A patient with acute kidney injury (AKI) and hyperkalemia is being managed in the hospital. The healthcare team has initiated treatment with calcium gluconate and insulin with glucose. Which nursing intervention is most critical to perform immediately after these treatments are administered?

C) Reassess the patient's cardiac rhythm continuously.

A) Monitor the patient's blood pressure every 4 hours.

B) Check the patient's urine output every shift.

C) Reassess the patient's cardiac rhythm continuously.

D) Measure the patient's daily weight.

A patient with acute kidney injury (AKI) presents with elevated BUN and creatinine levels, hyperkalemia, and mild hydronephrosis on ultrasound. The healthcare team is considering interventions to manage these findings. Which of the following nursing actions is most appropriate to address the patient's hyperkalemia?

A) Administer calcium gluconate to stabilize cardiac membranes.

B) Increase dietary intake of potassium-rich foods.

C) Withhold intravenous fluids to prevent fluid overload.

D) Encourage vigorous physical activity to lower potassium levels.

A patient with acute kidney injury secondary to hydronephrosis is experiencing fluid overload, evidenced by peripheral edema and pulmonary crackles. His potassium level is 5.2 mEq/L and he is receiving intravenous fluids. Which of the following interventions should the nurse prioritize to address his current condition?

B) Administer a loop diuretic to reduce fluid overload and manage hypertension.

A) Increase the rate of intravenous fluids to improve renal perfusion.

B) Administer a loop diuretic to reduce fluid overload and manage hypertension.

C) Provide supplemental oxygen to address potential hypoxia from pulmonary crackles.

D) Prepare the patient for immediate surgical intervention to relieve hydronephrosis.

A patient with hyperkalemia and acute kidney injury is being monitored in the ICU. After treatment, the patient's potassium level has decreased, but he now exhibits mild chest discomfort and an irregular heartbeat. Which nursing intervention is the most appropriate at this time to address these new symptoms?

C) Monitor the patient's ECG closely and prepare to administer antiarrhythmic medication if PVCs increase.

A) Administer a beta-blocker to manage the irregular heartbeat.

B) Increase the rate of intravenous fluids to improve renal perfusion.

C) Monitor the patient's ECG closely and prepare to administer antiarrhythmic medication if PVCs increase.

D) Administer an additional dose of calcium gluconate to further stabilize cardiac membranes.

A patient with worsening pulmonary congestion and mild dyspnea has been started on intravenous furosemide therapy. Which of the following nursing interventions is most appropriate to evaluate the effectiveness of the diuretic treatment in this patient?

C) Measure hourly urine output to determine diuretic effectiveness

A) Monitor daily serum potassium levels to assess electrolyte balance

B) Assess for changes in peripheral edema to evaluate fluid status

C) Measure hourly urine output to determine diuretic effectiveness

D) Check daily weights to monitor overall fluid balance

A patient receiving intravenous furosemide for fluid overload presents with an increase in urine output and mild hypokalemia. Which of the following nursing interventions is the priority to prevent complications associated with hypokalemia in this patient?

B) Administer prescribed potassium supplementation

A) Monitor the patient's blood pressure closely

B) Administer prescribed potassium supplementation

C) Encourage increased dietary intake of potassium-rich foods

D) Discontinue the furosemide infusion immediately

The healthcare team is managing a patient with heart failure and renal impairment who is experiencing diuresis after intravenous furosemide administration. Given the patient's condition and recent lab results, which nursing intervention should be prioritized to prevent complications?

B) Monitor serum potassium levels closely and administer prescribed potassium supplements.

A) Encourage increased fluid intake to maintain hydration.

B) Monitor serum potassium levels closely and administer prescribed potassium supplements.

C) Increase the rate of oxygen delivery to improve oxygen saturation.

D) Prepare the patient for immediate surgical intervention to address hydronephrosis.

A patient with worsening respiratory distress and bilateral pulmonary edema is being considered for an adjustment in diuretic therapy. Which of the following nursing interventions is most appropriate to implement first to address the patient's current condition?

C) Elevate the head of the bed to improve breathing and oxygenation.

A) Administer potassium supplements to address hypokalemia.

B) Increase the dosage of the prescribed diuretic to reduce fluid overload.

C) Elevate the head of the bed to improve breathing and oxygenation.

D) Prepare the patient for potential dialysis to manage fluid status.

A patient with known cardiac and renal issues is experiencing increasing respiratory distress, and a chest X-ray confirms bilateral pulmonary edema. The patient's serum potassium is 3.0 mEq/L, and they are currently on beta-blocker therapy with intermittent atrial fibrillation noted on ECG. Which nursing action is the priority in managing this patient's condition?

D) Collaborate with the healthcare team to adjust the diuretic regimen and consider ACE inhibitor initiation.

A) Administer the prescribed potassium supplement to address hypokalemia.

B) Initiate anticoagulation therapy to prevent thromboembolic events.

