CASE STUDY ON THE CONCEPT OF: MULTIPLE ORGAN FAILURE

Scenario:
You are working on a telemetry unit and have just received a transfer from the ICU. The 50 year
old male patient T.A., had a repair of an abdominal aortic aneurysm (AAA) measuring 8 cm in
diameter. This is his second postoperative day. He is an attorney with an active practice. Although he
routinely took medication for gastritis before surgery, T.A. considered himself to be healthy before
diagnosis of the aneurysm. In addition to these problems, T.A. has a 10 year history of type 2 diabetes
mellitus (DM), and he has required insulin the past 6 months to control his glucose levels; he has also
experienced progressive weakness of his lower extremities and decreasing urinary output since
surgery.
1. T.A. has questions about his surgery. He asks you, I was fine before surgery. Id still be fine
now if I hadnt been operated on, wouldnt I? based on your knowledge of AAA, what should
your response be?
There is a risk that this aneurysm may suddenly break open (rupture) if you do not have surgery to
repair it. The aorta is under constant pressure as blood is ejected from the heart. With each heart beat,
the walls of the aorta distend (expand) and then recoil (spring back), exerting continual pressure or
stress on the already weakened aneurysm wall. Therefore, there is a potential for rupture (bursting) or
dissection (separation of the layers of the aortic wall) of the aorta, which may cause life-threatening
hemorrhage (uncontrolled bleeding) and, potentially, death. The larger the aneurysm becomes, the
greater the risk of rupture. In your case, your AAA measures 8 cm which is so large that the possibility of
rupture is very high, thats why surgery is necessary.
2. You are performing your initial assessment of T.A.s legs. What findings should you record?
Assess using the 6 Ps (Pain, Pallor, Pulselessness, Paresthesia, Poikilothermia, and Paralysis)
due to a possibility of an arterial occlusion in the lower extremities or nerve damage from the
application of an aortic clamp and surgery that requires frequent assessment.
Cramping pain in the calf and leg muscles; cool, pale skin noted, absent pedal pulses, pins-and-
needles sensation and weakness or inability to move lower limbs may indicate arterial occlusion
secondary to nerve damage.
3. Four hours after the admission to your floor, you note that T.A. has had a urinary output of 75
ml of dark amber urine. You examine the catheter and tubing for obstructions and there are
none. What other assessment data should you gather to determine whether problem exists?
An amber colored urine signifies a concentrated urine output. To further assess the function
of the kidneys, additional laboratory tests such as Renal concentration test (Specific gravity
and Osmolality), 24 hour urine test (Creatinine clearance), and Serum tests (Creatinine level,
Urea nitrogen and BUN to creatinine ratio) needs to be conducted.
Vital signs; Intake and ouput; urine specific gravity; assess/palpate bladder for distention; blood
and urine laboratory tests as prescribed: sodium, potassium, calcium, phosphate, magnesium, pH,
urinalysis (especially for protein and blood), urine electrolytes, creatinine clearance, BUN,
creatinine; daily weights; signs and symptoms of excess fluid volume: edema, neck vein distention,
hypertension, lung crackles upon auscultation and increased respiratory rate
4. Laboratory tests reveal renal damage. T.A. is placed on fluid restriction and a renal diet. T.A.
asks what is he going to eat on his diet. What is your reply?
What you eat has a major impact on the health of your kidneys. Protein, sodium, fluids, and certain
minerals are especially important.
When protein breaks down in your body, it forms waste products. When you have kidney
disease, the kidneys have trouble getting rid of waste products. Eating more protein than your
body can handle can make you very sick.
Sodium helps you keep the right balance of fluids in your body. When you have kidney disease,
your kidneys have trouble clearing extra sodium from your body. Eating too much sodium can
cause fluids to build up.
Healthy kidneys flush excess fluids from your body. When you have kidney disease, your kidneys
have trouble getting rid of extra fluids. The extra fluid can raise your blood pressure and force
your heart to work harder.
Healthy kidneys keep the right balance of minerals such as phosphorus and potassium in the
blood. When you have kidney disease, you may need to keep track of these minerals in your diet
so you don't get either too much or too little.
The following are general food guidelines for people who have kidney disease. Be sure to follow the diet
your doctor or dietitian gave you.
