Nursing Assignment Help –Acute Kidney Injury
The patient’s story
- Name: Ms. Flora
- Sex: Female
- Age: 69yrs
- Marital status: Divorced
- Nationality: Australian
- Occupation: Housewife
- Family background: Ms. Flora is a divorced mother, staying with two adult children and relies on her son’ financial support. She lives with youngest daughter and for her medical checkup she has shifted temporarily to her son’s place. As her family relation is harmonious, her children are willing to support and bear their mother’s medical expenses. Because of her family’s positive support Ms. Flora accepts CAPD program.
Past medical history
Ms. Flora had history of type II diabetes mellitus. She had medical history of congestive and diastolic heart failure, atrial fibrillation, end stage renal disease, hypertensive heart and peripheral vascular disease. She had also undergone the surgical removal of gallbladder.
Ms. Flora had a record of hypertension and detected with ESRD. She undergone kidney transplant but grown multiple rejection. Her health condition became severe after she has decreased the immunosuppressive. Creatinine level shots up to 2.1mg/dl; urea: 25mg/dl; potassium: 7.5mmol/lit; renal biopsy performed that shown rigorous allograft nephropathy.
She found to have cellular elimination with moderate sternness. Renal biopsy had been performed. Persistent elimination caused non-function graft that indicated patient’s dialysis necessity (Lo et al., 2009). Catheter inserted and had received automated peritoneal dialysis program.
Patient had complained about poor outflow from peritoneal dialysis catheter along with abdominal pain. She diagnosed with peritonitis. Her creatinine level got increased. Due to reduced treatment response, CAPD cap was off and right jugular catheter was inserted for temporary dialysis.
BODY
Pathophysiology
Acute Kidney Injury (AKI) is commonly caused because of the event, which leads to the malfunction of kidneys, for example: loss of blood from main injury or surgery, dehydration or medication use (Bihorac et al., 2013). Chronic Kidney Disease (CKD) is commonly caused by continuing disease, for example: diabetes, high blood pressure that gradually damages kidneys and diminishes the function of the kidneys over time. Renal failure takes place while kidneys become unable to function (Bastin et al., 2013).
To effectively treat the condition of kidney failure, it is essential to understand if disease associated with kidney has developed over long term (chronic) or suddenly (acute). In different situations, medicines and diseases can produce conditions that bring about chronic and acute kidney disease (Chawla and Kimmel, 2012). Acute injury associated with kidney is also termed as Acute Renal Failure (ARF) and is more usually reversible than persistent kidney failure (Wald et al., 2014).
The difference between these two can also be determined by the presence or absence of indications. Indications of reduced kidney function, for example: electrolyte imbalance, fluid buildup is more probable to develop AKI, despite the consequences of the duration of kidney malfunctioning. Indications can reflect the original cause of kidney problem.
Indications of persistent kidney disease are generally not developed until persistent function of the kidneys remains (Hallan and Vikse, 2008). Other complications which may grow with persistent kidney disease, for example: hyperphosphatemia and anemia, together with difficulties attributable to kidney failure.
Excess fluid volume or hypervolemia takes place in kidney failure, from a rise in the content of total body serum and total water within the system. This is usually develops from compromised water and sodium regulatory mechanisms.
This can also caused by too much sodium intake from intravenous solutions, medications or foods (Purcell et al., 2004). Excess fluid volume can be a chronic or acute condition and managed in home setting, outpatient centers and hospitals. Treatment comprises restriction of sodium and fluid and application of diuretics, sometimes, dialysis is also required.
Peritoneal dialysis is an invasive process where abdomen is cleared at first for surgical process progression. Catheter is inserted in abdomen with one end and another end protruding through the skin. Before commencing each infusion process catheter should be cleaned properly to avoid any infection within the system.
