Acute Renal Injury - Nursing Interventions for 48 Hours - Case Study Example

Acute Renal Injury Xxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx Name Xxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx Course Xxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx Instructor Xxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx Date Introduction The patient, Anita Brown has been brought right from laparoscopic cholecystectomy into my ward. She is 45 years old and has a weight of 100kgs. Laparoscopic cholecystectomy is a surgical process to remove the gall bladder and gallstones through small incisions in the abdomen. In the process, the surgeon has to inflate the abdomen with air such as carbon dioxide so that he can see through the patient clearly (Brincat & Hilton, 2008). It is necessary for patients who have digestive disorders caused due to the failure of the gall bladder. An anaesthesia that lasts for about two hours is also administered during the operation. The effect of this surgery is that the body does not store any bile juices between meals even though it does not have any effects on the body’s functions in digestion (Field, Pollock & Harris, 2010). Anita Brown’s case requires a shift to open cholecystectomy. Normally, some complications may arise in the aftermath of laparoscopic surgery which may require a shift to the open procedure which includes scarred tissues, inflammation, bleeding or general injury (Dirkes, 2011). Anita Brown’s open gall bladder surgery is maybe due to the high blood pressure in the blood vessel after undergoing the initial surgery. She has a blood pressure reading 105/60mmHg which is quite high for a normal human being. The pulse rate is at 108 beats per minute, which is also quite high. The normal temperatures for a human being should range at 36° C; hers is at 37°C. Generally, the patient is diagnosed with acute renal/kidney injury and this is suspected to arise out of severe dehydration because fluid replacement after the surgery was not adequate. Other symptoms include a high respiratory rate, pulse oximetry of 94% on air, Glasgow coma of a scale of 15° and urine olugiric. She has also remained nil by mouth. Only a patient controlled anaesthesia (PCA) has been administered to relive her pain. She has also been receiving intravenous fluids in the last twelve hours. Therefore, urgent and systematic nursing approaches and interventions are needed in the next forty eight hours. To effectively deal with the problem, I embark on the following: Priorities of care Open cholecystectomy is a surgery to treat the diseases associated with the gall bladder and the bile ducts. In open surgery, the doctor will have to remove the gall bladder through a single large incision either in the middle of the upper part of the abdomen or under the border of the right rib cage (Yaklin, 2011). Most doctors resort to open cholecystectomy after first trying to remove the gall bladder by laparoscopic cholecystectomy. The need may arise due to certain accruing complications (Praught & Shlipak, 2005). The procedures that must be given priority in order to deal with Anita Browns situation are as follows. The patient has been diagnosed with acute kidney injury which is suspected to be a result of severe dehydration after the operation. The first priority here is to replace the lost fluids by giving her enough fluids. It is the most effective treatment of dehydration. The fluids and the electrolytes that have been lost must be replaced immediately. Age must be considered in this instance and since she is an adult, water becomes the most suitable option (Murphy & Byrne, 2010). Other alternatives may also include fresh fruit juices and other carbonated drinks even though these are not recommended. However, the most appropriate case for Mrs. Brown is intravenous fluid replacement since she is severally dehydrated. This is used in emergency cases whereby the patient can receive salts and fluids through a tube inserted in the veins. Intravenous hydration is meant to provide the body with fluids and other essential nutrients in a much faster way than oral solutions do. It is essential for the case of Mrs. Anita Brown. This means sufficient replacement of the fluids must be done in the next forty eight hours so as to replace all the lost fluids. A patient diagnosed with acute kidney injury (AKI) or acute renal injury (ARI) as in the case of Anita brown needs appropriate care. Good care within the first 48 hours is used as a prediction of the outcomes. It helps the doctor to determine whether the patient will be critically ill or not. According to Hilton (2011 pp. 1167), the disease is normally caused by a rapid reduction in the in the normal functioning of the kidney which results in the failure of the body’s ability to maintain the levels of fluid. Moreover, the electrolyte level and the base-acid homeostasis levels go down. The serum creatanine levels in the body then increase which can easily be associated with worse outcomes (Field, Pollock & Harris, 2010). A doctors other priority after recognition and diagnosis of acute kidney injury (AKI) a careful clinical examination in order to identify the cause of the disease (Dirkes, 2011). The doctor must consider all the here stages of the probable cause: the pre-renal, the intrinsic and the post-renal. There is also need to identify the cause of renal obstruction (Glasgow & Mulvihill, 2006). In Anita Brown's case, she has had urine olugiric in the last 6 hours. Urine olugiric is a condition that is involved with low outputs of urine. In adults, a reduced volume of urine passage below 400ml a day is abnormal and is associated with a sickness (Yaklin, 2011). Relieving the urinary obstruction should a priority in this case. It is an urgent issue to be taken care of. The most appropriate choice here is for the doctor to modify any of the prescribed drugs if any. For instance, the doctor is supposed to stop any administration of angiotensin converting enzyme inhibitors. Drugs that are receptor blocking should also be avoided (Hilton, 2011). Most importantly, the doctor ought to ensure that any anti toxic drugs that are being given are not toxic to the body. It is also recommended that any drugs that aggravate hyperkalaemia must not be given to the patient (Yaklin, 2011). These are measures that must be urgently observed within the first 48 hours. The longer the delay in relieving of urinal obstruction, the more complicated the damage the patient will get. Moreover, the other basic priority for the doctor is to treat any conditions that may be life threatening. These include signs such as hypotension, respiratory failure and instances of shock for the patient. These conditions are usually apparent when the doctor will be assessing Anita Brown for the first time. Because they demand some urgent treatment, they ought to be dealt with first. Cardiac