Nursing Care Plan (NCP) for Acute Kidney Injury

Lesson Objective for Acute Kidney Injury (AKI) Nursing Care Plan:

• Understanding of AKI Causes and Risk Factors:
  • Increase awareness and knowledge about the causes and risk factors of Acute Kidney Injury (AKI), emphasizing the importance of early recognition and preventive measures.
• Recognition of AKI Signs and Symptoms:
  • Educate healthcare professionals on the signs and symptoms of AKI, enabling prompt identification and intervention to mitigate the progression of kidney dysfunction.
• Management of AKI Complications:
  • Provide strategies for managing complications associated with AKI, including electrolyte imbalances, fluid overload, and metabolic disturbances, to optimize patient outcomes.
• Implementation of Preventive Measures:
  • 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.
• Promotion of Renal Health:
  • 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:

1. 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.
2. 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.
3. 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.
• Ischemic or Toxic Injury to Renal Tubules:
  • 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.
• Inflammatory Response and Cellular Injury:
  • The ischemic or toxic insult triggers an inflammatory response, causing cellular injury and dysfunction. Inflammatory mediators contribute to further damage within the renal tissue.
• Alterations in Glomerular Filtration Rate (GFR):
  • 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.
• Fluid and Electrolyte Imbalance:
  • 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.
• Nephrotoxic Medications:
  • 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.
• Infections and Sepsis:
  • 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.
• Obstruction of Urinary Tract:
  • Blockages or obstructions in the urinary tract, such as kidney stones or enlarged prostate, can impede normal urine flow and lead to AKI.
• Autoimmune Diseases:
  • 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.
• Fluid and Electrolyte Balance:
  • Attain and maintain a balanced fluid and electrolyte status, preventing imbalances and complications associated with fluid overload or electrolyte disturbances.
• Resolution of Symptoms:
  • Alleviate and manage symptoms associated with AKI, such as edema, hypertension, and electrolyte abnormalities, contributing to improved patient comfort and well-being.
• Prevention of Complications:
  • 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.
• Patient Education and Self-Management:
  • 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

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.
• Fluid Balance:
  • 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.
• Vital Signs:
  • Regularly assess vital signs, particularly blood pressure, heart rate, and respiratory rate, to identify signs of hypotension or other systemic issues affecting renal perfusion.
• Laboratory Values:
  • Review laboratory results, including serum creatinine, blood urea nitrogen (BUN), electrolytes (potassium, sodium), and arterial blood gases to evaluate renal function and identify imbalances.
• Urine Analysis:
  • 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.
• Medication Review:
  • Evaluate the patient’s current medications, paying special attention to nephrotoxic drugs. Collaborate with healthcare providers to adjust medications or dosages as needed.
• Assessment of Signs and Symptoms:
  • 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.
• Collaboration with Specialized Teams:
  • 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.
• Fluid and Electrolyte Balance Restoration:
  • Restore and maintain a balanced fluid and electrolyte status, preventing imbalances and complications associated with fluid overload or electrolyte disturbances.
• Resolution of Symptoms:
  • Alleviate and manage symptoms associated with AKI, such as edema, hypertension, and electrolyte abnormalities, contributing to improved patient comfort and well-being.
• Prevention of Complications:
  • 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.
• Patient Education and Empowerment:
  • 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.
• Fluid and Electrolyte Balance:
  • Monitor ongoing fluid and electrolyte balance, assessing for the resolution of imbalances and preventing complications associated with fluid overload or electrolyte disturbances.
• Symptom Resolution:
  • Assess for the resolution of symptoms related to AKI, such as edema, hypertension, and electrolyte abnormalities. Improvement in these symptoms indicates successful intervention.
• Complication Prevention:
  • Evaluate the prevention or mitigation of complications associated with AKI, such as uremia, acid-base imbalances, and cardiovascular complications, ensuring optimal patient outcomes.
• Patient Empowerment and Adherence:
  • 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