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The Deteriorating Patient: An Acute Kidney Injury Case Study Assessment

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The Deteriorating Patient: An Acute Kidney Injury Case Study Assessment

National Safety and quality healthcare (NSQH) is of fundamental essence in guiding to

ensure that the decline is recognized and responded to in time. Moreover, it outlines out the

factors that lead to the failure of proper detection and response to a patient's deteriorating health

status (Australian commission of safety and quality in healthcare,2012). It warns that there are

often adverse effects, including cardiac arrest and death, resulting from deterioration of patients.

However, the outcomes may be improved when the condition is identified early and the

necessary interventions. Therefore, in this case, the case of acute kidney disorder is of much

relevance in understanding where clinical and health professionals. The interventions include the

steps taken to ensure patient stabilization. According to the standard, deterioration of the patient

is not always recognized. Moreover, the right actions are not ever taken to provide medical

intervention. The workforce and organization factors that are required in recognition and respond

to patient deterioration are also often overlapping and complicated. Among them is a lack of

physiological observation understanding or inconsistent observation of the patient's physiological

status. Lack of adequate knowledge of the symptoms and signs that signifies the status of

deterioration and deficiencies in awareness of the mental state potential for a patient's decline is

also identified factors that may lead to poor outcomes in the management of deteriorating

patients. One of the conditions that are related to the deterioration of patients is Acute Injury to

the Kidney. In this case, Mr. Nobother inhibits signs like high respiration rate, increased blood,

and Tachycardia or increased heart rate. While it is uncommon, acute injury to the kidney has a

significant mortality rate. According to Connel and Laing (2017, p. 581), the condition is

common in hospitals, but poorly managed half of the time. This paper is an assessment of the
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NSQH guidelines for recognizing and responding to the deterioration condition based on a case

study of an accident victim and who suffers an acute injury to the kidney. The NSQH standard

under investigation is the attribution of physical symptoms to a condition in existence.

Problem Statement

Problem-Focused Diagnosis-related to acute kidney injury as evidenced by low urine

output and reduced electrolytes.

A 66-year old man named Charles Nobother suffers a motor vehicle accident and is

admitted to the trauma unit. The accident was a result of swerving to avoid hitting a Kangaroo.

Unfortunately, the man rolled into a ditch after hitting a tree. Upon examination, Nobother's

abdomen is distended. The bowel sounds are also hypoactive, leading to the limitation of the oral

taking of fluids. The hemoccult status of his vomitus is negative. The patient has discomfort in

taking a deep breath and has a shallow respiratory effect. The sound of the breath signifies fine

bilateral crackles. Moreover, the hands are shaky. There is severe pain which the medical

personnel attribute to the injury of the pelvic structure. The patient also feels uncomfortable

when lying on the back. The urine color is brown and frusemide, and fluid challenge results in

only a small urinary output increase. The patient has six fractures on his pelvic. Other injuries

include fracture on the left orbital, left ribs, the left superior pubic rami fracture, and left inferior

ischial rami fracture. There is also abrasion of the left arm and mesenteric hematoma.

The medical history of the patient reveals that Nobother has suffered from acute

pancreatitis in the recent past. The patient also has a history of drug and alcohol abuse. The

patient is a heavy drinker and has been referred to as alcohol and drug abuse services. Currently,
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the patient smokes cannabis and has previously used drugs injected intravenously. An

examination of social history reveals that Nobother lives alone, and is divorced. The family

relationship is strained.

One factor signifying failure to recognize and respond to the deterioration of Nobother is

attributing the patient's physical symptoms to a condition in existence. The patient's assessment

reveals that Nobother might have an acute kidney injury condition that has not been adequately

diagnosed courtesy of the attribution of the manifested physical signs to the accident. The high

level of pain is also attributed to the injuries that he has suffered due to the accident. The

reluctance to take a deep breath and discomfort when lying on his back also clouds the possible

discovery of the kidney injury since the physician in charge attributes it to other injuries,

including rib and pelvic fractures. The acute kidney injury he has suffered, however, is a result of

excessive consumption of alcohol. The low urine output is overlooked in the patient’s diagnosis,

with the attention concentrated on the injuries he suffered in the accident. The injury is also

manifested by the little improvement of his urine output after frusemide and fluid challenge.

