A.

Introduction

Background of the case study

Acute renal failure is characterized by a deterioration of renal function over a period of hours or
days, resulting in the failure of the kidney to excrete nitrogenous waste products and to maintain fluid and
electrolyte homeostasis. This condition is usually marked by a fall in the Glomerular filtration Rate (GFR),
accompanied by a concomitant rise in serum creatinine and urea nitrogen. However, immediately after a
kidney injury, BUN or creatinine levels may be normal, and the only sign of a kidney injury may be
decreased urine production.
Renal or kidney failure remains among the top 10 causes of morbidity and mortality in the country.Each year
an estimated 120 Filipinos per million population (PMP) develop kidney failure. This means that about
10,000 Filipinos need to replace their kidney function each year.The leading cause of kidney failure in the
Philippines is diabetes (41%), according to the Philippine Renal Disease Registry Annual Report in 2008,
followed by an inflammation of the kidneys (24%) and high blood pressure (22%). Patients were
predominantly male (57%) with a mean age of 53 years.

Acute renal failure (ARF) has four well-defined stages: onset, oliguric or anuric, diuretic, and convalescent.
Treatment depends on stage and severity of renal compromise. ARF can be divided into three major
classifications, depending on site.

Objectives of the Case Study

-To be able to explain the predisposing and precipitating factors of Acute Renal Failure
-To be able to discuss the pathophysiologic changes and clinical manifestations of Acute Renal
Failure
-To identify treatment goals for patients with Acute Renal Failure
-To identify effective nursing management and focus on the nursing care plan

Theoretical Framework
Care, Core, Cure (Lydia Hall)

BRIEF OVERVIEW OF THE THEORY

Lydia E. Hall presented her theory of nursing by drawing three interlocking circles, each circle representing a
particular aspect of nursing: care, core, and cure.
The care circle represent the nurturing component and is exclusive to nursing. The nurse provides bodily
care for the patient and helps the patient to complete such basic daily biological function as eating, bathing,
elimination, and dressing. When providing this care, the nurses goal is the comfort of the patient.
The core circle of patient care is based in the social sciences, involves the therapeutic use of self, and is
shared with other members of the health team. The nurse, by developing an interpersonal relationship with
the patient, is able to help the patient verbally express feelings regarding the disease process and its effect,
as well as discuss the patients role in recovery. If he accepts the invitation, he will explore the concerns in
his acts and as he listens to his exploration through the reflection of the nurse, he may uncover in sequence
his difficulties, the problem area, his problem, and eventually the threat which is dictating her out-of-control
behavior.
The cure circle of patient is based in the pathological and therapeutic sciences and is shared with the other
member of the health team. The nurse helps patient and family through the medical, surgical, and
rehabilitative prescription made by the physician. During this aspect of nursing care, the nurse is an active
advocate of the patient.
Because Hall emphasizes the importance of a total person approach, it is important that the three aspects of
nursing not be viewed as functioning independently but as interrelated. The three aspects interact, and the
circle representing them change size, depending on the patients total course of progress.

RELATION OF THE THEORY TO THE PATIENTS CASE

Our patient hasan acute renal failure. He is in need of both therapeutic and medical intervention. Hence
Lydia E. Hall theory promotes the importance of interpersonal relationship between the patient and the
professional nurse it is very much likely helpful to our patient. Our patient will need some assistance from
the member of the health team on how to deal with his situation. By simply helping him with activities of daily
living will have a great impact to him as a human being. Strong establishment of rapport will help us dig in to
her inner thoughts and feelings about his condition. Through this theory if applies correctly and
fundamentally it will actually help improve our clients condition in terms of healing process, pain
management and rendering her informative discussion about his condition.

PARADIGM

B. Patient Data Base

Personal Data
Patient X is a 94 year old male residing in Project 6, Quezon City. Married with 4 daughters and 2
sons. Important informantion were obtained from the wife of the patient, with good reliability. Retired
government employee for 30 years.

Medical History
Px first admission, no hypertension, no DM, . Current medications include unrecalled multivitamins.

History of the Present Illness

S and Sx started a month before admission. Reported lost of appetite, generalized body weakness,
and difficulty urinating. Consulted to an unrecalled hospital without any specific detail. Eldest daughter
advised admission to our institution. Arrived in ER on March 1 and accompanied by family with cc of lost of
appetite and diff of urinating followed by admission.