Protein
Eating too much protein can stress the kidneys. But if you don't get enough, you can become weak,
tired, and more likely to get infections. To get the right amount of protein:
Know how much protein you can have each day. Limit high-protein foods to 5 to 7 ounces a day,
or less, if your doctor or dietitian tells you to. A 3-ounce serving of protein is about the size of a
deck of cards.
Learn which foods contain protein. High-protein foods include meat, poultry, seafood, and eggs.
Milk and milk products, beans, nuts, breads, pastas, cereals, and vegetables also contain
protein.
Sodium
To limit sodium:
Don't add salt to your food. Avoid foods that list salt, sodium, or monosodium glutamate (MSG)
on the label. Buy foods that are labeled "no salt added," "sodium-free," or "low-sodium." Foods
labeled "reduced-sodium" and "light sodium" may still have too much sodium.
Avoid salted snacks such as pretzels, chips, and popcorn.
Avoid smoked, cured, salted, and canned meat, fish, and poultry. This includes ham, bacon, hot
dogs, and luncheon meats.
Don't use a salt substitute or lite salt unless your doctor or dietitian says it is okay. Most salt
substitutes and lite salts are high in potassium. Use lemon, herbs, and other spices to flavor your
meals.
Limit how often you eat food from restaurants. Most of the sodium we eat is hidden in
processed foods and restaurant food, especially at fast-food and take-out places.
Fluids
If you need to limit fluids:
Know how much fluid you can drink. Each day, fill a pitcher with that amount of water. If you
drink another fluid during the day, such as coffee, pour an equal amount of water out of the
pitcher. When the pitcher is empty, you're done drinking for the day.
Remember that soups and foods that are liquid at room temperature, such as gelatin dessert
(for example, Jell-O) and ice cream, count as fluids.
Be aware that some fruits and vegetables contain a lot of water and will count in your fluid
intake. Examples include grapes, oranges, apples, lettuce, and celery.
Count the liquid in canned fruits and vegetables as part of your daily intake, or drain them well
before serving.
Potassium
If you need to limit potassium:
Choose low-potassium fruits such as apples, blueberries, pears, plums, and tangerines. You can
also eat canned fruits, such as fruit cocktail, peaches, and pineapple.
Choose low-potassium vegetables such as asparagus, bean sprouts, cabbage, cucumber, green
beans, and lettuce.
Phosphorus
If you need to limit phosphorus:
Follow your food plan to know how much milk and milk products you can include.
Limit nuts, peanut butter, seeds, lentils, beans, organ meats, and sardines. Also limit cured
meats such as sausages, bologna, and hot dogs.
Avoid colas and soft drinks with phosphate or phosphoric acid.
Avoid bran breads and bran cereals.
General tips
Don't skip meals or go for many hours without eating. If you don't feel very hungry, try to eat 4
or 5 small meals instead of 1 or 2 big meals.
If you have trouble keeping your weight up, talk to your doctor or dietitian about ways you can
add calories to your diet. Healthy fats such as olive or canola oil may be good choices. Unless
you have diabetes, you can use honey and sugar to add calories and increase energy.
Don't take any vitamins or minerals, supplements, or herbal products without talking to your
doctor first.
Check with your doctor about whether it is safe for you to drink alcohol. If you do drink alcohol,
have no more than 1 drink a day. Count it as part of your fluids for the day.
5. T.A. has a dialysis inserted into his left subclavian vein. You are preparing to administer an IV
antibiotic and find that his only other IV access, a peripheral line, is obstructed. What should
you do?
First, I should check for mechanical obstruction: check for kinks in tubings, clamps, in - line filter.
Then check the catheter. If unable to flush with a 5cc or larger syringe, do not force it. Discontinue the
catheter. Then start a new IV line.
CASE STUDY PROGRESS
On return from his first dialysis, T.A. complains of (C/O) headache and nausea. He is restless
and slightly confused, and he has an elevated blood pressure (BP). You suspect disequilibrium
phenomenon. You notify the physician.
6. What measures can you institute at this point?
Disequilibrium syndrome may be due to the rapid decrease in BUN levels during dialysis. These
changes can cause cerebral edema that leads to increased intracranial pressure. The client is exhibiting
early signs of disequilibrium syndrome and appropriate treatments with anticonvulsant medications and
barbiturates may be necessary to prevent a life-threatening situation. The physician must be notified.
