Nursing Care Plan for Acute Kidney Injury

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Outline

Pathophysiology

Acute kidney injury, also known as acute renal failure,  is when the kidneys stop working over the period of a few hours or a few days. People at risk for AKI are those who have high blood pressure, a chronic illness such as heart or liver disease or diabetes, or those who have peripheral artery disease. AKI requires immediate treatment but is usually reversible if treated quickly.

Etiology

Acute kidney injury is a result of direct kidney damage, decreased blood flow or blockage of the urinary tract. Direct damage may be a result of sudden trauma to the kidneys, sepsis, scleroderma or allergic reaction. Other, more common, causes include a blockage in the ureters such as kidney stones, blood clots, enlarged prostate or multiple myeloma. Hypotension, severe diarrhea, infection, overuse of NSAIDs, dehydration or severe burns may cause decreased blood flow.

Desired Outcome

Restore kidney function to optimal state, patient will maintain hydration and be free from infection or chronic kidney damage.

Acute Kidney Injury Nursing Care Plan

Subjective Data:

  • Feeling tired
  • Feeling confused
  • Nausea
  • Pain or pressure in the chest
  • Shortness of breath

Objective Data:

  • Dependent edema
  • Periorbital edema
  • Seizures
  • Tachycardia with hypertension
  • Decreased urine output
  • Electrolyte abnormalities
    • ↑ Potassium
    • ↓ Sodium
    • ↑ Phosphate
    • ↓ Calcium
  • ↑ BUN/Creatinine
  • ↓ GFR

Nursing Interventions and Rationales

  • Monitor vitals
    • Heart rate
    • Blood pressure

 

Tachycardia and hypertension may occur because of the kidneys’ inability to excrete urine

 

  • Perform 12 lead EKG

 

To assess for arrhythmias

 

  • Asses heart and lung sounds for adventitious breath sounds or extra heart sounds

 

Fluid overload may lead to pulmonary edema and heart failure and may be manifested by shortness of breath and chest pain

 

  • Monitor mentation and changes in level of consciousness

 

Changes in LOC may indicate fluid shifts and electrolyte imbalance

 

  • Assess dependent and periorbital edema

 

Evaluate and report degree of edema (+1 – +4)

There may be a gain of up to 10lbs of fluid before pitting is noticed

 

  • Monitor diagnostic studies
    • Radiology: Chest x-ray, ultrasound or CT of kidneys
    • Lab: urine, blood

 

  • Chest x-ray may show increase in cardiac size, pleural effusion or pericardial congestion due to fluid overload
  • Urinalysis- urine creatinine usually decreases as serum creatinine increases
  • Serum- BUN, creatinine – monitor ratio, if >10:1, dialysis may be indicated
  • Sodium– may indicate hyponatremia (fluid overload) or hypernatremia (total body fluid deficit)
  • Potassium– elevation indicates kidney disease from lack of excretion or selective retention and leads to hyperkalemia

 

  • Insert indwelling urinary catheter unless contraindicated for infection

 

Indwelling catheter will provide for more accurate measurement of urine output

 

  • Monitor I & O for fluid retention

 

  • Measure for decreased output <400 mL/24 hr period may be evident by dependent edema
  • Daily weights at the same time on the same scale each day, >0.5kg/day is indicative of fluid retention
  • Note changes in characteristics of urine to include odor, blood, mucus or sediment present

 

  • Administer medications as ordered

 

  • IV Fluids- may be given for lack of fluid volume, but may be withheld in cases of fluid overload
  • Diuretics- furosemide, mannitol may be given to flush kidneys of debris and reduce fluid overload, reducing hyperkalemia
  • Calcium channel blockers-given early can help reduce influx of calcium in kidney cells to maintain cell integrity – if calcium level is too low, calcium may be infused
  • Antihypertensives- clonidine, methyldopa may be given to counteract the effects of decreased renal blood flow
  • Cation-exchange resins- sodium polystyrene sulfonate (Kayexalate) help reduce levels of potassium and treat hyperkalemia

 

  • Nutrition management and education

 

  • Limit intake of excess fluids
  • Limit sodium intake – avoid adding salt to foods and limit processed or canned foods that contain hidden sodium
  • Increase fresh fruits and vegetables
  • Limit foods high in potassium such as beans, rice, bananas, oranges, potatoes and tomatoes
  • Limit intake of whole grain breads, bran cereals, nuts and sunflower seeds due to their high phosphorus content
  • Refer patient to dietitian if further counseling is required

 

  • Prepare patient for dialysis if indicated
    • Peritoneal
    • Hemodialysis
    • Continuous Renal Replacement Therapy

 

  • Elevate the head of the bed to reduce pressure on the diaphragm and aid in respiration
  • Monitor for signs and symptoms of clot or infection at shunt site
  • Assess for thrill/bruit of shunt for patency

 


References

Transcript

Hey guys, let’s take a look at the care plan for acute kidney injury. So in this lesson, we’ll briefly take a look at the pathophysiology and etiology of acute kidney injury, also subjective and objective data, as well as the nursing interventions and rationales. 