Large fluid volume is introduced in the abdomen (Bieber et al., 2014). The entire volume is known as dwell. Fluid is referred as dialysate. The volume of dwell might be around 2.5litres. Suitable medications can also be mixed with the fluid instantly before infusion.
Tenckhoff catheter is placed during peritoneal dialysis. This is an indwelling catheter that is placed via open surgical method. Urinary catheter is said to be hollow flexible pipe like thing that is inserted to bladder to smooth the process of urination. Catheter is generally advised for staff convenience, urinary retention, urine leakage and for certain surgeries.
AKI may comprise heavy loss of blood, sepsis or injury to the kidneys that diminish the flow of blood; dehydration or less body fluid that harm kidneys; patients with heart surgery or having enduring health problems like: heart failure, obesity, liver disease, kidney disease, high blood pressure or diabetes; patients with kidney stones, an injury or tumor gland which can create blockage; dyes that are used in X-ray analysis; application of few medicines like: streptomycin and gentamycin; pain medications, like: ibuprofen, naproxen; drugs used for blood pressure: ACE inhibitors etc (Stokes and Bartges, 2006).
Nursing Assessment and Discharge Planning
Most favorable management of AKI requires close partnership among initial care hospitals, physicians, subspecialists, and other healthcare professional performing in Ms. Flora’s care. After AKI is set up, management is initially supportive (Wu et al., 2011). Patients with AKI need to be hospitalized except their condition is easygoing and undoubtedly brought about by simply reversible cause.
The key nursing management includes assuring sufficient renal perfusion by maintaining and achieving hemodynamic stability and evading hypovolemia. In few cases, it has been seen that the medical assessment of intravascular volume state and prevention of volume overload are difficult, where central venous pressure measurements in ICU is helpful.
It is the nurses responsibility to understand whether the patient require fluid resuscitation or not. If it is required as a consequence of intravascular volume depletion, then normal saline is mostly preferred over dextrans.
A rational goal is MAP greater than 65mm Hg that may need application of vasopressors within the patients with persistent hypotension (Chawla et al., 2011). But in Flora’s case, she has a hypertensive heart, so this factor can be ruled out.
Renal-dose dopamine is related to the poorer consequences among the patients with AKI, which is proper for Flora’s management. Her cardiac function should be optimized with positive inotropes or preload and after-load reduction.
Attention to the imbalances in electrolyte (hyperkalemia, hyperphosphatemia, hypermagnesemia, hypernatremia, metabolic acidosis and hyponatremia) is of utmost important in Flora’s case. Severe hyperkalemia occurs in abnormal potassium levels, that means 6.5mmol/L or greater and less than 6.5mmol/L along with the changes in electrocardiographs (typically peaked, tall T waves in hyperkalemia).
This is very much justified for Flora as her blood potassium level is 7.5mmol/L. To manage this condition 5-10units of insulin along with 50% dextrose can be administered intravenously (Mehrotra et al., 2012). This can shift the circulation of potassium out and to the cellular systems. Though electrocardiographic study has not been emphasized for Flora, but it can be said that to manage hyperkalemia administration of calcium gluconate is recommendable to stabilize membrane and diminish the arrhythmias risks.
But for Flora’s case calcium gluconate therapy can be avoided but sodium polystyreme sulfonate can be administered to reduce the levels of potassium gradually and diuretics can be administered. The healthcare professionals should also concentrate on the dietary intake of Flora, where potassium should be restricted. Basically, diuretics are used to manage Flora’s condition of fluid overload.
Intravenous diuretics as continuous infusion or bolus are helpful to deal with this purpose. On the other hand, nurse should understand the fact that diuretics never improve mortality, morbidity or renal consequences and need to be applied to treat or prevent AKI in the nonappearance of fluid overload.
The drugs which can potentially affect kidney function by hemodynamic techniques or direct toxicity need to be terminated, if required. For instance, metformin need to be recommended to the patients with diabetes mellitus and also suffering from AKI. This is especially significant for Flora’s case. The doses of important medicines need to be adjusted for lower kidney functioning level.