Indwelling catheter started upon admission. Urine output of 3700cc. BP fell to 80/50 and seizure
occurred.

Past Medical History

-no known allergies
-no prior surgical procedures
-no previous hospitalizations and hospital admissions

Family HX
-Mother with Hx of DM
-Father with HX of PTB.

Social HX
-non smoker
-occasional drinker
-coffee drinker drinking 1 cup a day

Physical Examination
Gordons Health Patter of Functioning
A. Health perception and Health management
Before hospitalization
ANALYSIS: According to the wife of patient X they have no
practices and routine physical examination. They only
consult to a physician if her husband is not feeling well. Mr.
Xs wife says that he is a non-smoker and occasional
drinker. She also says that her husband always practices
personal hygiene. According to his wife, they have enough
lighting, ventilation, and water supply in their house.
INTERPRETATION: Patient X doesnt have routine physical
examination and check-ups. He is hygienic and has an
adequate living

During hospitalization
ANALYSIS: Patient X wife says that her husband was n
able to perform hygienic practices such as trimming
fingernails, bathing, use of deodorant/cologne and brushi
of teeth more than before her husband has be
hospitalized. During hospitalization theyre following a
treatment regimen requested by the healthcare providers.

INTERPRETATION: Patient X cannot perform ways for his

personal hygiene, instead his family members are the one
providing for his hygienic practices.
PROBLEM: Ineffective Health maintenance related to lack
of information regarding the importance of health

B. Nutritional-Metabolic
Before hospitaliztion
ANALYSIS: Patient X wife verbalized mahilig siya sa mga
karne pero kumakain din naman ng gulay. she also says
that her husband doesnt have any food dislikes and no
discomfort in eating.

During hositalization
ANALYSIS: Patient X has difficulties in eating and drinking
He cannot eat by himself and needs to be fed by his wife.
Patients wife also said, lagi na nyang tinatanggihan yung
kahit anong pagkain

INTERPRETATION: Patient X is not a picky eater, has a

good appetite and eats variety of foods.

INTERPRETATION: He needs to be assisted by a family

member and needs to adhere by the diet that he was give
PROBLEM: Imbalanced Nutrition: less than body
requirements

C. Elimination
Before hospitalization
ANALYSIS: According to Patient Xs wife, he has no
problem about his bowel movement, defecates 5-6x a week
but has a difficulty in urinating before hospitalization since
last month despite that the urine is yellow and clear.

During hospitalization
ANALYSIS: Dumudumi siya bawat isang araw as
verbalized by patient Xs wife. She mentioned that the
characteristics of stool are soft and brown colored. The
patient has a foley catheter upon interview.

INTERPRETATION: patient X experiencing dysuria

INTERPRETATION: The patients bowel movement is

normal. The patient can urinate through foley catheter.
PROBLEM: Ineffective Elimination Pattern

D. Activity-Exercise
Before hospitalization
ANALYSIS: Patient X usually performs some of the

During hospitalization
ANALYSIS: Patient X doesnt have any physical activity. H

household chores and exercises. But as time passed, he

just spent his time sitting and watching television the whole
day.

just stays in the bed because of his condition. His family

members usually massage his extremities and move him
sometimes.

INTERPRETATION: Patient X wasnt physically active and

changed his daily routines.

INTERPRETATION: Patient X is not physically active. He

needs to be assisted especially in moving his body.
PROBLEM: Self care deficit

E. Sleep-Rest
Before hospitalization
ANALYSIS: Patient X usually sleeps around 8pm-9pm and
usually wakes up around 5am-7am, There are no any
problems that he experiences during and after sleeping.
INTERPRETATION: Patient X has no disruption in amount
and quality of sleep.
PROBLEM:

During hospitalization
ANALYSIS: he sleeps a lot most of the day.
INTERPRETATION: Patient has lots of sleep
PROBLEM: No problem on his sleeping pattern because
the patient has no disruptions upon sleeping.

F. Cognitive-Perceptual
Jean Piaget Theory/Model
Stage of devp
Formal operations
Phase/Stage

Definition
In this stage,
individuals move
beyond concrete
experiences and
begin to think
abstractly, reason
logically and draw
conclusions from the
information available,
as well as apply all
these processes to
hypothetical
situations.