 

Okay. So acute kidney injury or AKI also known as acute renal failure is when the kidneys stop working over a period of a few hours or days. People at risk for AKI are those who have high blood pressure, a chronic illness, such as heart or liver disease, or diabetes, or those who have peripheral artery disease. AKI requires immediate treatment, but is usually reversible if treated quickly. It’s a result of direct kidney damage, decreased blood flow or blockage of the urinary tract. Direct damage may be a result of sudden trauma to the kidneys, sepsis scleroderma, or an allergic reaction. 

 

More common causes include a blockage in the ureters, such as kidney stones, blood clots, enlarged prostate or multiple myeloma. Hypotension, severe diarrhea infection, overuse of NSAIDS, dehydration, or severe burns may cause decreased blood flow. So, the desired outcome for these patients is to restore kidney function to an optimal state with the patient maintaining hydration and being free from infection or chronic kidney damage. 

 

Okay, so let’s take a look at some of the subjective and objective data that your patient with acute kidney injury may present with. 

 

Now remember subjective data, these are going to be things that are based on your patient’s opinions or feelings like feeling tired, confused, being nauseous, having pain or pressure in the chest and shortness of breath. 

 

Objective or measurable data includes dependent edema, periorbital edema, seizures, tachycardia with hypertension, decreased urine output, electrolyte imbalances; including increased potassium, decreased sodium, increased phosphate and decreased calcium. Your patient may also present with increased bun, creatinine and decreased GFR. 

 

Let’s take a look at the nursing interventions included in the acute kidney injury care plan:

Monitor heart rate and blood pressure in your patient as tachycardia and hypertension may occur because of the kidneys inability to excrete urine. Perform a 12 lead EKG to assess for arrhythmias, assess heart and lung sounds for adventitious breath sounds or extra heart sounds. Fluid overload may lead to pulmonary edema and heart failure, which may be manifested by shortness of breath and chest pain. Be sure to monitor mentation and changes in the level of consciousness,  as these changes may indicate fluid shifts and electrolyte  imbalances. Assess dependent and periorbital edema. Evaluate and report the degree of edema between plus one and plus four. There may be a fluid gain of up to 10 pounds before pitting is noticed. It may be necessary to insert a catheter, unless it contra-indicated for infection. 

 

An indwelling catheter will provide a more accurate measure of urine output. Monitor intake and output for fluid retention. Measure for decreased output, less than 400 ML’s per 24 hour period, which may be evidenced by dependent edema. Perform daily weights at the same time on the same scale each day. Greater than a 0.5 kilo per day weight gain is indicative of fluid retention. 

 

Note changes in characteristics of the urine, including odor ,blood, mucus, or sediment. Diagnostic studies must be monitored, including chest x-rays ultrasound, CT of the kidneys. Chest x-ray may show an increase in cardiac size, pleural effusion, or pericardial congestion due to fluid overload. 

 

With your analysis, urine creatinine usually decreases as serum creatinine increases. Monitor BUN and if creatinine ratio is greater than 10 to one, dialysis may be indicated. Monitor sodium levels. Hyponatremia can indicate fluid overload as hypernatremia can indicate total body fluid deficit. Potassium elevation indicates kidney disease from lack of excretion or selective retention, and leads to hyperkalemia.

 

Okay. As far as medications are concerned, IV fluids may be given for lack of fluid volume, but maybe, withheld include cases of fluid overload. Diuretics like furosemide and mannitol may be given to flush the kidneys of debris and reduce fluid overload reducing hyperkalemia. Calcium channel blockers, If given early, can help reduce the influx of calcium and kidney cells to maintain cell integrity. If calcium level is too low, calcium may be infused. Anti-hypertensives like clonidine and methyldopa may be given to counteract the effects of decreased renal blood flow.  Sodium polystyrene sulfonate or kayexalate help reduce the levels of potassium and treat hyperkalemia. 

 

Nutrition management is extremely important for a patient with acute kidney injury. Limit the intake of excess fluids and limit sodium intake by avoiding salts and limiting processed or canned foods. Increase fresh foods and vegetables. Limit foods that are high in potassium like beans, bananas, oranges, potatoes, and tomatoes. Limit the intake of whole grain breads, brand cereals, nuts and sunflower seeds due to their high phosphorus content. Refer the patient to a dietician if further counseling is required. Finally, it may be necessary for the patient to receive dialysis, either peritoneal, hemodialysis, or continuous renal replacement therapy. In these instances, elevate the head of the bed to reduce pressure on the diaphragm and aid in respiration. Monitor for signs and symptoms of clot or infection at the shunt site and assess for a thrill or bruit of shunt for patency. 

 

Okay, guys, here is a look at the completed care plan for acute kidney injury. We love you guys.  Go out and be your best self today and as always, happy nursing.