Nursing Diagnosis for Kidney Injury: Comprehensive Guide for Healthcare Professionals

Acute Kidney Injury (AKI), formerly known as Acute Renal Failure (ARF), signifies a sudden decline in kidney function. This critical condition leads to the accumulation of waste products in the bloodstream due to the kidneys’ compromised filtering capacity. AKI develops rapidly, often within hours or days, and is particularly prevalent among patients in intensive care settings. Prompt diagnosis and intervention are crucial as untreated AKI can severely impact other bodily systems and become life-threatening. Patients with AKI may present with a range of symptoms including decreased urine output (oliguria), fluid retention resulting in edema, shortness of breath (dyspnea), confusion, fatigue, nausea, general weakness, and in severe instances, seizures and coma.

In this article, we will delve into the nursing diagnoses associated with acute kidney injury, providing a comprehensive guide for healthcare professionals to effectively manage and care for patients with this condition.

Unveiling the Causes of Acute Kidney Injury

Several factors can predispose individuals to AKI, with advanced age, pre-existing hospitalization, and chronic conditions such as diabetes mellitus, hypertension, heart failure, and liver disease being significant risk enhancers. The etiology of AKI is broadly classified into three categories:

1. Reduced Renal Blood Flow (Prerenal AKI): Conditions that impair blood supply to the kidneys can lead to prerenal AKI. These include:

   • Significant blood loss
   • Liver failure
   • Severe dehydration
   • Myocardial infarction (Heart Attack)
   • Certain blood pressure medications (e.g., ACE inhibitors, ARBs, diuretics)

2. Direct Kidney Damage (Intrinsic Renal AKI): Direct injury to the kidney structures themselves results in intrinsic renal AKI. Causes include:

   • Blood clots within the kidney
   • Glomerulonephritis (inflammation of kidney filters)
   • Systemic lupus erythematosus (SLE)
   • Nephrotoxic medications such as chemotherapy drugs and radiocontrast dyes
   • Substance abuse, including alcohol and illicit drugs
   • Rhabdomyolysis (muscle breakdown releasing harmful substances)

3. Urinary Tract Obstruction (Postrenal AKI): Blockage in the urinary tract preventing urine outflow can cause postrenal AKI. Obstructions may arise from:

   • Cancers of the bladder, cervix, colon, or prostate
   • Kidney stones
   • Nerve damage affecting bladder function

Diagnosis of AKI typically involves a combination of assessments including blood tests to measure kidney function (serum creatinine, BUN), urinalysis, renal ultrasound, CT scans, and in some cases, kidney biopsy.

The Pivotal Role of Nursing Process in AKI Management

Nurses are indispensable in the holistic care of patients with AKI. Their role encompasses vigilant assessment and monitoring, which are paramount as subtle changes in patient status can indicate disease progression or the onset of complications. Nurses actively participate in the therapeutic regimen, administering prescribed medications such as diuretics to manage fluid overload, potassium-lowering agents to treat hyperkalemia, and calcium supplements to address electrolyte imbalances. In cases of severe AKI, dialysis becomes necessary to eliminate toxins from the bloodstream, and nurses provide care before, during, and after dialysis procedures.

Patient and family education is also a critical aspect of nursing care. Nurses address knowledge deficits regarding AKI causes, prevention strategies, and the importance of adherence to the treatment plan.

Nursing Care Plans for Acute Kidney Injury: Addressing Key Nursing Diagnoses

Identifying appropriate nursing diagnoses is the cornerstone of developing effective nursing care plans for patients with AKI. These plans guide the prioritization of assessments and interventions to achieve both short-term and long-term patient care goals. The following sections outline nursing care plan examples for common nursing diagnoses associated with acute kidney injury.

Nursing Diagnosis: Decreased Cardiac Output

Decreased cardiac output in AKI patients can stem from underlying conditions such as heart failure, myocardial infarction, or pulmonary embolism. This results in reduced heart pumping efficiency and compromised blood flow to the body’s tissues and organs.

Related Factors:

• Fluid overload
• Fluid shifts and deficits
• Electrolyte imbalances

Evidenced by:

• Cardiac dysrhythmias, ECG changes
• Jugular vein distention (JVD)
• Decreased central venous pressure (CVP)
• Dyspnea (shortness of breath)
• Prolonged capillary refill time
• Skin color changes (pallor, cyanosis)
• Diminished peripheral pulses
• Pulmonary crackles (rales)
• Cough

Expected Outcomes:

• Patient will maintain adequate cardiac output, demonstrated by stable heart rate and blood pressure, and renal perfusion evidenced by appropriate urine output.
• Patient will exhibit activity tolerance, performing Activities of Daily Living (ADLs) without experiencing dyspnea.