According to Patschan and Muller (2014, p. 22), low urine output is manifested in about 70

percent of people suffering from acute kidney injury. There may also be the emergence of other

complications include heart failure courtesy of the retention of the fluids within the body.
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There are several reasons for failure to recognize and effectively respond to clinical

deterioration. Among the most significant is the lack of consideration for past experiences of the

patient. According to Massey et al. (2017, p. 16), the knowledge of the past occurrences in the

patient's medical life is influential in recognition of the clinical deterioration of the patient. While

the patient's alcohol and drug abuse history has been examined and recorded, it only serves to

hide the discovery of the acute kidney injury status. The pain is attributed to the injuries suffered

during the accident. The possibility of a kidney injury is overlooked despite such pointers as a

history of alcohol and drug abuse. The case also shows a lack of physical assessment skills on

the part of the medical personnel in charge of clinical evaluation of the patient's condition.

There have been determined efforts to enhance the safety of patients in acute settings.

Nevertheless, unplanned ICU admissions, death of patients, and patient injuries still occur

courtesy of nurses' failure to recognize the deterioration of patients under their care (Ruata, 2016,

p. 8). Many of the cases of unidentified patient deterioration occur in medical-surgical units.

Still, nurses need to recognize the conditions in which their patients are critically ill and make a

timely and effective response to enable improved outcomes. One of the most significant methods

of ensuring that patients deteriorating conditions are noted and responded to include the creation

of one of the most effective methods of ensuring that patients deteriorating conditions are

pointed out and responded to include the creation of RRTs (Rapid Response Teams). According

to Ruata (2016, p. 8), RRTs have enabled the improvement of patient conditions, which would

have otherwise led to deterioration and poor outcomes. A study carried out to determine the

effectiveness of the RRTs found out that the reduction of mortality was 40 percent. In

comparison, the cardiac arrest case reduction was 60 percent when the strategy was put in place.
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There are signs of acute kidney injury in the patient. The patient's review reveals that

Nobother's urine output does not improve even after frusemide and fluid challenge. According to

Patschan and Müller (2015, p.20), low fluid excretion is a sign of acute kidney injury. Hosohata

et al. (2018, p. 174) support the findings, positing that decreased urine output levels are one of

the significant determinants of the presence of acute injury in the kidney. The color of the urine

is also brown. An investigation of the electrolytes is expected to reveal a sudden increase in the

count of serum creatinine that would further reveal the presence of the injury on the kidneys

(Satirapoj et al. 2016, p.2). The investigation should involve the collection of blood samples and

analyzed through the biochemical method (Satirapog et al. 2016, p. 2). The enzymic method

should be used to analyze the serum creatinine. The fact that the patient had a number of pelvic

fractures should also have led to further investigation of internal organs held within the pelvic

structure. Coccolini et al. (2019, p. 4) state that pelvic trauma may lead to urogenital injuries

and should be diagnosed within the first few hours of the patient's entrance into the healthcare

institutions. Further, an examination of trauma should consider rib fractures, abdominal pain,

and hematuria. The symptoms and signs are present in Nobother's medical case.