Avoidance of gadolinium and iodinated contrast media is of utmost important, in case of the emergency of imaging, non-contrast analyses are recommended (Singbartl and Kellum, 2011). Based on the standard administration practices, supportive therapies (mechanical ventilation, adequate nutrition maintenance, antibiotics, anemia management and glycemic control) need to be followed.
Flora has undergone a kidney biopsy. If it is confirmed that Flora has a rapidly growing glomerulonephritis then she should be recommended with cytotoxic therapy, pulse steroids or both in combination (Golestaneh, Melamed and Hostetter, 2009). In Flora’s case, her metabolic consequences of AKI cannot be sufficiently controlled with traditional management and hence, renal replacement therapy is required.
The signs for beginning of renal replacement therapy comprise unmanageable hyperkalemia, fluid overload to medicinal management, pleuritis, intractable acidosis, uremic encephalopathy, intoxications (lithium, ethylene glycol) and certain poisonings. Flora should be monitored for worsening or development of chronic renal disease.
Being a 69 yrs old women, it is quiet hard to expect from her that she will be knowledgeable enough regarding her catheters. Therefore, it is the nurses’ duty to inform her regarding catheter care as much as the patient can remember and utilize in her daily life.
Nurse should not get impatient if their patient is unable to clearly understand the ways of managing catheters. Hence to avoid all such conditions, nurses should provide appropriate catheter management knowledge to the care providers or family members of the patient. From the case study it is clear that Flora gets support from her children, which means her children are supportive enough and willing to assist her mother in post-surgical stage.
They can also be assisted with a support care provider at Flora’s resident, who can continuously assist Flora in her regular daily activity. Flora’s effective discharge planning starts on her admission and the goal is to optimize her clinical condition and facilitate safe and timely discharge from the hospital.
Constructive discharge plan works as a supportive way to promote both Flora’s comfort and address the concerns of her family members.
Critique of care
After Flora’s initial medical assessment it is known that Ms. Flora accepted CAPD program because of her children’s positive support. Her wishes were also confirmed by various entries in patient notes filing her approval of treatment measures. Flora considered herself to possess a good quality of life.
In this case, the health care provider is obliged to initiate catheter placement to go along with Flora’s inferred and documented approval. The purpose of futility in ICU remains subjective process comprising assessments of potential and offered treatments and patient’s diagnosis.
Quality of life need to be discussed to attain consent from al the health care professionals and also need to include nursing input. During Flora’s care, she has dealt with complicated issues by having comprehensive discussions with the nursing staffs.
Meeting up instructions requires building up trust between the nurse and the patient association and allows patient to take charge of self care and thus supporting sovereignty and preserving self-esteem.
Optimizing her pain management had positive effects on diminishing her anxiety. Anxiety and pain are correlated and cause equal physiological determents to vitally ill patients.
Flora’s pain score was evaluated hourly by applying Likert scale and was also checked for non-verbal indications, like: frowning and restlessness. She specified her pain management achieved a state of relief to be at ease, devoid of compromising her emotional ability (Kastanias et al., 2009).
Conclusion
Evidence can guide to a better self-awareness which is considered as an initial step towards positive transformation (Melnyk et al., 2009). It is always necessary to identify the areas of development and escalation in both professional and personal circumstances.
Ms. Flora’s case has helped the reader to demonstrate knowledge and understanding of complicated association between therapeutics and clinical conditions. It also helps the reader to consider practice significantly and reflect on the evidence based best practice and explore management decisions.
In this article a holistic patient centered discussion has been structured that reflects the multidisciplinary approach to patient care in intensive care environment. Taking enough time to reflect can help the healthcare professionals to categorize accesses that have exerted well and in this manner strengthen good practices.
This patient care study is mainly concerned with different nursing care provision, and patient knowledge deficit for the acute renal failure care.
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