
SY 2020-2021
Case Study # 2: Ms. Jimeno
Gender Female
Age 56
Setting Hospital
Ethnicity Hispanic
Pre-existing Conditions Motor vehicle crash (MVC) eight weeks ago with no injury;
depression
Coexisting Conditions Suicide attempt with ethylene glycol (antifreeze) poisoning

Socioeconomic Financial difficulties secondary to divorce five years ago;
nonsmoker
Legal Safety sitter

Prioritization Client safety
Delegation Psychiatric consult; social services
Client Profile
Ms. Jimeno is a 56-year-old woman who has been having financial difficulties since her divorce five years
ago. She was recently involved in a motor vehicle crash (MVC) in which she drove over a curb and hit a
telephone pole. She did not sustain any significant injuries in the MVC. Two days ago, Ms. Jimeno’s
daughter Maria Clara returned home at 8:00 p.m. to find Ms. Jimeno sitting on the floor with a
decreased level of consciousness. Maria Clara was able to shake her mother awake. With slurred
speech, Ms. Jimeno told her daughter that she drank three large glasses of antifreeze (ethylene glycol)
at around 7:00 p.m. Maria Clara called 911 and emergency medical services transported Ms. Jimeno to
the local emergency department.
Case Study
It is forty-eight hours after her arrival in the emergency department. Ms. Jimeno has undergone twelve
hours of emergency dialysis, has been extubated, and is medically stable for transfer to a medical
surgical nursing unit. A safety sitter remains in Ms. Jimeno’s room at all times. Ms. Jimeno is alert and
oriented but has a flat affect. She is not remorseful for her actions and states, “I had hoped I would be
successful this time.” A psychiatrist sees Ms. Jimeno for a consultation. The psychiatric assessment
reveals that she has been planning the poisoning for a few weeks. She states, “I was hoping I would die
quickly and it would look like an accident.” Ms. Jimeno states that she has made attempts in the past to
overdose on medications. She did not seek care at the hospital when these suicide attempts were not
successful. She has been depressed since divorcing her husband five years ago. Since her divorce, she
has not paid taxes and there have been mounting financial bills with the Bureau of Internal Revenue. As
a result, her wages are being garnished (money is withheld from her paycheck and sent to a creditor).
She reports, “On the outside I appear bright and upbeat but on the inside I am so lonely and sad and just
don’t want to go on anymore.” She wonders how she will pay for her medical care now. “I had not
planned on the poison not working and needing dialysis. I bet dialysis is expensive.”
Questions
1. Explain acute renal failure (ARF).

2. Considering the conditions that cause ARF, which type of ARF is Ms. Jimeno experiencing?
3. What characteristics and laboratory data define the four phases of acute renal failure, and what
is the approximate duration of each phase?
4. It has been four days since admission. According to the definitions provided in the response to
question number 3, which phase of acute renal failure is Ms. Jimeno experiencing?
5. While the nurse is assessing the Quinton catheter insertion site, Ms. Jimeno asks what dialysis is
and how long she will need to do it. Her initial dialysis treatment was twelve hours long and she
is wondering if she will always have to be “hooked up” to the machine that long each time. How
should the nurse respond?
6. On admission, Ms. Jimeno’s creatinine was 1.4 mg/dL and her BUN was 25 mg/dL. Ms. Jimeno
has repeat creatinine and BUN labs drawn two days after admission. The results are a creatinine
of 4.7 mg/dL and a BUN of 24 mg/dL. A day later her creatinine is 8.5 mg/dL with a BUN of 57
mg/dL. Are these results getting better or worse since admission? Discuss why.
7. The following potassium values are reported: on admission, 3.6 mEq/L; forty-eight hours after
admission, 4.0 mEq/L; and seventy-two hours after admission, 4.2 mEq/L. What potential
cardiovascular change is of greatest concern to the nurse?
8. Identify five priority nursing diagnoses that are appropriate to include in Ms. Jimeno’s plan of
care.
9. Why has a safety sitter been included as part of Ms. Jimeno’s plan of care?
10. What are two collaborative services to consider when planning Ms. Jimeno’s discharge?
11. Discuss how Ms. Jimeno’s recent MVC may relate to her current admission.
Answers:
1. Acute Renal Failure

