Acute Kidney Injury (AKI), formerly known as Acute Renal Failure (ARF), is a critical condition characterized by the sudden loss of kidney function. This rapid deterioration occurs within hours to days, leading to the accumulation of waste products in the blood. AKI is particularly prevalent among critically ill patients and can have severe consequences if not promptly addressed.
Understanding Acute Kidney Injury
AKI affects multiple organ systems and can be life-threatening if left untreated. Common signs and symptoms include:
- Oliguria (decreased urine output)
- Fluid retention and edema
- Dyspnea (shortness of breath)
- Confusion
- Fatigue
- Nausea
- Weakness
- In severe cases, seizures and coma
Risk Factors and Causes
Several factors increase the risk of developing AKI:
- Advanced age
- Current hospitalization
- Chronic conditions such as diabetes, hypertension, heart failure, and liver disease
The causes of AKI can be categorized into three main groups:
- Impaired blood flow to the kidneys:
- Blood loss
- Severe dehydration
- Liver failure
- Myocardial infarction
- Certain blood pressure medications
- Direct kidney damage:
- Blood clots
- Glomerulonephritis
- Lupus
- Certain medications (e.g., chemotherapy drugs or IV contrast)
- Alcohol or drug abuse
- Rhabdomyolysis
- Urinary tract obstruction:
- Cancers of the bladder, cervix, colon, or prostate
- Kidney stones
- Nerve damage affecting bladder function
The diagnosis of AKI typically involves a combination of blood tests, urinalysis, imaging studies (ultrasound or CT scans), and, in some cases, kidney biopsy.
The Nursing Process in Acute Kidney Injury
Nurses play a crucial role in the care of patients with AKI. The nursing process involves:
- Assessment and Monitoring: Carefully observe and document changes in the patient’s condition, as subtle alterations can indicate disease progression or the development of complications.
- Treatment Administration: Administer prescribed medications such as diuretics, potassium-lowering drugs, and calcium supplements. In severe cases, nurses may be involved in the care of patients before, during, and after dialysis treatments.
- Patient Education: Addressing knowledge deficits of patients and family members regarding AKI’s causes, prevention, and management.
Nursing Care Plans for Acute Kidney Injury
Nursing care plans are essential for prioritizing assessments and interventions in short-term and long-term care goals for patients with AKI. Here are five comprehensive nursing care plans for managing Acute Kidney Injury:
Nursing Care Plan 1. Decreased Cardiac Output
Nursing Diagnosis: Decreased Cardiac Output related to fluid overload, fluid shifts, and electrolyte imbalances, as evidenced by dysrhythmias, jugular vein distention, dyspnea, and decreased peripheral pulses.
Related Factors/Causes:
- Fluid overload
- Electrolyte imbalances (mainly potassium and calcium)
- Myocardial dysfunction due to uremic toxins
Nursing Interventions and Rationales:
- Assess and monitor vital signs, particularly heart rate and blood pressure, every 2-4 hours or as indicated.
Rationale: Excess fluid volume and hypertension can increase cardiac workload, potentially leading to heart failure. - Auscultate heart and lung sounds every 4-6 hours.
Rationale: The onset of S3 or S4 heart sounds or crackles in the lungs may indicate developing heart failure or pulmonary edema. - Monitor EKG continuously and document any changes.
Rationale: Electrolyte imbalances, particularly in potassium and calcium levels, can lead to dangerous arrhythmias. - Administer oxygen therapy as prescribed and monitor oxygen saturation.
Rationale: Ensuring adequate oxygenation supports cardiac function and tissue perfusion. - Encourage frequent rest periods and group care activities to minimize exertion.
Rationale: Rest reduces cardiac workload and oxygen demand. - Administer medications as prescribed (inotropes, antiarrhythmics) and monitor for side effects.
Rationale: These medications can improve cardiac output but require careful monitoring to prevent adverse effects on renal function.
Desired Outcomes:
- The patient will maintain stable vital signs within normal limits for their condition.
- The patient will demonstrate improved cardiac output, as evidenced by adequate urine output (>0.5 mL/kg/hr) and the absence of symptoms of heart failure.
- The patient will report improved exercise tolerance and ability to perform ADLs without dyspnea.
