A patient with acute kidney injury (AKI) presents with hyperkalemia, as evidenced by a potassium level of 5.8 mEq/L, and signs of fluid overload, including peripheral edema and pulmonary crackles. Which nursing intervention should be prioritized to address the risk of cardiac complications in this patient?

A) Administer calcium gluconate as prescribed.

B) Restrict oral fluid intake to prevent further fluid overload.

C) Adjust antihypertensive medications to improve renal perfusion.

D) Encourage early ambulation to reduce peripheral edema.

A patient with acute kidney injury (AKI) and hyperkalemia is experiencing low urine output despite intravenous fluid administration. Which nursing intervention should be prioritized to address the patient's hyperkalemia and prevent cardiac complications?

B) Administer sodium polystyrene sulfonate (Kayexalate) as prescribed to lower potassium levels.

A) Increase the rate of intravenous fluid administration to enhance renal perfusion.

B) Administer sodium polystyrene sulfonate (Kayexalate) as prescribed to lower potassium levels.

C) Prepare the patient for hemodialysis to rapidly remove excess potassium from the bloodstream.

D) Encourage the patient to increase oral fluid intake to improve urine output.

A patient with hyperkalemia and fluid overload is being monitored closely. Which intervention should the nurse prioritize to address the patient's current complications?

A) Increase the dose of the prescribed diuretic to enhance fluid removal.

B) Administer sodium polystyrene sulfonate to decrease potassium levels.

C) Begin oxygen therapy to manage respiratory distress.

D) Prepare the patient for potential emergency dialysis.

A patient with persistent hyperkalemia and fluid overload is being closely monitored after initial interventions were ineffective. Which nursing action is the highest priority to prevent further complications?

C) Implement continuous telemetry monitoring to detect potential cardiac arrhythmias.

A) Administer prescribed sodium polystyrene sulfonate to lower potassium levels.

B) Increase the frequency of vital signs monitoring to detect early signs of respiratory distress.

C) Implement continuous telemetry monitoring to detect potential cardiac arrhythmias.

D) Adjust the patient's fluid intake to prevent further fluid overload.

A patient with fluid overload and hyperkalemia has been receiving aggressive diuretic therapy and sodium polystyrene sulfonate. Despite these treatments, the patient's potassium level remains elevated at 6.0 mEq/L, and there is ongoing respiratory distress. Which of the following interventions is the most appropriate next step in managing this patient's condition?

C) Initiate renal replacement therapy to address both fluid overload and hyperkalemia.

A) Increase the dose of diuretics to further reduce fluid overload.

B) Administer calcium gluconate to protect the heart from the effects of hyperkalemia.

C) Initiate renal replacement therapy to address both fluid overload and hyperkalemia.

D) Administer an additional dose of sodium polystyrene sulfonate to further lower potassium levels.

A patient undergoing renal replacement therapy for hyperkalemia and fluid overload is showing signs of improved respiratory effort and decreased pulmonary crackles. However, the nurse notes the patient has a blood pressure of 90/60 mmHg. What is the most appropriate nursing intervention at this time?

B) Administer a prescribed dose of IV fluids to address hypotension.

A) Increase the rate of dialysis to enhance fluid removal.

B) Administer a prescribed dose of IV fluids to address hypotension.

C) Call the physician to discuss stopping dialysis immediately.

D) Evaluate the patient's cardiac function before making any changes.

A patient undergoing renal replacement therapy has developed anemia with hemoglobin levels dropping to 8.5 g/dL. Considering the patient's condition, which of the following interventions should the nurse prioritize to address the patient's anemia and optimize cardiac function?

B) Initiate erythropoiesis-stimulating agents and assess iron status.

A) Administer a blood transfusion to rapidly increase hemoglobin levels.

B) Initiate erythropoiesis-stimulating agents and assess iron status.

C) Increase the patient's fluid intake to improve blood volume.

D) Recommend physical activity to enhance circulation and oxygen delivery.

A patient undergoing renal replacement therapy has developed anemia with a hemoglobin level of 8.5 g/dL and is experiencing fatigue. The patient's potassium level is also at the upper limit of normal. Which nursing intervention should be prioritized to address these issues while considering the patient's cardiac status?

A) Administer erythropoiesis-stimulating agents and schedule regular follow-up hemoglobin tests.

B) Increase dietary potassium intake to compensate for potential losses during dialysis.

C) Encourage the patient to engage in moderate physical activity to improve circulation and oxygenation.

D) Restrict fluid intake to prevent fluid overload and monitor cardiac output closely.