Clients behavior
Not assessed, patient
currently asleep

Analysis

Interpretation

G. Role-Relationship
Erik Erikson Theory/Model
Stage of devt
Late Adulthood: 55 or
65 to Death

Definition
They reflect on the
past, and either

Clients behavior
Not assessed

Analysis
According to his wife,
his husband is happy,

Interpretation
Patient X is enable to
look back on his life

conclude at
satisfaction or
despair. This stage
begins when the
individual experiences
a sense of mortality

satisfied and shows

accomplishment
through his lifetime.

with a sense of
closure and
completeness

H. Sexuality-Reproductive
Sigmund Freud Theory
Stage of devt
Genital (puberty to
adulthood)

definition
During this stage,
the individual
develops a strong
interest in the
opposite sex. If the
other psychosexual
stages have been
successfully
completed, the
individual will
develop into a wellbalanced, warm,
and caring adult.

Clients behavior
Not assessed

Analysis
Patient X had a
wife with 6
children.

Interpretation
Patient X had a
proper outlet of the
sexual instinct as
shown that he has a
wife and 6 children.

I.

Value and Belief Pattern

Patient was born and raised by a catholic family
Goes to church every week with the family
Minsan nag rorosaryo kami magkakasama as verbalized by the patients wife

J.

Coping or Stress Pattern

Copes to any perceived stressful situation by solving any problems encountered,
Asking help with family members or friends to help him cope with the stress

REVIEW OF SYSTEMS

General

Reports total loss of appetite. Unable to ambulate. No

fever. No night sweats. No fatigue, malaise or lethargy. No
fever or chills. Patient has no troubles in falling and staying

asleep at night.

Skin

Poor skin turgor. No rashes or pruritus. Does not bruise

easily.

HEENT

No headaches or dizziness. Theres a slight decrease in

visual acuity and hearing. Pink-pale palpebral conjunctiva.
No rhinitis. No dysphagia.

Respiratory

(-) shortness of breath, no cough, no rales, no crackles

Cardiovascular

No chest pains or palpitations

Gastrointestinal

No abdominal pain. No episodes of nausea or vomiting. No

diarrhea.

Genito-urinary

Reports Dysuria, with foley catheter upon interview

Endocrine

No heat or cold intolerance. No polydipsia or polyuria.

Musculoskeleta
l

No joint pain, arthritis or muscle pain.

Neuropsychiatri
c

Patient has history of seizures. Normal mood and affect

upon interview. Conscious and coherent. Oriented to time,
place and situation.

