Question

Chapter 46 Acute Kidney Injury Disease

Acute Kidney Injury

Patient Profile

A.S. is a 70-year-old white woman who presented to the emergency department because of a 4-day history of increased shortness of breath and generalized weakness. A.S. stated that she has been able to do her daily chores at home independently, but for the past few days, it was getting difficult for her to get around and that she needed to take frequent breaks because she was short of breath and had no energy. She has a long history of heart failure, type 2 diabetes, and hypertension. She is admitted with a tentative diagnosis of acute kidney injury (AKI).

Subjective Data

• Has been having headaches on and off, with nausea and dizziness
• Reported that she had not been taking her medications regularly at home because of “forgetfulness”
• Has not been urinating a lot
• Feels “puffy” in her legs and hands

Objective Data

Physical Examination

• Blood pressure 178/96, pulse 110, temperature 98.9°F, respirations 24, and an oxygenation of 93% on room air
• Alert and oriented to person, place, and time
• Mild jugular venous distention
• Fine crackles in bilateral lower lobes
• Heart rate regular, no murmurs
• Bowel sounds normoactive and present in all four quadrants
• 2+ edema bilateral lower extremities and hands

Diagnostic Studies

• Echocardiogram shows decreased left ventricular function
• Urinalysis: Urine dark yellow and cloudy, protein 28 mg/dL, negative for glucose and ketones, positive for casts, red blood cells and white blood cells
• 24-hour urine output = 380 mL
• Laboratory Tests:

*	Hemoglobin	8 g/dL
*	Hematocrit	23.8%
*	RBC	2.57 million/mm3
*	WBC	4.7 mm3
*	Sodium	132 mEq/L
*	Potassium	5.2 mEq/L
*	Calcium	9 mg/dL
*	BUN	36 mg/dL
*	Creatinine	4.9 mg/dL
*	BNP	182 pg/mL

Case Study Questions

• 1. A.S. has to have a 24-hour urine collection performed, as she is not urinating a lot. Describe in steps the collection procedure by the nurse.
• 2. What is your interpretation of A.S.'s BUN, Cr, and BNP?

BUN (10 -20 mg/dL)

Cr (<1.2 mg/dL for women <1.4 mg/dL for men)

BNP (<100 pg/mL):

3. Should you be concerned about A.S..'s potassium level of 5.2 meq/L? (Yes/No)

List two treatment types that the health care provider might prescribe if deciding to treat A. S. hyperkalemia.

1.

2.

• 4. Based on A.S.’s presentation, what nursing assessments, interventions, and monitoring skills need to be performed by you the registered nurse? Student must list at least six:
• 5. What orders do you as the nurse, anticipate the physician will order? Student must list at least six (frequencies not necessary to list; only what you think the physician will order):

6. Explain what might have contributed to A.S.’s present condition as described above? What are two evidence-based preventive health care provisions/programs that if put in place early might have prevented this from occurring?

Explain what might have contributed to A.S.’s present condition:

Evidence-based Preventive Health Care Provisions/Programs:

1.

2.

7. What is the significance of A.S.’s Hemoglobin, Hematocrit, and RBC levels being significantly decreased?

8. You are planning discharge for A.S. What would you include in your discharge instructions/teachings and what other interdisciplinaries/health professionals would you include? Student must list at least five each:

Nursing Teaching/Instructions                    Other Health Professionals

1.                                                                 1.
2.                                                                 2.
3.                                                                 3.
4.                                                                 4.
5.                                                                 5.

Reference: (Lewis, S. M., Bucher, L., Heitkemper, M. M. L., Harding, M., Kwong, J., & Roberts, D. (2017). Medical-Surgical Nursing: Assessment and Management of Clinical Problems. St. Louis: Elsevier

Answer 1

ACUTE KIDNEY INJURY ALSO KNOWN AS ACUTE RENAL FAILURE IS A SUDDEN EPISODE OF KIDNEY FAILURE OR KIDNEY DAMAGE THAT HAPPENS WITHIN A FEW HOURS OR A FEW DAYS ;.