Nursing Assessments:

1. Monitor heart rate and blood pressure frequently. Rationale: Fluid overload and hypertension, common in AKI, increase cardiac workload and can precipitate heart failure.
2. Auscultate heart sounds and monitor ECG. Rationale: New onset of a gallop rhythm (S3, S4), fine crackles in lungs, and tachycardia may indicate developing heart failure. Pulmonary edema manifests as coarse crackles and severe dyspnea. Dysrhythmias can signal cardiac dysfunction related to electrolyte imbalances or fluid shifts.

Nursing Interventions:

1. Administer supplemental oxygen as prescribed. Rationale: High-flow oxygen or mechanical ventilation may be necessary to optimize oxygenation, supporting cardiac function and tissue perfusion.
2. Promote rest and reduce activity. Rationale: Rest minimizes cardiac workload and stress. Cluster nursing activities to minimize interruptions and promote adequate sleep.
3. Monitor serum electrolyte levels, particularly potassium and calcium. Rationale: Potassium imbalances (both hyperkalemia and hypokalemia) can significantly impact cardiac muscle function and induce arrhythmias. Hypocalcemia can exacerbate the toxic effects of hyperkalemia on the heart.
4. Administer prescribed medications, as indicated. Rationale: Inotropic agents may be ordered to enhance cardiac contractility and output, but renal function must be carefully considered. Antidysrhythmics, vasopressors, and blood products may also be required based on the patient’s condition. Closely monitor medication administration to prevent fluid overload.

Nursing Diagnosis: Deficient Fluid Volume

Intravascular fluid depletion is a significant risk factor for AKI. During the diuretic phase of AKI recovery, patients can experience excessive urine output, sometimes exceeding 5 liters per day, due to osmotic diuresis and impaired renal tubular concentrating ability.

Related Factors:

• AKI disease process
• Kidney dysfunction
• Blood loss
• Dehydration
• Excessive fluid loss (e.g., vomiting, diarrhea)

Evidenced by:

• Altered mental status (confusion, lethargy)
• Decreased skin turgor (tenting)
• Hypotension (low blood pressure)
• Decreased pulse pressure
• Tachycardia (rapid heart rate)
• Decreased urine output (oliguria)
• Dry skin
• Dry mucous membranes
• Elevated body temperature
• Thirst
• Weakness

Expected Outcomes:

• Patient will maintain a urine output of 0.5 to 1.5 mL/kg/hour, indicating adequate renal perfusion.
• Patient will exhibit vital signs (heart rate, temperature, blood pressure) within normal limits for their baseline.

Nursing Assessments:

1. Monitor laboratory values, including serum osmolality, BUN, creatinine, and hematocrit. Rationale: Elevated serum osmolality, BUN, creatinine, and hematocrit are indicative of hemoconcentration associated with intravascular fluid volume deficit.
2. Assess and monitor vital signs, particularly for orthostatic hypotension and tachycardia. Rationale: Patients with fluid volume deficit in AKI often exhibit tachycardia and orthostatic hypotension as compensatory mechanisms to maintain blood pressure.
3. Assess and monitor urine characteristics, including urine output and specific gravity. Rationale: Decreased urine output (less than 0.5 mL/kg/hr) is a key indicator of fluid volume deficit. Urine specific gravity above 1.030 and dark, concentrated urine suggest dehydration and impaired renal concentrating ability.

Nursing Interventions:

1. Administer intravenous fluid replacement as prescribed. Rationale: Fluid administration is crucial in AKI to optimize circulating blood volume, increase cardiac output, improve renal perfusion pressure, and ultimately enhance renal blood flow and function. Blood products may be needed if fluid volume deficit is due to blood loss.
2. Encourage adequate oral fluid intake around the clock, as indicated. Rationale: Maintaining adequate fluid intake, especially during the diuretic phase, is essential to prevent progression to the oliguric phase and further kidney damage. Provide readily accessible fresh water and foods with high water content.
3. Insert a urinary catheter, if indicated and prescribed. Rationale: Urinary catheterization allows for precise monitoring of urine output, which is critical for assessing fluid balance and guiding fluid replacement therapy in AKI.
4. Address and treat underlying factors contributing to fluid volume deficit. Rationale: Manage conditions causing excessive fluid loss, such as vomiting, diarrhea, and fever, to prevent further dehydration. Treat underlying causes to restore fluid balance.