Diagnostic Examinations

Test Name

S.I Units
Result
H 9.9 mmol/L

Reference Units
3.85 - 5.44

Conventional Units
Results
180.00 mg/dL

Reference Range
70.00 99.00

-Urea

H 9.6 mmol/L

2.5 6.4

26.89 mg/dL

7.00 17.00

-Creatinine

H 126 umol/L

53 115

1.42 mg/dL

0.60 1.30

< or = 5.2

189.19 mg/dL

< or = 200.00

- Fasting Blood
Sugar

-Cholesterol

4.9 mmol/L

-Sodium

H 149 mmol/L

136.00 145.00

149.00 mmol/L

136.00 145.00

-Potassium

L 3.4 mmol/L

3.50 5.10

3.40 mmol/L

3.50 5.10

-Chloride

H 116 mmol/L

98.00 107.00

116.00 mmol/L

98.00 107.00

Test Name
-Urea

S.I Units
Result
H 19.5 mmol/L

Reference Units
2.5 6.4

Conventional Units
Results
54.62 mg/dL

Reference Range
7.00 17.90

-Creatinine

H 435 umol/L

53 115

4.92 mg/dL

0.60 1.30

-Sodium

H 146 mmol/L

136.00 145.00

146.00 mmol/L

136.00 145.00

3.50 5.10

4.40 mmol/L

3.50 5.10

98.00 107.00

112.00 mmol/L

98.00 107.00

Reference Units
53 115

Conventional Units
Results
9.51 mg/dL

Reference Range
0.60 1.30

-Potassium

4.4 mmol/L

-Chloride

H 112 mmol/L

C
-Creatinine

S.I Units
Result
H 842 umol/L

-Potassium

4.9 mmol/L

3.50 5.10

4.90 mmol/L

3.50 5.10

-Chloride

105 mmol/L

98.00 107.00

105.00 mmol/L

98.00 107.00

-Magnessium

0.87 mmol/L

0.66 1.07

2.12 mg/dL

1.60 0 2.60

-Uric Acid

S.I Units
Result
H 945 umol/L

Reference Units
155 428

Conventional Units
Results
15.97 mg/dL

Reference Range
2.62 7.23

-Lipid Profile
Total Protein

81

g/L

64 83

8.10 g/dL

5.40 8.30

Albumin

37

g/L

35 50

3.70 mg/dL

3.50 5.00

Globulin

H 44 g/L

15 35

4.40 mg/dL

1.50 3.50

A/G RATIO

L 0.84

1.10 2.40

0.84 --

1.10 2.40

Total Bilirubin

12.3 umol/L

3.4 20.5

0.72 mg/dL

0.20 1.20

Direct Bilirubin

4.9 umol/L

0 8.6

0.29 mg/dL

0 0.50

7.4 umol/L

0 11.9

0.43 mg/dL

0.20 0.70

Test Name

Indirect
Bilirubin

SGOT AST

30.00 U/L

5 35

30.00 U/L

5 35

SGPT ALT

15 U/L

0 55

15.00 U/L

0 55

Alkaline
Phosphatase

65.00 U/L

40. 00 150.00

65.00 U/L

40.00 150.00

Test Name

S.I Units
Result
93.0 mg/dL

Reference Units

Conventional Units
Results
93.00 mg/dL

Reference Range

-Urea

H 44.0 mmol/L

2.5 6.4

123.25 mg/dL

7.00 17.90

-Creatinine

H 1376 umol/L

53 115

15.55 mg/dL

0.60 1.30

136.00 145.00

137.00 mmol/L

136.00 145.00

3.50 5.10

6.70 mmol/L

3.50 5.10

-Capillary Blood
Glucose
* @ 10:48PM

-Sodium

137 mmol/L

-Potassium

H 6.7 mmol/L

Physical Analysis
Color
Transparency

Yellow
Cloudy

Chemical Analysis
-Specific Gravity
-pH
-Protein
-Sugar
-Ketone
-Blood
-Leukocytes
-Nitrite
-Bilirubin
-Urobilinogen
-Ascorbic Acid

Result
1.012
7
+2
Normal
Trace
+2
+3
Negative
Negative
Normal
Negative

Reference Range

Less than 0.15 g/L

Less than 1.7 mmol/L
Less than 0.5 mmol/L
Less than 5 Erys/uL
Less than 25 Leukos/uL
Negative
Less than 8.5 umol/L
Less than 35 umol/L

Sediment Analysis
Result

UNIT

Reference

Result

UNIT

Reference

-Red blood
cells

/HPF

Range
0

/uL

Range
0

-White blood
cells

380

/HPF

02

1672

/uL

0 11

-Epithelial
cells

/HPF

03

/uL

0 13

-Bacteria

450

/HPF

0 - 50

1980

/uL

0 - 220

Test
-Hematology
-CBC w/ Platelet
Hemoglobin
Hematocrit
Erythrocytes
MCV
MCH
MCHC
WBC
Differential Count
Segmenters
Lymphocytes
Monocytes
Platelet Count

Result

Unit

Reference Range

107
0.32
4.77
66.5
22.4
33.8

g/L
X10^12/L
fL
pg
g/dL

135 160
0.40 0.48
4.50 5.00
80.0 96.0
27.0 33.0
33.0 36.0

7.6

X10^9/L

5.0 10.0

X10^9/L

0.55 0.65
0.25 0.40
0.02 0.06
150 - 440

0.76
0.16
0.08
245

C. Clinical Discussion
Anatomy & Physiology
Anatomy and Physiology of the Renal System

1. Kidneys
Blood flow of the
kidneys
th
nd
Located at the 12 Thoracic Vertebrae and 2 LumbarVertebrae
Also known as the COSTOVERTEBRAL ANGLE(CVA)
Color & Shape: Reddish-brownish in
color; BEANSHAPED
People have 2 kidneys, but we can
survive with just 1 kidney as long as it
isnormal