24 HRS URINE COLLECTION IS USED TO CHECK KIDNEY FUNCTION

THE NURSE SHOULD EXPLAIN THE PROCEDURE

INSTRUCT THE PATIENT ( OR NURSE )TO COLLECT ALL VOIDED URINE DURING THE 24 HOURS COLLECTION PERIOD AND ADD IT TO THE COLLECTION CONTAINER .THE COLLECTION SHOULD AND EXACTLY 24 HOURS AFTER IT BEGAN,BY HAVING THE PATIENT EMPTY HIS OR HER BLADDER ,OR CATHETER BAG,AND ADDING THIS SPECIMEN TO THE COLLECTION CONTAINER.

THE PATIENT SHOULD FOLLOW THIS

ON DAY- URINATE INTO THE TIOLET WHEN GET UP IN THE MORNING

AFTERWARD- COLLECT ALL URINE IN A SPECIAL CONTAINER FOR THE NEXT 24 HOURS

ON DAY 2- URINATE INTO THE CONTAINER WHEN GET UP IN THE MORNING

CAP THE CONTAINER

1.FOLLOW THE PHYSICIAN ADVICE REGARDING ANY DRINK ,FOOD BEFOR AND DURING COLLECTION

INFORM THE PATIENT TO EMPTY THE BLADDER COMPLETELY UPON AWAKENING AND DISCARD THE URINE.THIS ATART DATE AND TIME , COLLECT ALL URINE FOR THE NEXT 24 HOURS,THE LAST URINE COLLECTED SHOULD BE THAT OIDED UPON AWAKENING THE SECOND DAY AT THE SAME TIME .THEN RECAP THE CONTAINER .

THE NURSE SHOULD LABEL THE CONTAINER .

2.THE VALUE HIGH BUN32 MG/DL CAN MEAN KIDNEY INJURY OR DISEASE IS PRESENT.KIDNEY DAMAGE CAN BE CAUSED BY DM OR HTN THAT DIRECTLY AFFECTS THE KIDNEYS. HIGH BUN LEVELS CAN ALSO BE CAUSED BY LOW BLOOD FLOW TO THE KIDNEYS CAUSED BY DEHYDRATION OR HEART FAILURE.

CEATININE IS 4.9 MG/DL HIGH LEVEL MEANS THAT THE KIDNEYS ARE NOT WORKING WELL , CREATININE LEVEL MAY TEMPORARILY INCREASE IF PATIENT IS DEHYDATED.

BNP-182PG/ML HIGH ,BNP LEVEL GO UP WHEN THE HEART CANNOT PUMP THE WAY IT SHOULD.THE HIGHER THE NUMBER ,MORE LIKELY HEART FAILURE IS PRESENT AND THE MORE SEVERE IT IS.

3. YES HYPERKALEMIA SHOULD BE CONCERNED .

HYPERKALEMIA -PATINET HAVE WEAKNESS , FATIQUE ,SHORTNESS OF BREATH AND IT AFFECT THE HEART ALSO .

SHOULD CONCERNED THIS CONDITION

THE TREATMENT=

1.DECREASING THE INTAKE OF POTTASIUM INDIET OR TUBE FEEDS

2.EXCHANGING POTASSIUM ACROSS THE GUT LUMEN USING POTASSIUM BINDING RESINS

3.PROMOTING INTRACELLULAR SHIFTS IN POTASSIUM WITH INSULIN ,DEXTROSE SOLUTION ,AND BETA AGONISTS.

4.THE NURSE ASSESS URINE OUTPUT ,URINE OUTPUT VARIES FROM SCANTY TO A NORMAL VOLUME .

ASSESS BLOOD IN THE URINE - HEMATURIA MAY BE PRESENT IN PATIENTS WITH ARF.

ASSESS LABORATORY RESULTS MAY INCREASE ,DECREASE AND THESE MAY INDICATE EACH PHASE OF ARF

ASSESS CREATININE AND BUN IN THE BLOOD

ASSESS ULTRASONOGRAPHY

ASSESS PATIENT VITAL SIGNS,MAINTAIN ELECTROLYTES

ASSESS PATIENT WEIGHT EVERY DAY

ASSESS INTAKE AND OUTPUT CHART

NURSING INTERVENTION- AND MONITORING SKIILSINCLUDE=

MONITORING FLUID INTAKE AND OUTPUT-ACCURATELY MONITOR AND DOCUMENT

WEIGH THE PATIENT EVERY DAY ON THE SAME SCALE

MONITOR FLUID AND ELECTROLYTE BALANCE

CHECK THE VITAL SIGNS AND DOCUMENTED

CHECK THE EDEMA IN THE LIMBS

ALSO THE LABORATORY VALUES INFORMED THE PHYSICIAN AS SOON AS POSSIBLE

PREVENTING INFECTION

PROVIDING SAFETY MEASURES.