The examination of the patient led to the discovery of brown urine excretion. The priority

problem, while attributed to the consumption of alcohol, was a manifestation of damage to the

kidneys. According to Petejova and Martinek (2014, p.4), dark brown urine is one of the vital
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signs of acute kidney damage. Vaught et al. (2015, p. 1345) propose that acute kidney damage

may also manifest after a surgical procedure. The patient had gone through a surgical session

before he was placed under nursing care. Forni et al. (2017, p. 4) also argue that the amount of

urine discharge is a determinant of the presence of acute kidney injury and should be monitored

during the hospitalization and recovery process. The condition in which there is a low discharge

of urine shows that there is reduced in the function of the kidneys. Vanmassenhove (2017, p. 93)

supports the diagnostic measure, stating that the output of urine is an influential step in

determining the presence of acute injury of the kidney.

According to Sykes et al. (2017, p. 524) the criteria in which the urine output is measured

to determine the presence of kidney injuries in patients. Ostermann and Joannidis (2016, p. 10)

also propose that urine output is one of the most popular ways of investigating the presence of

acute kidney injuries in patients. Kanagasundaram (2019, p.6) explains that measures should be

taken to improve the output of urine, in addition to its monitoring before discharge. Diuretics are

some of the most important means of management of fluids in the body. Furosemide

administration – as a means of diuretic intervention for acute kidney injury patients – helps in

necrotic debris clearance and oxygen demand reduction. According to Bove et al. (2019, p. 2),

furosemide, when administered in low doses, may also result in apoptosis reduction. It may also

change acute renal failure outcome severity, eliminating the oliguric state. In the end, diuretic

interventions aim to induce renal function recovery and improve the chances for continued use of

existing renal structures without a need for replacement intervention. The second intervention

for the acute kidney patient is the correction of electrolyte imbalances. Bove et al. (2019, p.2)

propose that the intervention efforts should also be aimed at the correction of imbalances in the

electrolyte composition. The intervention should involve the administration of intravenous fluids
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to ensure the optimum balances in electrolyte composition in the body. The intervention is aimed

to prevent the occurrence of acute kidney injury complications, which may stand in the way of

an improved outcome. They include hypomagnesemia, hypocalcemia, hyponatremia,

hypophosphatemia, and hypokalemia.

National safety and quality health service standards is crucial in improving the provision

of quality health service .Moreover, the NQHS provides evidence based strategies to deal with

practices that affects a vast number of patients. Acute Injury Kidney Disease is a condition

which may lead to high mortality rates among the patients it afflicts. The early diagnosis and

intervention are hindered by the medical professional’s lack of recognition and response to the

condition. One of the factors that influence the poor outcomes of acute kidney injury patients is

the attribution of the condition to another that is in existence. Nurses are charged with the duty of

providing evaluation and monitoring services that would lead to the discovery of the condition

early. Some of the most significant determinants of the disease include low urine output and rise

in levels of creatine. The difference between poor and favourable outcome can be determined by

not only the early recognition and response to the condition but also proper management of the

recovery process, which monitoring for improvements.

References
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Australian Commission on Safety and Quality in Health Care, National Safety and Quality

Health Service Standard (September 2012). Sydney. ACSQHC, 2012

Bove, T., Belletti, A., Putzu, A., Pappacena, S., Denaro, G., Landoni, G., Bagshaw, S. M., &

Zangrillo, A. (2018). Intermittent furosemide administration in patients with or at risk for

acute kidney injury: Meta-analysis of randomized trials. PLOS ONE, 13(4),

e0196088. https://doi.org/10.1371/journal.pone.0196088

Coccolini, F., Moore, E. E., Kluger, Y., Biffl, W., Leppaniemi, A., Matsumura, Y., Kim, F.,

Peitzman, A. B., Fraga, G. P., Sartelli, M., Ansaloni, L., Augustin, G., Kirkpatrick, A.,

Abu-Zidan, F., Wani, I., Weber, D., Pikoulis, E., Larrea, M., & Catena, F. (2019).