WE CANT LIVE WITHOUT AKIDNEY

The RIGHT is slightly LOWER due tothe
liver which is located at the right upper quadrant
On TOP of each kidney are the ADRENALGLANDS
The blood supply of the kidneys are
supplied by the RENALARTERIES
20 25% of the CARDIAC OUTPUT
goes to the KIDNEY! (HighlyVascular)

2. Nephrons
If in the Event
There are 1 millionnephrons
Also known as: The UNIT of functioning of theKIDNEYS!
There is damage to the
Nephrons are made upof:
kidneys
a. Glomerulus
And 20% areleft
FILTERINGELEMENT
Encapsulated by the BowmansCapsule *We should consider RENAL
b. TubularComponents
REPLACEMENT/TRANSPLANT
BowmansCapsule
ProximalTubule
Loop ofHenle
o Descending and Ascending Loop ofHenle
DistalTubule
3. Ureterss
Getsoutthroughthe
Transport of
urine from the
kidneysto
the urinary bladder is by PERISTALSIS!
Right URETER is SHORTER than the LEFT due to thelocation
Ureters is roughly about 24 40 cmLONG
Once the urine is transported, it is stored in the URINARYBLADDER
URINARY BLADDER
Storage / Reservoir ofurine
Canhold
300 ml 400 ml of urine!!

If in the Event

The person cannot void due to some factors The URINARY

BLADDER CAN HOLD UPTO 1 LITER ofURINE!
But Can BRING DAMAGE to the muscles of thebladder
To PREVENTDAMAGE:
o
Instruct to VOID every 3HOURS

4. Urethra
If in the Event
Function: For the passageway of urine to theoutside
Female Urethras are more shorter,
a. Male: (Size andFunction)
then they are more at risk for UTI /
1. Excretion ofurine
Ascendinginfections
2. Reproduction (Passage ofsemen)
b. Female: (Size differs frommale)
1. Excretion of urineONLY
NursingConsideration
Correct technique of perineal care (UP DOWN)
Urethritis Males have a much larger emotional IMPACT
Functions of the Kidney
1. UrineFormation
GlomerularFiltration
TubularReabsorption
TubularExcretion
2. Excretion of wasteproducts
UREA is the most important waste
producttoberemoved!!
Assessment of KidneyFunction
BUN (Blood Test)
Urea (24 Hour urine collection!~)
Creatinine
If in the Event
Sulfate
Phosphate
There is an abnormal LIVER, then the ammonia cant be
URIC ACID Waste product of
converted into urea, there would be an ACCUMULATION
Purine metabolism
of WASTEPRODUCTS
(At risk for HEPATIC ENCEPHALOPATHY)
Waste products of drugs!

Situation

Start
End

NO UREA if NOPROTEIN~
Intake of PROTEIN is , then amount of UREA is also

Saturday 7:00 AM
Sunday 7:00 AM

Saturday woke up at 8:30 AM,DISCARD

and not part of the 24 Hour urine collection
But when urinated at 9:00 AM, already a part of thecollection

3. Regulation ofElectrolytes
Sodium (Na) [135 145mEq/L)
If in the Event
Most ABUNDANT electrolyte in the ECF!
Normal Intake: 6 8 grams
There is more INTAKE ofNa
Then there would be
Function: Where Na goes, H2O goes
OVERHYDRATION!
Potassium (K) [3.5 5.5mEq/L]
Most ABUNDANT electrolyte in the ICF
Normal Intake: 6 8 grams
o The amount of Na and K passed out is affected byAldosterone
o DietaryIntake:
K Diet =Hyperkalemia
K Diet =Hypokalemia
GREATEST PROBLEM IS WHEN K
CANNOT BE EXCRETED(heartcontraction)

4. Regulates Acid-BaseBalance
Two Functions of the kidneys for regulating acid-basebalance
i. REABSORPTION ofBICARBONATE
fl TubularReabsorptionBringsbacktheHCO3tothecirculation
ii. EXCRETION of URICACID
fl TubularExcretion
5. Control of H2OBalance
If in the Event
Controlled through URINEOUTPUT
Fluid intake (DILUTEDURINE)
Amount of fluid intake should be equal to theoutput

Fluid intake (CONCENTRATEDURINE)

6. Control of BloodPressure
Vasa Recta
Special type of bloodvessel
Responsibleforrecognizingpressureonthebloodvessel
7. RenalClearance
Ability of the kidney to CLEAR solutes from theplasma
To perform: Use the 24 Hour UrineCollection
8. Production of erythropoietin or regulation of RBCproduction
ErythropoietinBoneMarrowErythropoiesis