5. THE DOCTOR WILL PRESCRIBE

CATION-EXCHANGE RESINS OR KAYEXALATE ,KIONEXCAN REDUCE ELEVATED POTASSIUM LEVEL

DIURETICS -CONTROL FLUID VOLUME /REDUCE EDEMA/HTNN

ERYTHROPOIETIN TO TREAT ANEMIA

ACE INHIBITORS AND ARBs LOWER BLOOD PRESSURE

ANTIDEPRESSANTS --- IT HELP TO REDUCE THE ANXIETY AND REDUCE THE CHANCE OF WORSENING THE DECEASE BY TENSION

AND PHYSICIAN WILL ORDER DIALYSIS

FOR FLUID MANAGEMENT -IV FLUIDS FOR THE DARK YELLOW COLOUR URINE AND PROTEIN IS 28

6.ALL PRESCRIBED MEDICINES ARE IMPORTANT .

CKD IS A MAJOR RISK FACTOR OF AKI ,SOME NONRENAL COMORBID DISEASE,DM AND CHF HAVE BEEN IMPLICATED AS SIGNIFICANT PREDICTORS OF AKI ,MANAGING HTN ALSO IMPORTANT

TAKING GOOD CARE OF KIDNEY HELP TO PREVENT AKI.TO MANAGE DM AND HTN

LIFE STYLE CHANGES---EAT A DIET LOW IN SALT AND FAT,

EXERCISE FOR 30 MINUTES AT LEAST FIVE DAYS PER WEEK

TAKE MEDICINE APPROPRIATELY TO MANAGE THE HTN AND DM

TALK TO HEALTHCARE PROVIDER BEFORE TAKE OVER -THE -COUNTER MEDICINE ( NSAIDs , STOMACH MEDICINE MAY HARM THE KIDNEYS .FOLLOW THE DIRECTIONS ON THE PACKAGE.DO NOT TAKE MORE THAN DIRECTED.

7.WHEN KIDNEYS ARE DISEASED OR DAMAGED ,THEY DO NOT MAKE ENOUGH EPO(ERYTHROPOIETIN), AS ARESULT THE BONE MARROW MAKING FEWER RBC ,IT DEPRIVES THE BODY OF THE OXYGEN IS NEED.SO IT CAUSE LOW HB ,RBC AND HAEMATOCRIT LEVEL.

-DISCHARGE INSTRUCTIONS

YOUR SYMPTOMS GET WORSE IMMEDIATELY CONTACT ER DEPARTMENT

MEASURE AND DOCUMENT INTAKE AND OUT PUT CHART /DRINK LESS FLUIDN

TAKE MEDICINE AND LABEL IT IN THE FORM, IT HELPS TO REDUCE FORGETFULNESS

CHECK THE VITALSIGNS AND WEIGHT REGULARLY /LEARN TO TAKE YOUR OWN BLOOD PRESSURE

INSTRCT THE PATIENT ABOUT THE SKIN CARE -KEEPING THE SKIN CLEAN AND WELL MOISTURIZED

INSTRUCT THE PATIENT TO THE IMPORTANCE OF FOLLOW UP - EXAMINATION

STAY AWAY FROM PEOPLE WHO HAVE INFECTIONS

THE NUTRITIONIST HAVE MANY RESPONSIBILITIES IN AKI - INSTRUCT THE PATIENT REPLACEMENT OF DIETARY PROTEINS.

INSTRUCT THE PATIENT TO FOLLOW THE DIET PLAN-FOODS

EAT FOOD LOW IN SODIUM (SALT),POTASSIUM,PHOSPHOROUS,OR PROTEIN .-RENAL DIET

INSTRUCT THE PATIENT TO TAKE LOW FLUID