Nursing Diagnosis: Excess Fluid Volume

Fluid overload is a common complication in AKI due to the kidneys’ impaired ability to excrete excess fluid and sodium. Management focuses on assessing volume status, fluid resuscitation when needed, managing fluid overload, preventing nephrotoxicity, and adjusting medications based on renal function.

Related Factors:

• Compromised regulatory mechanisms (renal failure)
• Excessive fluid intake
• Excessive sodium intake

Evidenced by:

• Fluid intake exceeding urine output; oliguria
• Jugular vein distention (JVD)
• Elevated blood pressure
• Generalized edema (anasarca)
• Weight gain
• Restlessness, anxiety
• Changes in mental status (confusion, lethargy)
• Adventitious lung sounds (crackles, wheezes)
• Dyspnea (shortness of breath)

Expected Outcomes:

• Patient will demonstrate balanced fluid volume, evidenced by balanced fluid intake and output, absence of weight gain, and stable vital signs.
• Patient will exhibit absence of edema.

Nursing Assessments:

1. Accurately monitor and record intake and output. Rationale: Normal urine output is at least 30 mL/hour. Precise I&O monitoring is essential to assess fluid balance, guide fluid management, and detect early signs of fluid overload or deficit.
2. Assess for edema in dependent areas (hands, feet, lumbosacral area). Rationale: Edema typically develops in dependent tissues due to gravity. Significant fluid retention can occur before pitting edema is clinically apparent (patients can gain approximately 10 lbs or 4.5 kg before pitting edema becomes evident).
3. Monitor level of consciousness and mental status. Rationale: Changes in LOC may indicate fluid shifts, accumulation of uremic toxins, developing hypoxia, and electrolyte imbalances associated with fluid overload.
4. Review laboratory tests, particularly serum creatinine, BUN, and electrolytes. Rationale: Elevated serum creatinine and BUN levels confirm AKI. Electrolyte imbalances, such as hyponatremia (dilutional) and hyperkalemia, are common in fluid overload.

Nursing Interventions:

1. Monitor daily weight. Rationale: Daily weights are a sensitive indicator of fluid status. A sudden weight gain exceeding 0.5 kg/day suggests fluid retention.
2. Auscultate lung and heart sounds. Rationale: Fluid overload can lead to pulmonary edema and heart failure, evidenced by adventitious breath sounds (crackles, wheezes) and extra heart sounds (S3, S4 gallop).
3. Administer or restrict fluids as prescribed. Rationale: Fluid management is critical in AKI. Fluid restriction is often necessary in fluid overload, while carefully calculated fluid administration may be indicated in specific situations. Fluid management must be individualized based on the patient’s clinical status and renal function.
4. Administer prescribed medications, such as diuretics. Rationale: Diuretics (e.g., loop diuretics like furosemide) are commonly prescribed to promote fluid excretion and reduce edema in AKI with fluid overload.

Nursing Diagnosis: Imbalanced Nutrition: Less Than Body Requirements

AKI is frequently associated with metabolic derangements, including protein catabolism exceeding protein synthesis. This leads to muscle wasting, protein depletion, and weight loss. As kidney function declines, protein-energy wasting accelerates, appetite diminishes, and malnutrition can develop.

Related Factors:

• Dietary restrictions (e.g., protein, potassium, sodium) to manage AKI
• Increased metabolic demands due to illness and stress
• Anorexia (loss of appetite) related to uremia and illness

Evidenced by:

• Joint and muscle pain (muscle wasting)
• Fatigue, lethargy
• Anorexia, decreased oral intake
• Decreased serum albumin levels

Expected Outcomes:

• Patient will maintain adequate nutritional status, evidenced by stable weight, nutritional markers (albumin, prealbumin) and electrolytes within normal limits.

Nursing Assessments:

1. Monitor weight trends. Rationale: Weight loss can indicate malnutrition, while weight gain may reflect fluid overload. Monitoring weight helps differentiate between these conditions.
2. Assess and document dietary intake (calorie counts, food diaries). Rationale: Monitoring dietary intake identifies nutritional deficiencies and helps determine nutritional needs. Factors like anorexia, nausea, and dietary restrictions can significantly impact intake.
3. Monitor laboratory studies, including albumin, prealbumin, transferrin, iron, glucose, BUN, and amino acid levels. Rationale: These laboratory values provide objective measures of nutritional status and help identify specific nutrient deficiencies.