Nursing Care Plan 2. Fluid Volume Excess
Nursing Diagnosis: Fluid Volume Excess related to impaired renal regulatory mechanisms, as evidenced by edema, weight gain, and respiratory difficulties.
Related Factors/Causes:
- Decreased glomerular filtration rate
- Sodium and water retention
- Impaired hormonal regulatory mechanisms (e.g., renin-angiotensin-aldosterone system)
Nursing Interventions and Rationales:
- Accurately measure and record intake and output every 2-4 hours.
Rationale: Close monitoring of fluid balance helps in the early detection of fluid overload and guides treatment decisions. - Weigh the patient daily at the same time and using the same scale.
Rationale: Sudden weight gain (>0.5 kg/day) can indicate fluid retention. - Assess for peripheral and sacral edema, and measure abdominal girth daily if ascites is present.
Rationale: These assessments help quantify fluid retention and track its progression or resolution. - Monitor respiratory rate, effort, and lung sounds every 4 hours.
Rationale: Fluid overload can lead to pulmonary edema, manifesting as increased respiratory rate, effort, and crackles in the lungs. - Elevate the head of the bed 30-45 degrees unless contraindicated.
Rationale: This position helps reduce pulmonary congestion and improves breathing. - Administer diuretics as prescribed and monitor response.
Rationale: Diuretics can help reduce fluid overload but require careful monitoring of urine output and electrolyte levels. - Implement fluid restrictions as ordered by the physician.
Rationale: Limiting fluid intake helps prevent further fluid accumulation.
Desired Outcomes:
- The patient will demonstrate balanced fluid volume as evidenced by stable weight, resolved edema, and normalized respiratory function.
- The patient will maintain urine output within the normal range (0.5-1 mL/kg/hr) without the use of diuretics.
- The patient will verbalize understanding of fluid restrictions and demonstrate compliance with the prescribed regimen.
Nursing Care Plan 3. Risk for Electrolyte Imbalance
Nursing Diagnosis: Risk for Electrolyte Imbalance related to impaired renal regulatory function and potential side effects of treatment.
Related Factors/Causes:
- Compromised kidney function
- Effects of medications (e.g., diuretics, ACE inhibitors)
- Acid-base imbalances
- Altered nutritional intake
Nursing Interventions and Rationales:
- Monitor serum electrolyte levels (potassium, sodium, calcium, and phosphate) as ordered.
Rationale: Early detection of electrolyte imbalances allows for prompt intervention. - Assess for signs and symptoms of electrolyte imbalances every 4 hours:
- Potassium: muscle weakness, cardiac arrhythmias
- Sodium: confusion, seizures
- Calcium: muscle cramps, tetany
- Phosphate: bone pain, pruritus
Rationale: These clinical manifestations can indicate severe electrolyte disturbances requiring immediate attention.
- Administer electrolyte replacement or binding agents as prescribed.
Rationale: Correcting electrolyte imbalances is crucial for maintaining cellular function and preventing complications. - Monitor EKG for changes indicating electrolyte imbalances (e.g., peaked T waves in hyperkalemia).
Rationale: EKG changes can be early indicators of life-threatening electrolyte disturbances, particularly hyperkalemia. - Provide dietary education regarding foods high in potassium, phosphorus, and sodium.
Rationale: Dietary management is crucial in preventing electrolyte imbalances in AKI patients. - Ensure proper administration of medications that affect electrolyte balance.
Rationale: Certain medications can significantly impact electrolyte levels and require careful monitoring.
Desired Outcomes:
- The patient will maintain serum electrolyte levels within normal ranges.
- The patient will remain free from signs and symptoms of electrolyte imbalances.
- The patient will demonstrate an understanding of dietary restrictions related to electrolyte management.
Nursing Care Plan 4. Acute Pain
Nursing Diagnosis: Acute Pain related to inflammation, edema, and potential complications of AKI, as evidenced by verbal reports of pain, guarding behavior, and changes in vital signs.
Related Factors/Causes:
- Kidney inflammation and swelling
- Uremic neuropathy
- Potential kidney stones or urinary tract obstruction
- Edema causing tissue stretching
Nursing Interventions and Rationales:
- Assess pain characteristics (location, intensity, quality, aggravating/relieving factors) using a standardized pain scale every 4 hours and as needed.