9. Synthesis of Vitamin D to its activeFORM

Functions of VitaminD
o To maintain the normal balance of Ca in thebody
o Sun is a good source for VitaminD
(Infants are exposed under the sun for 10 15 minutes)
o 1,25dihydroxycholecalciferol
10. Production ofPROSTAGLANDIN
Produces VASODILATION
To maintain the normal renal blood flow

D. Medical/Surgical Interventions
Acute Kidney Injury
Acute Kidney Injury (AKI), which is characterised by a sudden rise in blood urea and creatinine secondary
to an underlying fall in glomerular filtration rate (GFR), with or without decreased urine output, is common
in patients in hospital. The most frequent cause, from which recovery is eminently possible, is acute
tubular necrosis (ATN). This is usually the result of hypovolaemia (surgery, haemorrhage, burns), sepsis
or nephrotoxic insult (e.g. drugs, IV contrast media, myoglobinaemia or haemoglobinaemia). Other less
common causes of AKI are obstruction, acute interstitial nephritis, as seen with drug hypersensitivity, and
rapidly progressive glomerulonephritis occurring as a primary event or complicating multi-system disease.
AKI has been classified into three stages (see table below).
AKI is sometimes associated with a normal urine output or even polyuria. More often there is oliguria
(urine output less than 400 ml/day) and occasionally anuria. If there is complete anuria exclude
obstruction by ultrasound examination or, if there could be bladder outlet obstruction, by passing a
bladder catheter (note the urine volume passed).
Definition and stages of Acute Kidney Injury (AKI)

Stage I
Stage II
Stage III

Creatinine (increase in levels

over 48 hours)
1.5- 1.9 fold rise from baseline
or 26 mol/L within 48 hours
2-2.9 fold rise from baseline
3 fold rise from baseline or >
300 mol/L or increase of > 50
mol/L or renal replacement
therapy irrespective of stage

Urine output
0.5 ml/kg/hr for >6 hours
0.5 ml/kg/hr for >12 hours
0.3 ml/kg/hr for > 24 hours or
anuria for >12 hours

ACUTE KIDNEY INJURY CARE BUNDLE

THIS IS A MEDICAL EMERGENCY
Institute for all stages of AKI (1-3)
CONSULTANT REVIEW within 24 hours

Airway Breathing Circulation

Full set of physiological observations
Assess for signs of shock/hypoperfusion
If necessary give oxygen, begin resuscitation and contact ICU

Fluid therapy in AKI

If hypovolaemic, give bolus 250 ml 0.9% sodium chloride
Continue with crystalloid until volume replete
Review response regularly: HR, BP, JVP, capillary refill, mental status
Senior review (SPR or above) if >2 litres IV rehydration needed

If fluid replete give maintenance fluids: estimated fluid output + 500 ml/24 hours
Set daily targets for fluid input and output

Monitoring in AKI
Insert urinary catheter and measure hourly urine volume
Hourly fluid balance recording on fluid chart
At least 4 hourly observations for temperature, pulse, BP, O2 saturations
Twice daily urea, creatinine and electrolytes whilst creatinine is rising
Arterial blood gases
Daily weight
If oliguria > 6 hours +/- creatinine rising, consider central venous pressure (CVP) monitoring : aim
for CVP 8-12 cm above the mid-axillary line

Investigation of AKI
Mandatory except for cases with multi-organ failure or obvious precipitant
Urine dipstick: for blood and protein (glomerulonephritis; consider systemic immune disease)
Ultrasound scan < 24 hours after recognition (to look for obstruction)
Significant proteinuria: urgent urine Bence Jones Protein (myeloma)
Liver function (hepatorenal syndrome); Creatinine kinase (CK for rhabdomyolysis)
Low platelets: blood film, LDH, bilirubin and reticulocytes (Haemolytic Uraemic Syndrome)
Other AKI care
Treatment of sepsis: antibiotics < 1 hour after diagnosis (refer to section Severe Sepsis)
Stop NSAIDs, ACE inhibitors, Angiotensin receptor blockers, metformin, potassium-sparing
diuretics. Review all other drug doses. If low BP stop anti-hypertensives
Avoid radiological contrast (if possible). If given, follow prophylaxis protocol