Kidney and uro-trauma: WSES-AAST guidelines. World Journal of Emergency

Surgery, 14(1). https://doi.org/10.1186/s13017-019-0274-x

Connell, A., & Laing, C. (2015). Acute kidney injury. Clinical Medicine, 15(6), 581-584. doi:

10.7861/clinmedicine.15-6-581

Forni, L. G., Darmon, M., Ostermann, M., & Oudemans, H. (2017). Renal recovery after acute

kidney injury. Intensive Care Medicine, 43(6). DOI 10.1007/s00134-017-4809-x

Hosohata, K., Inada, A., Oyama, S., & Iwanaga, K. (2018). Acute kidney injury

(AKI). Advances in Nephropathy. https://doi.org/10.5772/intechopen.79348

Kanagasundaram, S. (2019). Clinical Practice Guideline Acute Kidney Injury (AKI). The Renal

Association. https://doi.org/10.22141/2307-1257.8.4.2019.185121
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Massey, D., Chaboyer, W., & Anderson, V. (2016). What factors influence ward nurses’

recognition of and response to patient deterioration? An integrative review of the

literature. Nursing Open, 4(1), 6-23. https://doi.org/10.1002/nop2.53

Moore, P. K., Hsu, R. K., & Liu, K. D. (2018). Management of acute kidney injury: Core

curriculum 2018. American Journal of Kidney Diseases, 72(1), 136-

148. https://doi.org/10.1053/j.ajkd.2017.11.021

Ostermann, M., & Joannidis, M. (2016). Acute kidney injury 2016: Diagnosis and diagnostic

workup. Critical Care, 20(1). https://doi.org/10.1186/s13054-016-1478-z

Patschan, D., & Müller, G. A. (2014). Acute kidney injury. Journal of Injury and Violence

Research. https://doi.org/10.5249/jivr.v7i1.604

Petejova, N., & Martinek, A. (2014). Acute kidney injury due to rhabdomyolysis and renal

replacement therapy: A critical review. Critical Care, 18(3),

224. https://doi.org/10.1186/cc13897

Ruata, T. A. (2016). Recognizing acute patient deterioration. Nursing Management

(Springhouse), 47(6), 8. https://doi.org/10.1097/01.numa.0000483124.63354.cc

Satirapoj, B., Kongthaworn, S., Choovichian, P., & Supasyndh, O. (2016). Electrolyte

disturbances and risk factors of acute kidney injury patients receiving dialysis in

exertional heat stroke. BMC Nephrology, 17(1). https://doi.org/10.1186/s12882-016-

0268-9
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Sykes, L., Nipah, R., Kalra, P., & Green, D. (2017). A narrative review of the impact of

interventions in acute kidney injury. Journal of Nephrology, 31(4), 523-

535. https://doi.org/10.1007/s40620-017-0454-2

Vanmassenhove, J., Vanholder, R., & Lameire, N. (2017). Points of concern in post acute

kidney injury management. Nephron, 138(2), 92-

103. https://doi.org/10.1159/000484146

Vaught, A., Ozrazgat-Baslanti, T., Javed, A., Morgan, L., Hobson, C., & Bihorac, A. (2014).

Acute kidney injury in major gynaecological surgery: an observational study. BJOG: An

International Journal Of Obstetrics & Gynaecology, 122(10), 1340-1348. doi:

10.1111/1471-0528.13026
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Annoted References

Bove, T., Belletti, A., Putzu, A., Pappacena, S., Denaro, G., Landoni, G., Bagshaw, S. M., &

Zangrillo, A. (2018). Intermittent furosemide administration in patients with or at

risk for acute kidney injury: Meta-analysis of randomized trials. PLOS ONE, 13(4),

e0196088. https://doi.org/10.1371/journal.pone.0196088

The study investigated the impact of furosemide administration as a method for reversal

and prevention of acute kidney injury. It is also meta-analysis aimed at finding out furosemide

effects on patient survival. The conclusion that there was an improvement in urine output with

diuretics initiation. Benefits, rather than shortcomings, were identified in regard to patient

mortality.