C) Prepare the patient for potential dialysis to manage fluid overload.

D) Collaborate with the healthcare team to adjust the diuretic regimen and consider ACE inhibitor initiation.

Acute Kidney Injury - Nursing Case Study

Pathophysiology

• Primary mechanism: Reduced blood flow (prerenal causes) - Decreased renal perfusion due to factors like dehydration or heart failure leads to inadequate oxygen and nutrient delivery, causing renal tissue damage and impaired filtration.

• Secondary mechanism: Direct kidney damage (intrarenal causes) - Injury to kidney structures from toxins, infections, or inflammatory processes results in tubular necrosis or glomerular damage, disrupting normal renal function.

• Key complication: Obstruction of urine flow (postrenal causes) - Blockages in the urinary tract from stones or tumors increase pressure in the nephrons, further impairing kidney function and potentially leading to irreversible damage if not promptly addressed.

Patient Profile

Demographics:

54, male, construction worker

History:

• Key past medical history: Hypertension, Type 2 Diabetes, Chronic Back Pain

• Current medications: Lisinopril, Metformin, Ibuprofen

• Allergies: Penicillin

Current Presentation:

• Chief complaint: Decreased urine output and fatigue

• Key symptoms: Swelling in legs, nausea, confusion, shortness of breath

• Vital signs: Blood pressure 160/95 mmHg, heart rate 105 bpm, respiratory rate 24 breaths per minute, temperature 98.6°F, oxygen saturation 92% on room air

Section 1

As the healthcare team continues to monitor the patient, new diagnostic results reveal significant insights into his condition. The laboratory tests indicate elevated blood urea nitrogen (BUN) and creatinine levels, confirming impaired renal function. His BUN is measured at 56 mg/dL, and creatinine is at 3.8 mg/dL, both significantly higher than normal, suggesting acute kidney injury (AKI). Additionally, his potassium level is elevated at 5.8 mEq/L, indicating hyperkalemia, which poses a risk for cardiac complications. An ultrasound of the kidneys shows mild hydronephrosis, suggesting possible postrenal obstruction, which could be due to urinary retention or a ureteral stone.

This new information necessitates a careful review of the patient's medication regimen and fluid status. The use of ibuprofen is reconsidered due to its potential nephrotoxic effects, especially in the context of decreased renal perfusion. The healthcare team discusses the potential need for adjustment in his antihypertensive therapy, particularly considering his blood pressure remains high despite current treatment. The decision is made to initiate intravenous fluids to improve renal perfusion, along with closely monitoring fluid balance to avoid fluid overload due to his existing heart failure risk.

The critical elevation in potassium levels prompts immediate intervention with calcium gluconate to stabilize the cardiac membranes, alongside measures to lower potassium, such as insulin and glucose administration. The team remains vigilant for signs of worsening kidney function or new complications, such as cardiac arrhythmias, while planning further imaging studies to precisely identify and address the cause of the hydronephrosis. These steps are crucial in mitigating the risk of irreversible kidney damage and ensuring a comprehensive approach to the patient's complex presentation, setting the stage for ongoing management and potential recovery of renal function.

Section 2

As the healthcare team monitors the patient's progress, initial interventions begin to take effect, but new complications arise, requiring further clinical reasoning and adjustment of the care plan. Over the next 24 hours, the patient shows a partial response to the treatment for hyperkalemia. His potassium level decreases to 5.2 mEq/L, closer to the upper limit of normal, but vigilance is maintained due to the potential for rebound hyperkalemia. The administration of calcium gluconate has successfully stabilized his cardiac membranes with no immediate signs of arrhythmias. However, during the assessment, the patient reports mild chest discomfort and an irregular heartbeat. An electrocardiogram (ECG) is performed, revealing occasional premature ventricular contractions (PVCs), which warrant close observation.

In addition to the cardiac concerns, the patient's fluid status presents a new challenge. The introduction of intravenous fluids results in slight improvement in his renal perfusion, evidenced by a marginal decrease in creatinine to 3.5 mg/dL. However, there is a concurrent development of peripheral edema and mild pulmonary crackles on auscultation, suggesting fluid overload. The patient's blood pressure remains elevated at 158/92 mmHg, necessitating a reassessment of his antihypertensive regimen. The team debates the adjustment of diuretics to address both the hypertensive crisis and fluid overload, while also considering the potential impact on renal function.

The patient's overall status continues to be complicated by the underlying hydronephrosis. A repeat renal ultrasound is scheduled to evaluate for any progression or resolution of the obstruction. The possibility of urinary catheterization or surgical intervention, such as ureteral stenting, is discussed pending further imaging results. This complex interplay of issues requires the healthcare team to integrate clinical reasoning to balance the management of acute kidney injury, potential cardiac complications, and fluid dynamics. Ongoing monitoring and timely adjustments to the care plan are essential to optimize patient outcomes and prevent further deterioration.