MANAGEMENT
Use the AKI care bundle algorithm (above)
1. Assess status of patients circulating blood volume. Measurement of CVP may be essential in
very unwell patients. However, in patients who are clearly volume depleted it is probably safer
(and technically easier) to go some way to achieving repletion before attempting central venous
access.
2. Correct hypovolaemia using sodium chloride 0.9% or colloids to achieve correction of
hypotension, tachycardia and other sings of hypovolaemia; if possible a CVP (mid-axillary line as
zero) of 8-10cm H2O.
3. 3. Treat hyperkalaemia (K+ greater than 6.5mmol/L). Refer to the next chapter: Electrolyte
disturbances (Hyperkalaemia)
4. 4. Monitor urine output. Insert a urinary catheter. If there is oliguria/anuria, it needs to remain in
situ.
5. 5. If the systolic BP is < 100mmHg despite optimal intravascular volume, discuss the position with
the ITU/ICU SpR with a view to inotropic support.
6. 6. If diuresis does not occur despite achieving optimal intravascular volume, give fluid hourly on
the basis of replacing measured losses plus estimated insensible losses (approximately 30ml/h)
appropriate to clinical state. The primary goal is to achieve optimal (blood) volume; urine flow is of
secondary importance.
7. 7. Examine urine for protein, dysmorphic RBC and RBC casts (indicating a glomerular disorder),
urine sodium, urine creatinine, and urine osmolality. If the urine sodium is <10 mmol/L or the
FeNa<1%* the patient is probably still volume depleted.
*FeNa = Fraction of plasma sodium excreted in the urine
= (urine sodium divided by plasma sodium/ urine creatinine divided by plasma creatinine) x 100
8. Urinary and other sepsis should be treated and any potentially nephrotoxic drugs stopped. Give
all patients an H2-blocker or proton pump inhibitor to prevent gastrointestinal haemorrhage.
Renal ultrasound must be performed as soon as possible to exclude obstructive nephropathy and
to assess renal size. Also do urine microscopy and culture. Loss of parenchymal mass with small
kidneys suggests chronic renal disease. Renal biopsy should be considered if there are atypical
clinical features or features to suggest a multisystem disease.
9. Measure arterial pH and plasma bicarbonate. To help correct acidosis (if pH<7.20) give 50-100ml
of 8.4% sodium bicarbonate slowly IV into a central vein. A lower concentration of sodium
bicarbonate (1.26%) can be given if the CVS can cope with the larger volume of infusion needed.
Seek senior/ITU advice.
Indications for dialysis or haemofiltration:
Life-threatening or intractable pulmonary oedema
Uncontrollably rising K+
Severe (pH < 7.2) or worsening acidosis
Uraemia (eg. uraemic pericarditis)
Early referral to the consultant renal physician should be considered in any patient with:
AKI stage 3 176
Oliguria or anuria
Creatinine > 400mol/L
K + > 6.5mmol/L

Remember AKI can often be prevented. So, for example, take special care to avoid volume depletion in
high-risk patients (e.g. those with diabetes, myeloma, or established renal failure), and those subjected to
overnight fast, surgery or investigations involving IV contrast. Hypovolaemia due to blood or fluid loss
should be avoidable or rapidly reversible. Be very cautious when using drugs such as aminoglycosides
and NSAIDs that might cause renal damage.
Checklist for patients with AKI (stages 1-3):
1. Review of drugs stop all nephrotoxic drugs
2. Urinalysis
3. IV fluid status
4. Catheterisation and hourly fluid balance recordings
5. Ultrasound kidneys within 24 hours of onset
6. Consultant review within 12 hours of onset
7. Timely referral to a nephrologist

E. Nursing Management

Discharge Planning
Discharge Planning for Pneumonia
Objectives:
1.
2.
3.
4.
5.

Ventilation and oxygenation adequate for individual needs.

Complications prevented/minimized.
Disease process/prognosis and therapeutic regimen understood.
Lifestyle changes identified/initiated to prevent recurrence.
Plan in place to meet needs after discharge.

Seek care immediately if:

You are confused and cannot think clearly.

You have increased trouble breathing.

Your lips or fingernails turn gray or blue.

Contact your healthcare provider if:

Your symptoms do not get better, or they get worse.