Continuous monitoring of the patients vital signs, weight, intake & output is necessary.
7. T.A. has an episode of vomiting. His abdominal wound dehisces, and a loop of his intestines
eviscerates. Another staff member has summoned the physician. What care should you render
before the physicians arrival?
Provide reassurance and support to ease the patient's anxiety. Tell him to stay in bed. If
possible, stay with him while someone else notifies the physician and collects the necessary
equipment.
Place a linen-saver pad under the patient to keep the sheets dry when you moisten the exposed
viscera.
Using sterile technique, unfold a sterile towel to create a sterile field. Open the package
containing the irrigation set, and place the basin, solution container, and 50-ml syringe on the
sterile field.
Open the bottle of normal saline solution and pour about 400 ml into the solution container.
Also pour about 200 ml into the sterile basin.
Open several large abdominal dressings, and place them on the sterile field.
Put on the sterile gloves, and place one or two of the large abdominal dressings into the basin to
saturate them with saline solution.
Place the moistened dressings over the exposed viscera. Then place a sterile, waterproof drape
over the dressings to prevent the sheets from getting wet.
Moisten the dressings every hour by withdrawing saline solution from the container through the
syringe and then gently squirting the solution on the dressings.
When you moisten the dressings, inspect the color of the viscera. If it appears dusky or black,
notify the physician immediately. With its blood supply interrupted, a protruding organ may
become ischemic and necrotic.
Keep the patient on absolute bed rest in low Fowler's position (no more than 20 degrees'
elevation) with his knees flexed. This prevents injury and reduces stress on an abdominal
incision.
Don't allow the patient to have anything by mouth to decrease the risk of aspiration during
surgery.
Monitor the patient's pulse, respirations, blood pressure, and temperature every 15 minutes to
detect shock.
If necessary, prepare the patient to return to the operating room. After gathering the
appropriate equipment, start an I.V. infusion, as ordered.

CASE STUDY PROGRESS
T.A. returns from the OR. You note that his blood glucose levels have ranged from 62 to 387
mg/dl over the last 7 days.
8. A sliding scale with regular insulin has been ordered. He comments, thats funny, you are
giving me about the same amount of insulin that I give myself at home. I dont understand
why its not working. How should you respond?
Due to massive inflammatory responses, your body was unable to compensate and regulate for the
increased demands which causes you to have uncontrolled high blood glucose levels.
9. T.A.s wound is not healing. Explain the relationship between his blood glucose readings and
wound healing.
There are several factors that influence wound healing in a diabetic patient, and may include:
Blood Glucose Levels
It all starts here. An elevated blood sugar level stiffens the arteries and causes narrowing of the blood
vessels. The effects of this are far-reaching and include the origin of wounds as well as risk factors to
proper wound healing.

Poor Circulation
Narrowed blood vessels lead to decreased blood flow and oxygen to a wound. An elevated blood sugar
level decreases the function of red blood cells that carry nutrients to the tissue. This lowers the
efficiency of the white blood cells that fight infection. Without sufficient nutrients and oxygen, a wound
heals slowly.
Diabetic Neuropathy
When blood glucose levels are uncontrolled, nerves in the body are affected and patients can develop a
loss of sensation. This is called diabetic neuropathy. When there is a loss of sensation, patients cannot
feel a developing blister, infection or surgical wound problem. Because a diabetic patient may not be
able to feel a change in the status of a wound or the actual wound, the severity can progress and there
may be complications with healing.
Immune System Deficiency
Diabetes lowers the efficiency of the immune system, the body's defense system against infection. A
high glucose level causes the immune cells to function ineffectively, which raises the risk of infection for
the patient. Studies indicate that particular enzymes and hormones that the body produces in response
to an elevated blood sugar are responsible for negatively impacting the immune system.
Infection
With a poorly functioning immune system, diabetics are at a higher risk for developing an infection.
Infection raises many health concerns and also slows the overall healing process.
Left untreated, infection can heighten the risk of developing gangrene, sepsis or a bone infection like
osteomyelitis.