- Increase awareness and knowledge about the causes and risk factors of Acute Kidney Injury (AKI), emphasizing the importance of early recognition and preventive measures.
- Educate healthcare professionals on the signs and symptoms of AKI, enabling prompt identification and intervention to mitigate the progression of kidney dysfunction.
- Provide strategies for managing complications associated with AKI, including electrolyte imbalances, fluid overload, and metabolic disturbances, to optimize patient outcomes.
- Foster an understanding of preventive measures to reduce the risk of AKI, emphasizing the importance of hydration, medication management, and monitoring for individuals at risk.
- Encourage practices that promote renal health, such as maintaining adequate hydration, avoiding nephrotoxic substances, and seeking medical attention promptly for conditions that may impact kidney function.
Definition of Acute Kidney Injury
Acute Kidney Injury (AKI), formerly known as acute renal failure, is a sudden and rapid loss of kidney function over a relatively short period. AKI occurs when the kidneys are unable to filter waste products and excess fluids from the blood effectively. This condition can lead to a buildup of toxins and electrolyte imbalances in the body, which can have serious and potentially life-threatening consequences if not treated promptly.
Acute Kidney Injury (AKI) is typically classified into three stages based on the severity of kidney damage:
- Stage 1 (Mild AKI): This stage involves a slight increase in serum creatinine levels and a decrease in urine output. Kidney function may still be partially preserved.
- Stage 2 (Moderate AKI): In this stage, there is a more significant increase in serum creatinine levels and a further decrease in urine output. Kidney function is moderately impaired.
- Stage 3 (Severe AKI): This is the most severe stage of AKI, characterized by a substantial increase in serum creatinine levels and a significant decrease in urine output. Kidney function is severely compromised, and this stage often requires urgent medical intervention, including dialysis, to support kidney function and remove waste products from the body.
What is the Most Common Cause of Acute Kidney Injury
The most common cause of acute kidney injury (AKI) is often related to issues with the kidney’s blood supply, either due to decreased blood flow (prerenal causes) or direct damage to the kidney tissue (intrinsic renal causes). Prerenal causes, which result in reduced blood flow to the kidneys, are typically more common than intrinsic renal causes.
- Hypovolemia (Dehydration): This is one of the leading causes of prerenal AKI. It occurs when the body loses significant amounts of fluids due to conditions like severe diarrhea, vomiting, excessive sweating, or inadequate fluid intake.
- Hypotension (Low Blood Pressure): A sudden drop in blood pressure can lead to decreased blood flow to the kidneys, causing AKI. Conditions like sepsis, shock, or severe bleeding can result in hypotension.
- Medications: Certain medications, particularly nonsteroidal anti-inflammatory drugs (NSAIDs), some antibiotics, and contrast agents used in medical imaging, can be nephrotoxic (toxic to the kidneys) and cause AKI.
- Infections: Serious infections, such as sepsis, can lead to AKI due to widespread inflammation and reduced blood flow to the kidneys.
- Kidney Obstruction: Blockages in the urinary tract, such as kidney stones, blood clots, or an enlarged prostate, can prevent urine from draining properly, causing pressure and damage to the kidneys.
- Direct Kidney Damage: Conditions that directly damage kidney tissue, such as glomerulonephritis, acute interstitial nephritis, and certain autoimmune diseases, can lead to intrinsic renal AKI.
- Trauma: Severe physical injuries, accidents, or surgeries can sometimes lead to AKI due to reduced blood flow or direct kidney damage.
- Contrast-Induced Nephropathy (CIN): AKI can occur after the administration of contrast agents during imaging procedures like CT scans or angiography, particularly in individuals with preexisting kidney problems.
- Rhabdomyolysis: This condition results from the breakdown of muscle tissue, releasing toxic byproducts into the bloodstream that can damage the kidneys. It can be caused by trauma, muscle injury, or certain medications.
Pathophysiology of Acute Kidney Injury (AKI):
- Renal Blood Flow Disruption:
- AKI often begins with a disruption in renal blood flow, leading to decreased perfusion of the kidneys. Causes may include hypotension, severe dehydration, or conditions affecting blood vessels supplying the kidneys.
- Reduced blood flow can result in ischemic injury to the renal tubules. Additionally, exposure to nephrotoxic substances, such as certain medications or contrast agents, can contribute to tubular damage.
- The ischemic or toxic insult triggers an inflammatory response, causing cellular injury and dysfunction. Inflammatory mediators contribute to further damage within the renal tissue.