Coccolini, F., Moore, E. E., Kluger, Y., Biffl, W., Leppaniemi, A., Matsumura, Y., Kim, F.,

Peitzman, A. B., Fraga, G. P., Sartelli, M., Ansaloni, L., Augustin, G., Kirkpatrick,

A., Abu-Zidan, F., Wani, I., Weber, D., Pikoulis, E., Larrea, M., & Catena, F.

(2019). Kidney and uro-trauma: WSES-AAST guidelines. World Journal of

Emergency Surgery, 14(1). https://doi.org/10.1186/s13017-019-0274-x

The paper is a guideline for the management of urogenital trauma. The authors advance

the non-operative method of management as the priority in handling urogenital and kidney

trauma. The conclusion was that the injury anatomy and the effects on physiological aspects

should be considered in pursuit of a strategy for treatment.

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Connell, A., & Laing, C. (2015). Acute kidney injury. Clinical Medicine, 15(6), 581-584. doi:

10.7861/clinmedicine.15-6-581

The paper emphasizes the need for early interventions exploiting best practices in acute

kidney injury care. It sheds light on the symptoms signifying the onset of the condition. The

authors paint a dire picture of acute kidney injury patient care and recommends ways of

remedying the situation.

Forni, L. G., Darmon, M., Ostermann, M., & Oudemans, H. (2017). Renal recovery after

acute kidney injury. Intensive Care Medicine, 43(6). DOI 10.1007/s00134-017-4809-

The paper isa presentation of approaches to acute kidney injury interventions in the

course of recovery. It identifies the right diagnosis of the condition. The article proposes urine

output as a method of determination of presence of acute injuries to the kidneys.

Hosohata, K., Inada, A., Oyama, S., & Iwanaga, K. (2018). Acute kidney injury

(AKI). Advances in Nephropathy. https://doi.org/10.5772/intechopen.79348

The article provides an overview of the prognosis, causes, and definitions of Acute

Kidney Injury. The authors propose a follow-up of acute kidney injury patients to reduce the

possibilities of mortality and improve outcomes. Physician communication is one of the

significant factors considered in the management of the condition.

Ostermann, M., & Joannidis, M. (2016). Acute kidney injury 2016: Diagnosis and

diagnostic workup. Critical Care, 20(1). https://doi.org/10.1186/s13054-016-1478-z

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The review makes a summary of acute kidney injury investigation tools. It also identifies

the pitfalls that stand in the way of proper management of the condition in patients considered

critically ill. The authors determine that the most crucial diagnosis for acute kidney injury

involves considering urine output and serum creatinine levels.

Patschan, D., & Müller, G. A. (2014). Acute kidney injury. Journal of Injury and Violence

Research. https://doi.org/10.5249/jivr.v7i1.604

The article is an investigation of the effectiveness of new therapies in acute kidney injury

intervention. It proposes regimens that are stem-based as a means of reducing poor outcomes in

the treatment of the condition. Further, the authors explore fluid excretion signs in the

manifestation of the problem. 

Petejova, N., & Martinek, A. (2014). Acute kidney injury due to rhabdomyolysis and renal

replacement therapy: A critical review. Critical Care, 18(3),

224. https://doi.org/10.1186/cc13897

The paper discusses the manifestation of acute kidney injury as a result of

rhabdomyolysis, a condition in which the contents of fibers of the skeletal muscle are released

into the circulation. The authors propose the restoration of proper flow of urine in acute kidney

injury patients through fluid resuscitation. In-depth pathophysiology knowledge is recommended

for the patients.

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Forni, L. G., Darmon, M., Ostermann, M., & Oudemans, H. (2017). Renal recovery after

acute kidney injury. Intensive Care Medicine, 43(6). DOI 10.1007/s00134-017-4809-

The paper is a presentation of approaches to acute kidney injury interventions in the

course of recovery. It identifies the right diagnosis of the condition. The article proposes urine

output as a method of determination of presence of acute injuries to the kidneys.