Rationale: Systematic pain assessment guides appropriate pain management strategies. - Administer prescribed pain medications, considering renal clearance and potential side effects.
Rationale: Proper pain management improves patient comfort and may prevent complications, but medication choice must account for impaired renal function. - Apply non-pharmacological pain relief methods such as repositioning, heat or cold therapy (as appropriate), and relaxation techniques.
Rationale: These methods can complement pharmacological interventions and reduce reliance on medications. - Monitor vital signs before and after pain medication administration.
Rationale: Changes in vital signs can indicate pain relief or potential adverse effects of pain medications. - Assess for signs of uremic neuropathy or other AKI-related complications that may cause pain.
Rationale: Early identification of complications allows for prompt treatment and pain relief. - Provide patient education on pain management strategies and the importance of reporting pain.
Rationale: Empowering patients in pain management improves overall pain control and patient satisfaction.
Desired Outcomes:
- The patient will report pain levels at 3 or less on a 0-10 scale.
- The patient will demonstrate the use of non-pharmacological pain relief methods.
- The patient will verbalize understanding of the pain management plan and report satisfaction with pain control.
Nursing Care Plan 5. Risk for Impaired Skin Integrity
Nursing Diagnosis: Risk for Impaired Skin Integrity related to edema, altered perfusion, and potential immobility.
Related Factors/Causes:
- Fluid retention leading to edema
- Altered peripheral circulation
- Potential for prolonged bed rest or immobility
- Uremic toxins affecting skin condition
- Potential malnutrition or altered nutritional status
Nursing Interventions and Rationales:
- Assess skin integrity every shift, paying particular attention to edematous areas and pressure points.
Rationale: Early detection of skin breakdown allows for prompt intervention. - Implement a regular turning schedule (every 2 hours when in bed) and encourage position changes when sitting.
Rationale: Frequent position changes reduce pressure on vulnerable areas and improve circulation. - Use pressure-relieving devices such as specialized mattresses, heel protectors, and cushions.
Rationale: These devices help distribute pressure and reduce the risk of pressure injuries. - Keep skin clean and dry by using pH-balanced skin cleansers and applying moisture barrier creams to areas at risk of moisture-associated skin damage.
Rationale: Proper skin care helps maintain skin integrity and prevent breakdown. - Elevate edematous extremities when in bed or sitting unless contraindicated.
Rationale: Elevation helps reduce edema and improve circulation, reducing the risk of skin breakdown. - Encourage mobility and perform passive range of motion exercises for bedbound patients.
Rationale: Movement improves circulation and reduces the risk of pressure injuries and contractures. - Optimize nutrition and hydration status in consultation with a dietitian.
Rationale: Proper nutrition supports skin health and wound healing.
Desired Outcomes:
- The patient will maintain intact skin throughout hospitalization.
- The patient will demonstrate an understanding of skin care principles and participate in prevention strategies as able.
- If wounds are present, they will show signs of healing without complications.
Conclusion
Acute Kidney Injury presents significant challenges in patient care, requiring vigilant monitoring, prompt interventions, and comprehensive nursing care. By implementing these nursing care plans, healthcare providers can effectively manage the complex needs of patients with AKI, potentially improving outcomes and quality of life. Remember that each patient is unique, and care plans should be individualized based on specific patient needs and responses to treatment.
References
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- Pickering, J. W., & Endre, Z. H. (2014). The definition and detection of acute kidney injury. Journal of renal injury prevention, 3(1), 21-25.
- Schetz, M., & De Jong, A. (2017). Fluid Management in Acute Kidney Injury. Contributions to nephrology, 190, 66-76.
- Rosner, M. H., & Ronco, C. (2014). Dysnatremias in the intensive care unit. Contributions to nephrology, 182, 81-91.
- Kane-Gill, S. L., Sileanu, F. E., Murugan, R., Trietley, G. S., Handler, S. M., & Kellum, J. A. (2015). Risk factors for acute kidney injury in older adults with critical illness: a retrospective cohort study. American journal of kidney diseases, 65(6), 860-869.
- Doyle, J. F., & Forni, L. G. (2016). Acute kidney injury: short-term and long-term effects. Critical Care, 20(1), 188.