Section 3

The healthcare team decides to focus on the patient's fluid status and cardiac concerns. Over the next few hours, the patient's peripheral edema worsens, and his respiratory status becomes more concerning. He develops mild dyspnea, with respiratory rates increasing to 24 breaths per minute and oxygen saturation dropping to 92% on room air. Auscultation reveals more pronounced pulmonary crackles bilaterally, indicating worsening pulmonary congestion. A chest X-ray confirms the presence of pulmonary edema. The patient's blood pressure remains elevated at 160/94 mmHg, and heart rate is noted to be irregular, fluctuating between 88 and 104 beats per minute.

In response to these changes, the team decides to adjust the patient's diuretic therapy. Furosemide is administered intravenously to promote diuresis and relieve fluid overload. This decision is made with caution, considering the patient's renal status and the need to prevent further decline in kidney function. Meanwhile, the cardiology team is consulted to address the recurrent premature ventricular contractions (PVCs) and potential arrhythmia risk, initiating a low-dose beta-blocker to stabilize the heart rhythm without significantly impacting blood pressure.

As the healthcare team continues to monitor the patient closely, they await the results of the repeat renal ultrasound to guide further management of the underlying hydronephrosis. The decision regarding possible surgical intervention or catheterization hinges on these imaging results. The integration of diuretic therapy and beta-blocker management exemplifies the need for continuous clinical reasoning to balance cardiovascular stability, renal function, and fluid dynamics. This careful monitoring and adjustment of the care plan aim to optimize patient outcomes and prevent further complications.

Section 4

As the healthcare team continues to monitor the patient, they observe a significant response to the interventions. Within a few hours of administering intravenous furosemide, the patient begins to show signs of diuresis, with an increase in urine output noted at 150 mL/hour. This contributes to a slight improvement in peripheral edema, though the patient's respiratory status still requires close observation. The oxygen saturation improves marginally to 94% on supplemental oxygen at 2 liters per minute via nasal cannula, and the respiratory rate stabilizes at 22 breaths per minute. However, the crackles in the lungs remain prominent on auscultation, indicating persistent pulmonary congestion.

Laboratory results return, showing a serum creatinine level of 2.3 mg/dL, slightly elevated from previous values, necessitating cautious management to prevent further renal impairment. Electrolyte levels reveal a mild hypokalemia with a serum potassium of 3.2 mEq/L, likely secondary to diuretic therapy. The healthcare team decides to initiate potassium supplementation to correct the imbalance and prevent potential arrhythmias. Meanwhile, the beta-blocker therapy appears to be effective in reducing the frequency of premature ventricular contractions, although the patient's heart rate remains irregular, fluctuating between 90 and 98 beats per minute.

The repeat renal ultrasound reveals moderate hydronephrosis, consistent with previous findings, prompting a multidisciplinary discussion regarding potential surgical intervention. The nephrology and urology teams evaluate the need for possible catheterization to relieve the obstruction contributing to the renal impairment. The patient's overall status necessitates ongoing assessment and adjustment of the care plan, balancing the improvement in fluid overload with the need to maintain renal function and stabilize cardiac rhythm. This dynamic scenario underscores the importance of integrated clinical reasoning to navigate the complexities of the patient's condition and optimize outcomes.

Section 5

As the healthcare team continues to monitor the patient, a change in status becomes evident. Despite initial improvement in urine output and a slight reduction in peripheral edema, the patient begins to exhibit signs of increasing respiratory distress. Oxygen saturation drops to 90% even with supplemental oxygen, and the respiratory rate increases to 28 breaths per minute. Auscultation reveals worsening crackles throughout both lung fields, suggesting exacerbation of pulmonary congestion. The patient's anxiety levels rise, likely secondary to dyspnea, and the decision is made to escalate respiratory support.

A chest X-ray confirms bilateral pulmonary edema, reinforcing the need for vigilant fluid management. The multidisciplinary team discusses adjusting the diuretic regimen, balancing the risk of further hypokalemia with the need to manage fluid overload. Serum potassium is re-evaluated, and results show a decrease to 3.0 mEq/L, necessitating an increase in potassium supplementation. The nephrology team considers the possibility of dialysis to manage fluid status more aggressively while protecting renal function. Concurrently, the cardiology team reassesses cardiac management, contemplating the addition of an ACE inhibitor to assist with both cardiac and renal protection.

The patient's fluctuating heart rate and persistent irregularity prompt a reevaluation of the current beta-blocker therapy. An electrocardiogram reveals intermittent atrial fibrillation, further complicating the clinical picture. The healthcare team deliberates the initiation of anticoagulation therapy to mitigate the risk of thromboembolic events while closely monitoring renal function and potential bleeding risks. This evolving scenario highlights the intricate interdependence of the patient's cardiac, respiratory, and renal systems, demanding careful coordination and clinical reasoning to navigate the complexities and optimize care outcomes.