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Difficulty: Very hardEstablishing Priorities

A 77-year-old client weighing 2525 kg (5555 lb) is hospitalized for induction chemotherapy to treat acute lymphoblastic leukemia. The first infusion was completed 4848 hours ago. The nurse reviews the morning assessment data and laboratory results. Which of the following findings demand immediate clinical intervention? Select all that apply.

  1. Serum uric acid level of 11.811.8 mg/dL (0.700.70 mmol/L)Answer
  2. Client reports a tingling, "pins and needles" sensation around the lipsAnswer
  3. Total urine output of 105105 mL over the previous 88-hour shiftAnswer
  4. D
    Current platelet count of 88,00088,000/mm³ (88×10988 \times 10^9/L)
  5. E
    Two episodes of non-bloody emesis during the night

Answer

The findings requiring immediate clinical intervention are the severely elevated serum uric acid level, the tingling sensation around the lips, and the oliguric urine output of 105 mL over 8 hours.
The client is experiencing Tumor Lysis Syndrome (TLS), a life-threatening oncologic emergency characterized by massive cell destruction that releases intracellular contents into the blood. This results in hyperuricemia, hyperkalemia, hyperphosphatemia, and secondary hypocalcemia (indicated by perioral tingling). The precipitation of uric acid and calcium phosphate in the kidneys leads to acute kidney injury, manifested by the severe oliguria (0.52 mL/kg/hr). These three findings require immediate, aggressive intervention to prevent seizures, cardiac arrest, and permanent renal failure.

Step-by-Step Solution

1
Analyze the client's clinical context.
The client is a pediatric patient receiving induction chemotherapy for leukemia, placing them at extremely high risk for Tumor Lysis Syndrome (TLS) roughly 48 to 72 hours after initiation.
Understanding the timeline of oncologic emergencies is crucial for differentiating expected side effects from life-threatening complications.
2
Evaluate the laboratory values and physical symptoms against TLS pathophysiology.
The uric acid level of 11.8 mg/dL indicates severe hyperuricemia. The perioral tingling is a classic sign of hypocalcemia (caused by hyperphosphatemia in TLS). Both are critical emergencies.
Rapid cell lysis releases potassium, phosphorus, and nucleic acids (which convert to uric acid) into the blood, leading to a triad of metabolic derangements.
3
Calculate the client's weight-based urine output to assess renal function.
105 mL divided by 8 hours equals 13.1 mL/hr. Divided by 25 kg, this yields approximately 0.52 mL/kg/hr. Because normal pediatric urine output is at least 1 mL/kg/hr, this indicates acute oliguria.
Uric acid and calcium phosphate crystals can precipitate in the renal tubules during TLS, causing acute kidney injury.
4
Differentiate critical findings from expected adverse effects.
The platelet count of 88,000/mm³ and non-bloody emesis are expected consequences of leukemia and chemotherapy. While requiring monitoring and routine care, they are not immediate, life-threatening priorities compared to TLS and acute kidney injury.
Prioritization requires identifying which findings pose an immediate threat to life, airway, breathing, or circulation.

Key Concept

Prioritizing oncologic emergencies and recognizing Tumor Lysis Syndrome (TLS) complications.
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Establishing Priorities

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