Acute Kidney Injury (AKI) Prevention PDF

2/22/24, 2:39 PM Realizeit for Student Prevention AKI has a high mortality rate that ranges from 10% to 80%. Factors that influence mortality include severity of kidney injury, level and availability of medical care, requirements for RRT, increased age, increased number of comorbid conditions, and p...

2/22/24, 2:39 PM Realizeit for Student Prevention AKI has a high mortality rate that ranges from 10% to 80%. Factors that influence mortality include severity of kidney injury, level and availability of medical care, requirements for RRT, increased age, increased number of comorbid conditions, and preexisting kidney and vascular diseases and respiratory failure (Odom, 2017). Therefore, prevention of AKI is essential. A careful history is obtained to identify exposure to nephrotoxic agents or environmental toxins. The kidneys are susceptible to the adverse effects of medications because the metabolic by-products of most medications are excreted by the kidneys. Patients taking nephrotoxic medications (e.g., aminoglycosides, such as gentamicin and tobramycin, polymyxin B, amphotericin B, vancomycin, amikacin, cyclosporine, tacrolimus) should have drug levels monitored closely, since high serum levels will cause changes in renal function. Kidney function needs to be monitored prior to initiation of these medications and during therapy (Schira, 2017). Chronic use of analgesic agents, particularly NSAIDs, may cause interstitial nephritis (inflammation within the renal tissue) and papillary necrosis. Patients with heart failure or cirrhosis with ascites are at particular risk for NSAID-induced kidney disease. Increased age, preexisting kidney disease, diabetes, and the simultaneous administration of several nephrotoxic agents increase the risk of kidney damage (Schira, 2017; Schonder, 2017). Contrast-induced acute kidney injury is a major cause of hospital-acquired AKI. However, this is potentially preventable in many, but not all, cases. Patients at high risk for the development of contrast-induced AKI are those with CKD and/or elevated creatinine due to dehydration. Those who need to undergo a coronary interventional procedure, which requires larger amounts of contrast media to be given, are at the greatest risk. Limiting the patient’s exposure to contrast agents and nephrotoxic medications will reduce the risk of contrasted-induced AKI. Prehydration with IV normal saline is considered the most effective method to prevent contrast-induced AKI. N-acetylcysteine administration is no longer recommended as a preventative measure (Nahar, 2017). Gerontologic Considerations About half of all patients who develop AKI during hospitalization are older than 60 years and 40% have diabetes (Pavkov, Harding, & Burrows, 2018). The etiology of AKI in older adults includes prerenal causes such as dehydration, intrarenal causes such as nephrotoxic agents (e.g., medications, contrast agents), and complications of major surgery (Hain, 2017). Suppression of thirst, enforced bed rest, lack of access to drinking water, and confusion all contribute to the older patient’s failure to consume adequate fluids and may lead to dehydration, further compromising already decreased renal function. AKI in older adults is also often seen in the community setting. Nurses in the ambulatory setting need to be aware of the risk to patients taking medications that could result in damage to the kidney either through reduced circulation or nephrotoxicity. Outpatient procedures that require fasting or a bowel preparation may cause dehydration and, therefore, patients undergoing such procedures need careful monitoring. Medical Management The kidneys have a remarkable ability to recover from insult. The objectives of treatment for AKI are to restore normal chemical balance and prevent complications until repair of renal tissue and restoration of renal function can occur. Management includes eliminating the underlying cause; maintaining fluid balance; avoiding fluid excesses; and, when indicated, providing RRT. Prerenal azotemia is treated by optimizing renal perfusion, whereas postrenal failure is treated by relieving the obstruction. Intrarenal or intrinsic azotemia is treated with supportive therapy, with removal of causative agents, aggressive management of pre- and postrenal failure, and avoidance of associated risk factors. Shock and infection, if present, are treated promptly. The patient who has had a crush injury, compartment syndrome, or heatinduced illness with subsequent myoglobinuria (myoglobin in the urine) is treated for rhabdomyolysis (Odom, 2017). Maintenance of fluid balance is based on daily body weight, serial measurements of central venous pressure, serum and urine concentrations, fluid intake and output, blood pressure, and the clinical status of the