AKI - Nursing Case Study

Pathophysiology

• Primary mechanism: Decreased renal perfusion leads to prerenal AKI, where inadequate blood flow to the kidneys causes reduced glomerular filtration rate (GFR). This can result from hypotension, dehydration, or heart failure, prompting kidney hypoxia and cellular injury.

• Secondary mechanism: Intrinsic renal damage, often due to acute tubular necrosis (ATN), where prolonged ischemia or nephrotoxic insult damages renal tubules, impairing reabsorption and filtration. This can be triggered by toxins, drugs, or severe ischemia, leading to cell death and obstruction in tubules.

• Key complication: If unresolved, AKI can progress to chronic kidney disease (CKD), characterized by persistent reduction in kidney function, fluid overload, electrolyte imbalances, and increased risk of cardiovascular events, highlighting the need for early intervention and monitoring.

Patient Profile

Demographics:

55-year-old male, construction worker

History:

• Key past medical history: Hypertension, Type 2 Diabetes, Hyperlipidemia

• Current medications: Lisinopril, Metformin, Atorvastatin

• Allergies: Penicillin

Current Presentation:

• Chief complaint: Decreased urine output and swelling in legs

• Key symptoms: Fatigue, nausea, mild shortness of breath, confusion

• Vital signs: Blood pressure 150/95 mmHg, heart rate 105 bpm, respiratory rate 22 breaths/min, temperature 37.8°C, oxygen saturation 92% on room air

Section 1

As the healthcare team proceeds with the initial assessment, further diagnostic tests are conducted to better understand the extent of the patient's acute kidney injury (AKI). Blood tests reveal elevated serum creatinine levels at 2.8 mg/dL, indicating a significant decline in kidney function from his baseline. Blood urea nitrogen (BUN) is also elevated at 45 mg/dL, suggesting impaired waste elimination. Electrolyte panels show hyperkalemia with a potassium level of 5.8 mEq/L, posing a risk for cardiac complications, and mild hyponatremia with a sodium level of 132 mEq/L, contributing to the patient's confusion and fatigue.

A urinalysis is performed, showing a dark amber color with a specific gravity of 1.030, suggesting concentrated urine due to decreased renal perfusion. The presence of granular casts in the urine indicates potential acute tubular necrosis (ATN), pointing towards intrinsic renal damage. An ultrasound of the kidneys shows no evidence of obstruction but confirms reduced renal blood flow, aligning with the prerenal etiology of the AKI. The patient's echocardiogram reveals mild left ventricular hypertrophy, a consequence of his longstanding hypertension, which may be contributing to the decreased renal perfusion and further complicating the clinical picture.

The healthcare team initiates interventions focusing on improving renal perfusion and correcting electrolyte imbalances. Intravenous fluids are administered cautiously to optimize blood volume without overloading the cardiovascular system. The patient's antihypertensive regimen is reviewed and adjusted to prevent further renal insult while managing his blood pressure. Continuous cardiac monitoring is set up to watch for arrhythmias due to hyperkalemia. Despite these measures, the patient's urine output remains low, and he continues to exhibit signs of fluid overload, such as increased peripheral edema and mild pulmonary crackles on auscultation. This scenario necessitates ongoing assessment and adaptation of the care plan to prevent further deterioration and guide the patient towards recovery or stabilization.

Section 2

As the healthcare team continues to monitor the patient, a new complication emerges. The patient's potassium level remains elevated despite initial interventions, now reaching 6.2 mEq/L, increasing the risk for severe cardiac arrhythmias. Concurrently, the patient develops more pronounced peripheral edema and worsening pulmonary crackles, indicating persistent fluid overload. Vital signs show a slightly elevated heart rate at 102 bpm, with blood pressure remaining stable at 130/85 mmHg, but respiratory rate has increased to 24 breaths per minute, suggestive of respiratory distress possibly due to fluid accumulation in the lungs.

Given these developments, the team decides to initiate more aggressive diuretic therapy to promote diuresis and prevent further fluid retention, while closely monitoring electrolyte levels to avoid exacerbating the hyperkalemia. Additionally, they consider the use of sodium polystyrene sulfonate to help lower the potassium level, with the potential for dialysis if the patient's condition does not improve. The patient's mental status is assessed frequently, noting persistent confusion and fatigue, likely exacerbated by the electrolyte imbalances and fluid status.

The team remains vigilant for signs of cardiac instability, implementing continuous telemetry monitoring to detect any arrhythmias promptly. As the patient's clinical picture becomes more complex, the healthcare team emphasizes the importance of regular reassessment and timely adjustments to the treatment plan, understanding that the balance between managing fluid status and maintaining electrolyte stability is crucial in avoiding further complications. This ongoing challenge requires the integration of multidisciplinary expertise to guide the patient towards stabilization.