- The combination of reduced blood flow and tubular injury leads to a decline in Glomerular Filtration Rate (GFR), impairing the kidney’s ability to filter and excrete waste products and maintain fluid and electrolyte balance.
- As AKI progresses, the kidneys struggle to regulate fluid and electrolyte balance. Accumulation of waste products, retention of fluid, and disturbances in electrolyte levels (such as elevated potassium) can occur, contributing to systemic complications.
Etiology of Acute Kidney Injury (AKI):
- Hypovolemia and Hypotension:
- Inadequate blood volume (hypovolemia) or low blood pressure (hypotension) can diminish renal perfusion, leading to AKI. Conditions such as severe dehydration, hemorrhage, or shock contribute to these issues.
- Certain medications, particularly those with nephrotoxic properties, can damage renal structures, leading to AKI. Examples include nonsteroidal anti-inflammatory drugs (NSAIDs), certain antibiotics, and contrast agents used in imaging procedures.
- Systemic infections and severe cases of sepsis can trigger inflammatory responses that affect the kidneys, leading to AKI. Infections affecting the urinary tract or systemic bloodstream infections pose a risk.
- Blockages or obstructions in the urinary tract, such as kidney stones or enlarged prostate, can impede normal urine flow and lead to AKI.
- Autoimmune conditions like lupus or vasculitis can cause inflammation and damage to renal tissues, contributing to the development of AKI.
Desired Outcomes for Acute Kidney Injury (AKI) Nursing Care:
- Renal Function Restoration:
- Restore and optimize renal function to achieve an improvement in Glomerular Filtration Rate (GFR), ensuring effective filtration and excretion of waste products.
- Attain and maintain a balanced fluid and electrolyte status, preventing imbalances and complications associated with fluid overload or electrolyte disturbances.
- Alleviate and manage symptoms associated with AKI, such as edema, hypertension, and electrolyte abnormalities, contributing to improved patient comfort and well-being.
- Prevent or mitigate complications related to AKI, including uremia, acid-base imbalances, and cardiovascular complications, promoting overall health and reducing the risk of long-term sequelae.
- Educate the patient on kidney health, preventive measures, and self-management strategies to empower them in maintaining renal function, recognizing warning signs, and participating actively in their care.
Acute Kidney Injury Nursing Care Plan
Subjective Data for Acute Kidney Injury:
- Feeling tired
- Feeling confused
- Nausea
- Pain or pressure in the chest
- Shortness of breath
Objective Data for Acute Kidney Injury:
- Dependent edema
- Periorbital edema
- Seizures
- Tachycardia with hypertension
- Decreased urine output
- Electrolyte abnormalities
- ↑ Potassium
- ↓ Sodium
- ↑ Phosphate
- ↓ Calcium
Nursing Assessment for Acute Kidney Injury (AKI):
- Health History:
- Obtain a comprehensive health history, including information on pre-existing renal conditions, recent illnesses, medication history (especially nephrotoxic drugs), and any known risk factors for AKI.
- Monitor fluid balance by assessing intake and output, changes in body weight, and signs of fluid overload or dehydration. Document urine characteristics, including color, clarity, and volume.
- Regularly assess vital signs, particularly blood pressure, heart rate, and respiratory rate, to identify signs of hypotension or other systemic issues affecting renal perfusion.
- Review laboratory results, including serum creatinine, blood urea nitrogen (BUN), electrolytes (potassium, sodium), and arterial blood gases to evaluate renal function and identify imbalances.
- Perform a thorough analysis of urine, looking for abnormalities such as proteinuria, hematuria, and changes in specific gravity. Collecting a 24-hour urine sample may be necessary for more detailed assessment.
- Evaluate the patient’s current medications, paying special attention to nephrotoxic drugs. Collaborate with healthcare providers to adjust medications or dosages as needed.
- Assess for signs and symptoms of AKI, including edema, changes in mental status, nausea, vomiting, and diminished urine output. Monitor for complications such as metabolic acidosis or hyperkalemia.
- Collaborate with specialized teams, such as nephrology and infectious disease, for a comprehensive assessment and management of underlying conditions contributing to AKI.
Outcomes for Acute Kidney Injury (AKI) Nursing Care:
- Renal Function Improvement:
- Achieve an improvement in renal function, as evidenced by a decrease in serum creatinine levels and normalization of urine output, indicating effective management and resolution of AKI.
- Restore and maintain a balanced fluid and electrolyte status, preventing imbalances and complications associated with fluid overload or electrolyte disturbances.