patient. The parenteral and oral intake and the output of urine, gastric drainage, stools, wound drainage, and perspiration are calculated and are used as the basis for fluid replacement. The insensible fluid produced through the normal metabolic processes and lost through the skin and lungs is also considered in fluid management. Fluid excesses can be detected by the clinical findings of dyspnea, tachycardia, and distended neck veins. The patient’s lungs are auscultated for moist crackles. Because pulmonary edema may be caused by excessive administration of parenteral fluids, extreme caution must be used to prevent fluid overload. The development of generalized edema is assessed by examining the presacral and pretibial areas several times daily. Furosemide or bumetanide, both loop diuretics, may be prescribed to initiate diuresis, although there is no consensus regarding the use of loop diuretics in AKI (Odom, 2017). https://herzing.realizeithome.com/RealizeitApp/Student.aspx?Token=lqf9HhURQ5RqpgqAkzH2zYjdcLReD0xWqoW33TqQEI8BS%2f7OmZzvGp21HqGixm2HQ… 1/4 2/22/24, 2:39 PM Realizeit for Student Adequate renal blood flow in patients with prerenal causes of AKI may be restored by IV fluids or transfusions of blood products. If AKI is caused by hypovolemia secondary to hypoproteinemia, an infusion of albumin may be prescribed. Dialysis may be initiated to prevent complications of AKI, such as hyperkalemia, metabolic acidosis, pericarditis, and pulmonary edema. Dialysis corrects many biochemical abnormalities; allows for liberalization of fluid, protein, and sodium intake; diminishes bleeding tendencies; and promotes wound healing. Hemodialysis (HD) (a procedure that circulates the patient’s blood through an artificial kidney [dialyzer] to remove waste products and excess fluid), peritoneal dialysis (PD); a procedure that uses the patient’s peritoneal membrane (the lining of the peritoneal cavity) as the semipermeable membrane to exchange fluid and solutes, or a variety of continuous renal replacement therapy (CRRT) (methods used to replace normal kidney function by circulating the patient’s blood through a hemofilter) may be performed (Odom, 2017). Nutritional Therapy AKI causes severe nutritional imbalances (because nausea and vomiting contribute to inadequate dietary intake), impaired glucose use and protein synthesis, and increased tissue catabolism. The patient is weighed daily and loses 0.2 to 0.5 kg (0.5 to 1 lb) daily if the nitrogen balance is negative (i.e., caloric intake falls below caloric requirements). If the patient gains or does not lose weight or develops hypertension, fluid retention should be suspected. Nutritional support is based on the underlying cause of AKI, the catabolic response, the type and frequency of RRT, comorbidities, and nutritional status. Replacement of dietary proteins is individualized to provide the maximum benefit and minimize uremic symptoms. Caloric requirements are met with high-carbohydrate meals, because carbohydrates have a protein-sparing effect (i.e., in a high-carbohydrate diet, protein is not used for meeting energy requirements but is “spared” for growth and tissue healing). Foods and fluids containing sodium, potassium, or phosphorus (e.g., bananas, citrus fruits and juices, dairy foods) are restricted. The oliguric phase of AKI may last 10 to 14 days and is followed by the diuretic phase, at which time urine output begins to increase, signaling the patient is in the recovery phase (Odom, 2017). Results of blood chemistry tests are used to determine the amounts of sodium, potassium, and water needed for replacement, along with assessment for over- or under hydration (daily weights). Following the diuretic phase, the patient is placed on a high-protein, high-calorie diet and is encouraged to resume activities gradually. Nursing Management The nurse has an important role in caring for the patient with AKI. The nurse monitors for complications, participates in emergency treatment of fluid and electrolyte imbalances, assesses the patient’s progress and response to treatment, and provides physical and emotional support. In addition, the nurse keeps family members informed about the patient’s condition, helps them understand the treatments, and provides psychological support. Although the development of AKI may be the most serious problem, the nurse continues to provide nursing care indicated for the primary disorder (e.g., burns, shock, trauma, obstruction of the urinary tract). Monitoring Fluid and Electrolyte Balance Because of the serious fluid and electrolyte imbalances that can occur with AKI, the nurse monitors the patient’s serum electrolyte levels and physical indicators of these complications during all phases of the disorder. IV solutions must be carefully selected based on the patient’s fluid and electrolyte status. The