Renal failure results when the kidneys cannot remove the body’s metabolic wastes or perform their
regulatory functions. The substances normally eliminated in the urine accumulate in the body ɻuids as a
result of impaired renal excretion, aʃecting endocrine and metabolic functions as well as ɻuid,
electrolyte, and acid–base disturbances. Acute kidney injury or failure is a rapid loss of renal function
due to damage to the kidneys. Depending on the duration and severity of AKI, a wide range of
potentially life-threatening metabolic complications can occur, including metabolic acidosis as well as
ɻuid and electrolyte imbalances. Treatment is aimed at replacing renal function temporarily to minimize
potentially lethal complications and reduce potential causes of increased kidney injury with the goal of
minimizing long-term loss of renal function.
2. Type of ARF is Ms. Jimeno experiencing is Intrarenal or Intrinsic Acute Renal Failure
Acute tubular necrosis (ATN), or AKI in which there is damage to the kidney tubules, is the most
common type of intrinsic AKI. Characteristics of ATN are intratubular obstruction, tubular back leak
(abnormal reabsorption of ɹltrate and decreased urine flow through the tubule), vasoconstriction, and
changes in glomerular permeability.
3. There are four phases of AKI: initiation, oliguria, diuresis, and recovery.
The initiation period begins with the initial insult and ends when oliguria develops.
• The oliguria period is accompanied by an increase in the serum concentration of substances usually
excreted by the kidneys (urea, creatinine, uric acid, organic acids, and the intracellular cations
[potassium and magnesium]). The minimum amount of urine needed to rid the body of normal
metabolic waste products is 400 mL. In this phase, uremic symptoms first appear and life-threatening
conditions such as hyperkalemia develop. Some patients have decreased renal function with increasing
nitrogen retention but actually excrete normal amounts of urine (1 to 2 L/day). This is the nonoliguric
form of renal failure and occurs predominantly after exposure of the patient to nephrotoxic agents,
burns, traumatic injury, and the use of halogenated anesthetic agents.
• The diuresis period is marked by a gradual increase in urine output, which signals that glomerular
filtration has started to recover. Laboratory values stabilize and eventually decrease. Although the
volume of urinary output may reach normal or elevated levels, renal function may still be markedly
abnormal. Because uremic symptoms may still be present, the need for expert medical and nursing
management continues. The patient must be observed closely for dehydration during this phase; if
dehydration occurs, the uremic symptoms are likely to increase.
• The recovery period signals the improvement of renal function and may take 3 to 12 months.
Laboratory values return to the patient’s normal level. Although a permanent 1% to 3% reduction in the
GFR may occur, it is not clinically significant.
4. The phase of acute renal failure Ms. Jimeno is experiencing is in the Oliguria period specifically
nonoliguric form of renal failure and occurs predominantly after exposure of the patient to nephrotoxic
agents.
5. Dialysis is used to remove medications or toxins (poisoning or medication overdose) from the blood or
for edema that does not respond to other treatment, hepatic coma, hyperkalemia, hypercalcemia,
hypertension, and uremia. Depending on Ms. Jimeno complication which she has acute renal failure she
will be undergoing hemodialysis which last 6-8 hours, she will be hooked up to those remainder of
hours. During the dialysis treatment as a nurse role in monitoring, supporting, assessing, and educating
the patient.
6. The results of her present serum creatinine and BUN were far more worse compare to when she was
admitted. Her results of creatinine of 4.7 mg/dL and a BUN of 24 mg/dL which has a total ratio of 5.1
and 8.5 mg/dL with a BUN of 57 mg/dL which has a total ratio of 6.7 which is below the normal
creatinine and Bun ratio. Both of her recent result indicates due to her intrinsic renal cause that her
results are still at the abnormal range and she is still not recovering.
7. Cardiovascular changes the BUN level increases steadily at a rate that depends on the degree of
catabolism (breakdown of protein), renal perfusion, and protein intake. Serum creatinine levelsare
useful in monitoring kidney function and disease progression and increase with glomerular damage.With
a decline in the GFR, oliguria, and anuria, patients are at high risk forhyperkalemia. Protein catabolism
results in the release of cellular potassium into thebody fluids, causing severe hyperkalemia (high serum
potassium levels).Hyperkalemia may lead to dysrhythmias, such as ventricular tachycardia and
cardiacarrest.
8. Nursing Diagnosis.
1. Excess fluid volume related to Compromised regulatory mechanism
2. Risk for decreased cardiac output related to electrolyte imbalance
3. Risk for Imbalanced Nutrition: Less Than Body Requirements
4. Risk for Deficient Fluid Volume
5. Risk for Infection
9. A safety sitter was included as part of Ms. Jimeno’s plan of care so that she could be kept in check at
all times. She was undergoing depression due to her divorced and safety sitter was included so that she
wouldn’t do any harm to herself and also to cope with her needs, safe sitters observe and monitor the
health condition of patients under the supervision of trained nurses in hospitals or nursing homes.I
tinvolves a range of tasks, including recording the patient’s food and liquid intake, reporting changes to
senior staff, helping patients with walking and moving in and out of bed, and assisting them with eating
or dressing.
10.
11. Discuss how Ms. Jimeno’s recent MVC may relate to her current admission.

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ST. ANTHONY COLLEGE OF ROXAS CITY, INC.

San Roque Extension, Roxas City, Capiz, Philippines 5800

Case Study # 2: Ms. Jimeno

Coexisting Conditions Suicide attempt with ethylene glycol (antifreeze) poisoning

Legal Safety sitter

Delegation Psychiatric consult; social services

1. Explain acute renal failure (ARF).

1. Acute Renal Failure

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