You are urinating less, or not at all.

You have questions or concerns about your condition or care.

Medicines:

Medicines may be given to treat a bacterial, viral, or fungal infection. You may also be given
medicines to dilate your bronchial tubes to help you breathe more easily.
Take your medicine as directed. Call your healthcare provider if you think your medicine is not
helping or if you have side effects. Tell him if you are allergic to any medicine. Keep a list of the
medicines, vitamins, and herbs you take. Include the amounts, and when and why you take them.
Bring the list or the pill bottles to follow-up visits. Carry your medicine list with you in case of an
emergency.

Follow up with your healthcare provider within 3 days or as directed:

You may need another x-ray. Write down your questions so you remember to ask them during your
visits.

Deep breathing and coughing:

Deep breathing helps open the air passages in your lungs. Coughing helps bring up mucus from
your lungs. Take a deep breath and hold the breath as long as you can. Then push the air out of your
lungs with a deep, strong cough. Spit out any mucus you have coughed up. Take 10 deep breaths in
a row every hour that you are awake. Remember to follow each deep breath with a cough.

Do not smoke or allow others to smoke around you:

Nicotine and other chemicals in cigarettes and cigars can cause lung damage. Ask your healthcare
provider for information if you currently smoke and need help to quit. E-cigarettes or smokeless
tobacco still contain nicotine. Talk to your healthcare provider before you use these products.

Manage CAP at home:

Breathe warm, moist air. This helps loosen mucus. Loosely place a warm, wet washcloth over
your nose and mouth. A room humidifier may also help make the air moist.
Drink liquids as directed. Ask your healthcare provider how much liquid to drink each day and
which liquids to drink. Liquids help make mucus thin and easier to get out of your body.
Gently tap your chest. This helps loosen mucus so it is easier to cough. Lie with your head lower
than your chest several times a day and tap your chest.
Get plenty of rest. Rest helps your body heal.

Prevent CAP:

Wash your hands often with soap and water. Carry germ-killing hand gel with you. You can use
the gel to clean your hands when soap and water are not available. Do not touch your eyes, nose, or
mouth unless you have washed your hands first.
Clean surfaces often. Clean doorknobs, countertops, cell phones, and other surfaces that are
touched often.
Always cover your mouth when you cough. Cough into a tissue or your shirtsleeve so you do not
spread germs from your hands.
Try to avoid people who have a cold or the flu. If you are sick, stay away from others as much as
possible.
Get the influenza vaccine each year to prevent the flu. The virus that causes the flu can also
cause viral pneumonia. If you have immunization records, show them to your healthcare provider.
You may need other vaccines or booster shots to prevent pneumonia and other infections.

Discharge Plan for Obstructive Uropathy

Objectives of Care:

Homeostasis achieved.

Complications prevented or minimized.

Dealing realistically with current situation.

Disease process, prognosis, and therapeutic regimen understood.

Plan in place to meet needs after discharge.

Home care

Follow any instructions for eating and drinking given to you by your doctor.

Keep a record of everything you eat and drink.

Measure the amount of urine and stool you have each day.

Weigh yourself every day, at the same time of day, and in the same kind of clothes. Keep a daily
record of your daily weights.

Take your temperature every day. Keep a record of the results.

Learn to take your own blood pressure. Keep a record of your results. Ask your doctor when you
should seek emergency medical attention. He or she will tell you which blood pressure reading is
dangerous.

Avoid contact with people who have infections (colds, bronchitis, or skin conditions).

Practice good personal hygiene. This is especially important if you have a catheter in place when
you leave the hospital. Doing so helps keep you safe from infection.

Take your medications exactly as directed.

You may require frequent blood and urine tests to monitor your kidney function.

Follow-up care
Make a follow-up appointment as directed by our staff.

When to seek medical care

Call your doctor right away if you have any of the following:

Signs of bladder infection (urinating more often than usual; burning, pain, bleeding, or hesitancy
when you urinate)

Signs of infection around your catheter (redness, swelling, warmth, or drainage)

Rapid weight loss or gain, such as 3 pounds or more in 24 hours or 6 pounds or more in 7 days

Fever above 100.4F (38.0C) or chills

Muscle aches

Night sweats

Very little or no urine output

Swelling of your hands, legs, or feet

Back pain

Abdominal pain

Extreme tirednes