patient’s cardiac function and musculoskeletal status are monitored closely for signs of hyperkalemia. Quality and Safety Nursing Alert Hyperkalemia is the most immediate life-threatening imbalance seen in AKI. Parenteral fluids, all oral intake, and all medications are screened caref are not inadvertently given or consumed. The nurse monitors fluid status by paying careful attention to fluid intake (IV medications should be given in the smallest volume possible), urine output, apparent edema, distention of the jugular veins, alterations in heart sounds and breath sounds, and increasing difficulty in breathing. Accurate daily weights, as well as I&O records, are essential. Indicators of deteriorating fluid and electrolyte status are reported immediately to the primary provider, and preparation is made for emergency treatment. Severe fluid and electrolyte disturbances may be treated with HD, PD, or CRRT. Reducing Metabolic Rate The nurse takes steps to reduce the patient’s metabolic rate. Fever and infection, both of which increase the metabolic rate and catabolism, are prevented and treated promptly; blood, urine and wound cultures are ordered as indicated. Promoting Pulmonary Function https://herzing.realizeithome.com/RealizeitApp/Student.aspx?Token=lqf9HhURQ5RqpgqAkzH2zYjdcLReD0xWqoW33TqQEI8BS%2f7OmZzvGp21HqGixm2HQ… 2/4 2/22/24, 2:39 PM Realizeit for Student Attention is given to pulmonary function, and the patient is assisted to turn, cough, and take deep breaths frequently to prevent atelectasis and respiratory tract infection. Drowsiness and lethargy may prevent the patient from moving and turning without encouragement and assistance. Preventing Infection Asepsis is essential with invasive lines and catheters to minimize the risk of infection and increased metabolism. An indwelling urinary catheter is avoided whenever possible due to the high risk of UTI associated with its use, but may be required to provide ongoing data required to accurately monitor fluid I&O. Providing Skin Care The skin may be dry or susceptible to breakdown as a result of edema; therefore, meticulous skin care is important. In addition, excoriation and itching of the skin may result from the deposit of irritating toxins in the patient’s tissues. Bathing the patient with cool water, frequent turning, and keeping the skin clean and well moisturized and the fingernails trimmed to avoid scratching are often comforting and prevent skin breakdown. Providing Psychosocial Support The patient with AKI may require treatment with HD, PD, or CRRT. The length of time that these treatments are necessary varies with the cause and extent of damage to the kidneys. The patient and family need assistance, explanation, and support during this period. The purpose of the treatment is explained to the patient and family by the primary provider. However, high levels of anxiety and fear may necessitate repeated explanation and clarification by the nurse. The family members may initially be afraid to touch and talk to the patient during these procedures but should be encouraged and assisted to do so. In an intensive care setting, many of the nurse’s functions are devoted to the technical aspects of patient care; however, it is essential that the psychological needs and other concerns of the patient and family be addressed. Continued assessment of the patient for complications of AKI and precipitating causes is essential (Odom, 2017). Example Video: YouTube: Acute Kidney Injury (AKI) - Prerenal, Intrarenal, Postrenal Summary Acute kidney injury (AKI) is common and often preventable. Nurses should be able to recognize it and respond when it occurs. Through prevention or early detection, nurses can help to reduce morbidity and mortality associated with AKI, improving patients’ quality of life and reducing the financial impact of AKI. https://herzing.realizeithome.com/RealizeitApp/Student.aspx?Token=lqf9HhURQ5RqpgqAkzH2zYjdcLReD0xWqoW33TqQEI8BS%2f7OmZzvGp21HqGixm2HQ… 3/4 2/22/24, 2:39 PM Realizeit for Student Patients present with AKI or risk factors for AKI in all sectors of healthcare. The extent to which nurses can influence the management of AKI will depend on their role and place of work. However, all nurses can make a major contribution by assessing risk factors for AKI and actively looking for serum creatinine rises or oliguria when assessing patients. In all settings, suspicion or confirmation of AKI must be immediately escalated to a doctor. An AKI core competency document promotes the acquisition of competence in multidisciplinary teams to improve care for patients with or at risk of AKI, recognizing that only by good integrated teamwork can the best results be achieved. https://herzing.realizeithome.com/RealizeitApp/Student.aspx?Token=lqf9HhURQ5RqpgqAkzH2zYjdcLReD0xWqoW33TqQEI8BS%2f7OmZzvGp21HqGixm2HQ… 4/4