- Alleviate and manage symptoms associated with AKI, such as edema, hypertension, and electrolyte abnormalities, contributing to improved patient comfort and well-being.
- Prevent or mitigate complications related to AKI, including uremia, acid-base imbalances, and cardiovascular complications, promoting overall health and reducing the risk of long-term sequelae.
- Educate the patient on kidney health, preventive measures, and self-management strategies to empower them in maintaining renal function, recognizing warning signs, and participating actively in their care.
Nursing Interventions and Rationales for Acute Kidney Injury
Monitor for complications of AKI
- Cardiac and respiratory complications may occur; perform routine assessments of vital signs, heart and lung sounds, and cardiac rhythm
- Collaborate with ancillary departments for ordered diagnostic testing such as x-rays
Assess Dependent and Periorbital Edema:
Rationale: Evaluating the degree of edema (graded from +1 to +4) helps gauge the extent of fluid retention, as significant weight gain may occur before pitting edema becomes noticeable.
Educate patient to elevate legs throughout the day and not wear constricting clothes or footwear
Insert Indwelling Urinary Catheter Unless Contraindicated for Infection:
Rationale: An indwelling catheter provides accurate measurement of urine output, which is crucial in assessing kidney function and fluid balance.
Monitor fluid balance each shift
Rationale: Monitoring for decreased urine output (less than 400 mL/24 hr) and daily weights can help detect fluid retention, a common complication in AKI.
Administer Medications as Ordered:
- IV Fluids (may be given for lack of fluid volume or withheld in cases of fluid overload)
- Diuretics (e.g., furosemide, mannitol, to flush kidneys of debris and reduce fluid overload)
- Calcium channel blockers (early administration to maintain cell integrity)
- Antihypertensives (e.g., clonidine, methyldopa, to counteract decreased renal blood flow)
- Cation-exchange resins (e.g., sodium polystyrene sulfonate, to treat hyperkalemia)
Rationale: Medications play a pivotal role in managing fluid balance and addressing underlying complications in AKI.
Nutrition Management and Education:
- Limit excess fluid intake
- Restrict sodium intake
- Increase consumption of fresh fruits and vegetables
- Limit foods high in potassium and phosphorus
- Refer to a dietitian for further counseling if needed
Rationale: Proper nutrition management is crucial in preventing exacerbation of AKI and supporting overall health.
Prepare Patient for Dialysis if Indicated:
- Peritoneal
- Hemodialysis
- Continuous Renal Replacement Therapy
Rationale: Dialysis is a critical intervention for patients with severe AKI to remove waste products and excess fluids when kidney function is compromised.
Elevate the Head of the Bed to Reduce Pressure on the Diaphragm and Aid in Respiration:
Rationale: Proper positioning can alleviate respiratory distress, particularly in patients with pulmonary complications.
Monitor for Signs and Symptoms of Clot or Infection at Shunt Site:
Assess for thrill/bruit of shunt for patency
Rationale: Patients undergoing dialysis are at risk of shunt-related complications, and early detection is essential for timely intervention
Evaluation for Acute Kidney Injury (AKI) Nursing Care:
- Renal Function Assessment:
- Evaluate renal function by assessing trends in serum creatinine and blood urea nitrogen (BUN) levels. A decline in these values indicates improved kidney function.
- Monitor ongoing fluid and electrolyte balance, assessing for the resolution of imbalances and preventing complications associated with fluid overload or electrolyte disturbances.
- Assess for the resolution of symptoms related to AKI, such as edema, hypertension, and electrolyte abnormalities. Improvement in these symptoms indicates successful intervention.
- Evaluate the prevention or mitigation of complications associated with AKI, such as uremia, acid-base imbalances, and cardiovascular complications, ensuring optimal patient outcomes.
- Assess the patient’s understanding of self-management strategies, medication adherence, and adherence to lifestyle modifications. Patient empowerment and active participation in their care contribute to successful long-term outcomes.
References
- http://www.kidneyfund.org/kidney-disease/kidney-problems/acute-kidney-injury.html#Who_gets_acute_kidney_injury
- https://www.mayoclinic.org/diseases-conditions/kidney-failure/diagnosis-treatment/drc-20369053
- https://www.kidney.org/atoz/content/AcuteKidneyInjury
- http://www.kidneyfund.org/kidney-disease/chronic-kidney-disease-ckd/kidney-friendly-diet-for-ckd.html
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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.
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