Section 3

As the team continues to address the patient's critical needs, they initiate the more aggressive diuretic therapy and administer sodium polystyrene sulfonate. Over the next few hours, the team closely monitors the patient's response to these interventions. Notably, the patient's urine output begins to increase, suggesting a positive response to the diuretics. However, the potassium level remains elevated at 6.0 mEq/L, indicating that additional measures may be necessary to manage the hyperkalemia effectively. The healthcare team remains concerned about the potential for cardiac complications, given the persistent electrolyte imbalance.

Despite the increased diuresis, the patient's peripheral edema shows only slight improvement, and pulmonary crackles continue to be pronounced on auscultation. The patient's respiratory rate remains elevated at 24 breaths per minute, and while the heart rate stabilizes slightly at 98 bpm, the ongoing respiratory distress suggests that the fluid overload is not yet fully controlled. Mental status assessments reveal intermittent confusion, raising concerns about the potential impact of hypoxia or electrolyte disturbances on neurological function.

Given the partial response to the current interventions and the potential for further complications, the team considers the initiation of renal replacement therapy as a more definitive approach to manage both the fluid overload and hyperkalemia. Additionally, they plan to reassess the patient's cardiac function with an echocardiogram to evaluate for any underlying cardiac issues that may be contributing to the fluid retention. The team recognizes the importance of a multidisciplinary approach, coordinating with nephrology, cardiology, and pulmonology specialists to refine the treatment plan and guide the patient's path to stabilization.

Section 4

The team decides to prioritize the initiation of renal replacement therapy (RRT) to address the persistent hyperkalemia and fluid overload, recognizing that the current interventions have not achieved the desired outcomes. As preparations are made for the therapy, they receive new diagnostic results from the echocardiogram, which reveal a reduced ejection fraction of 35%, suggesting underlying systolic heart failure that may be exacerbating the patient's fluid retention issues. This finding prompts the cardiology team to initiate a more targeted approach, including the careful titration of ACE inhibitors and beta-blockers, to support cardiac function while RRT is underway.

As renal replacement therapy begins, the patient's status undergoes a notable change. Within the first few hours, there is a gradual improvement in respiratory effort, with the respiratory rate decreasing to 20 breaths per minute, and a reduction in pulmonary crackles on auscultation, suggesting effective fluid removal. However, the team remains vigilant, monitoring for potential complications associated with RRT, such as hypotension and further electrolyte imbalances. The patient's mental status shows slight improvement, with fewer episodes of confusion, indicating a possible positive response to both the correction of electrolyte disturbances and improved oxygenation.

Despite these encouraging signs, the team remains cautious, aware that the patient's journey to stabilization is ongoing. Continuous monitoring of vital signs, electrolyte levels, and cardiac function is essential, as is the ongoing collaboration among the multidisciplinary team. The nephrology team plans to make daily adjustments to the dialysis regimen based on the patient's evolving clinical status, while the cardiology and pulmonology teams continue to refine medical management strategies. This coordinated approach aims to address the underlying causes of the acute kidney injury, manage associated complications, and support the patient's gradual recovery.

Section 5

As the renal replacement therapy progresses, new diagnostic results come to light that add another layer of complexity to the patient's condition. A repeat set of laboratory tests reveals a significant drop in hemoglobin levels to 8.5 g/dL from a previous 10.2 g/dL, indicating the development of anemia, which could be contributing to the patient's ongoing fatigue and pallor. Additionally, the patient's potassium level, although improved, remains at the upper limit of normal at 5.0 mmol/L, necessitating continued vigilance in electrolyte management.

The team conducts a thorough assessment to determine the potential causes of anemia, considering factors such as recent blood loss, hemolysis, and the potential impact of renal dysfunction on erythropoiesis. Given the patient's reduced ejection fraction and ongoing cardiac issues, the presence of anemia poses an additional risk to cardiac output and tissue perfusion. The multidisciplinary team, including nephrology, cardiology, and hematology, discusses the possibility of initiating erythropoiesis-stimulating agents and iron supplementation, alongside careful monitoring to avoid exacerbating the heart failure status.

In response to these findings, the patient's care plan is adjusted to include more frequent monitoring of hemoglobin levels and the introduction of supportive therapies to manage anemia, with the overarching goal of optimizing cardiac function and oxygen delivery to tissues. The cardiology team remains attentive to the delicate balance required in managing heart failure, as efforts to improve cardiac output must be tempered with the risk of fluid overload. This nuanced approach underscores the importance of continuous reassessment and adaptation of the care plan to address the evolving clinical picture, guiding the patient toward stabilization and recovery.