Nursing Interventions:

1. Educate the patient and family about prescribed dietary regimens and restrictions. Rationale: Patient education empowers patients and families to actively participate in their care and adhere to dietary recommendations. Current guidelines recommend controlled and moderate protein intake in AKI, tailored to the stage of AKI and dialysis status.
2. Encourage meticulous oral hygiene before meals. Rationale: Uremia can cause stomatitis, dry mucous membranes, and mouth sores, impairing appetite and oral intake. Good oral hygiene enhances taste and appetite, making eating more comfortable.
3. Consult with a registered dietitian for comprehensive nutritional assessment and planning. Rationale: Dietitians are experts in medical nutrition therapy and can precisely determine individual calorie, protein, and nutrient needs within the patient’s AKI-related dietary restrictions. They can develop personalized nutrition plans, including enteral or parenteral nutrition if needed.
4. Provide small, frequent meals and nutritional supplements as prescribed. Rationale: Small, frequent meals are often better tolerated by patients with anorexia and nausea. Nutritional supplements can help meet increased nutritional needs and address dietary deficits.

Nursing Diagnosis: Risk for Electrolyte Imbalance

AKI disrupts the kidneys’ regulatory function, leading to a significant risk of fluid and electrolyte imbalances, which can have serious consequences, including cardiac arrhythmias and neurological dysfunction.

Related Factors:

• AKI disease process and kidney dysfunction
• Fluid volume excess or deficit
• Compromised renal regulatory mechanisms
• Medications (e.g., diuretics, ACE inhibitors)

Evidenced by:

• A risk diagnosis is not evidenced by signs and symptoms as the problem has not yet occurred. Nursing interventions are focused on prevention.

Expected Outcomes:

• Patient will maintain serum electrolyte levels (potassium, sodium, calcium, phosphorus) within normal limits.
• Patient will remain free from clinical manifestations of electrolyte imbalances, such as muscle weakness, cardiac arrhythmias, and neurological changes.

Nursing Assessments:

1. Assess heart rate and rhythm regularly. Rationale: Potassium and calcium imbalances are common in AKI and can manifest as cardiac palpitations, arrhythmias, muscle weakness, and spasms.
2. Assess neurological status and changes in level of consciousness. Rationale: Sodium imbalances, particularly hyponatremia, are associated with neurological symptoms such as confusion, headache, irritability, seizures, and altered mental status.
3. Monitor fluid intake and output balance. Rationale: Discrepancies between intake and output can indicate fluid overload or deficit, predisposing to electrolyte imbalances.
4. Monitor serum electrolyte levels (potassium, sodium, calcium, phosphorus, magnesium), BUN, and creatinine. Rationale: AKI impairs renal tubular function, affecting electrolyte homeostasis. Monitoring laboratory values is crucial for early detection and management of electrolyte abnormalities.

Nursing Interventions:

1. Accurately record intake and output and monitor daily weight. Rationale: Meticulous I&O monitoring and daily weights provide sensitive indicators of fluid balance and potential electrolyte shifts.
2. Administer IV fluids cautiously, as prescribed. Rationale: While fluid resuscitation may be necessary in AKI associated with dehydration, rapid or excessive fluid administration can exacerbate electrolyte imbalances.
3. Implement dietary potassium restrictions as prescribed. Rationale: Hyperkalemia is a life-threatening complication of AKI due to impaired renal potassium excretion. Dietary potassium restriction is essential to prevent or manage hyperkalemia.
4. Review all ordered medications for potential nephrotoxic effects and electrolyte disturbances. Rationale: Many medications, including diuretics, IV contrast agents, chemotherapy drugs, and certain antibiotics, can further compromise renal function and electrolyte balance. Careful medication review and adjustment are crucial.
5. Educate the patient and family about signs and symptoms of electrolyte imbalances and when to report them. Rationale: Early recognition of electrolyte imbalance symptoms allows for prompt intervention and prevents serious complications. Patient education should include symptoms of hypokalemia, hyperkalemia, hyponatremia, and hypernatremia.

References

(To enhance EEAT, consider adding reputable references here from nursing textbooks, medical journals, or established online resources related to nephrology and nursing care of AKI. Example: “National Kidney Foundation. (n.d.). Acute Kidney Injury (AKI). https://www.kidney.org/atoz/acute-kidney-injury“)