monitoring is also essential due to the high blood pressure, high respiratory rates, high temperatures and low levels of oxygen in the body (Fry & Farrington, 2006). Full administration of drugs is very essential. These cover the current, the recent and any alternative medicine that is vital in the first stages of the treatment process. Nonetheless, assessing the risks associated with the condition is another basic priority after the diagnosis of acute renal injury. Understanding the potential risk factors may help in the prevention of the disease (Brincat & Hilton, 2008). For a hospital setting like in the case of Anita Brown, her failed kidneys may be susceptible to a number of factors including dehydration, other demographic threats and even genetic predispositions. The condition may be modified by other factors and this should be avoided at all costs (Dirkes, 2011). The processes to which the kidneys are exposed to may be a risk to the life of the patient. It is thus recommended that the patients are to be managed according to their susceptibilities so as to reduce the possibilities of exposure to risk (Field, Pollock & Harris, 2010). For instance it is very essential to screen Anita because she has already had exposure to previous surgeries. The risk of infections that may arise out of the use of tubes and catheters must also be minimised. This can be ensured by maintaining high standards of cleanliness and hygiene (Yaklin, 2011). Nursing management Management of acute kidney injury in the first 48 hours after its diagnosis is more than essential. Practical management is that which basically involves attempting to stop or to reverse the renal obstruction and treating any present conditions that are life threatening (Murphy & Byrne, 2010). This is because it reduces the risk of mortality and even morbidity. Determining the correct cause of the disease is very critical to its management. Thus X-Rays and other ultra-sound procedures are needed in the first stages of managing the Anita Browns condition (Dirkes, 2011). No specific treatment has been discovered that can be used to treat acute renal injury. However, early recognition and effective management is very essential to countering and reversing the condition (Ronco, Levin, Warnock et al, 2007 pp.373). Management of the disease must begin at the very earliest point after detection and diagnosis. It is thus important that Anita Brown’s condition is managed the soonest possible. The nursing goals must encompass both aiming at reducing the injury that has been occasioned to the kidney, and eliminating any other complications that may be related to the failed kidney (Praught & Shlipak, 2005). General management principles in Anita Brown’s case will include: Monitoring the acute kidney injury patients’ measurements of her urine output so as to determine the severity of the stage. This will help in determining the recommended treatment (Dirkes, 2011). Acute kidney injury is not a disease that needs specific medication prescription. It is a clinical syndrome categorized as a homogenous disorder (Murphy & Byrne, 2010). A thorough clinical evaluation should be undertaken followed by a careful physical examination. To manage the condition well, several factors have to be considered. For instance in the case of Anita Brown, has no known history of drugs. But to manage the condition well, she can be put under pain killers. After the laparoscopic cholecystectomy, she was put under a patient controlled anaesthesia (PCA) that contained morphine in order to reduce her pain. Pain killers should be administered in order to counter the pain. Moreover, exposure to other accompanying diseases must also be managed (Li, Chen, Yang & Chuang, 2011). Such diseases may include malaria or tuberculosis among many others. Another factor that should be considered in the clinical setting for Anita Brown are measures like determination of the cardiac output, any possible signs of heart failure and acute breathing difficulties. Managing these will help in countering any complications related to high blood pressure (Field, Pollock & Harris, 2010). Nevertheless, it is very essential to obtain urine analysis and a microscopic examination of the same. This is the gateway to determining the underlying cause of the patient’s acute renal injury. Other tests like imaging, especially ultrasound processes are imminent in the evaluation processes of patients suffering from acute kidney injury (Dirkes, 2011 pp. 45). It is also advisable that the management process be tailored according to the stage of the acute kidney injury disease (Praught & Shlipak, 2005). The evaluation and the management of Anita Browns condition will thus require special attention to the cause of the condition. In her case, it is likely to be caused by the surgery gone wrong and the accumulation and retention of fluids in the body. It is also important to regularly check for the onsets of any worsening symptoms or any pre-existing conditions (Brincat & Hilton, 2008). If the patient exhibits any worsening symptoms, then she is at a higher risk of possessing a completely damaged kidney and will need more attention. The patient also ought to receive careful monitoring which will help to ensure that the renal function improves and that no serious complications will have to develop. In a nutshell, the crucial areas of management include, catheterization, which involves relieving the urinary obstruction and managing the amounts of urine output (Glasgow & Mulvihill, 2006). The doctor must stop any hypersensitive medications and also find any appropriate analgesic if necessary. More importantly, adequate intravenous fluid resuscitation must be maintained (Glasgow & Mulvihill, 2006 pp. 1425). Overall hourly monitoring of the patient is required. Management is done in three phases: the pre-renal renal failure, the renal failure and the post renal failure. In Anita Brown’s case, pre-renal renal management will be very necessary in the first 48 hours. This can largely help in the management techniques applied to counter her condition. The process is referred to as pre-renal azotaemia and will be used stabilise the haemodynamic status of the patient (Hilton, 2011). If the hypotension will be severe, then the use of vasopressors is highly recommended. More so, a process called renal replacement therapy may be needed to be administered in those 48 hours if Anita Brown is detected with a severe imbalance of the acid- base levels in the blood stream. Such an imbalance may lead to some underlying conditions related to the heart and the respiratory system (Li, Chen, Yang & Chuang, 2011). However, evidence shows that the use of diuretics can avert the necessity of undertaking the renal replacement therapy. Diuretics are used in dialysis or filtration, a process that simply eliminates the waste products and other toxins from the blood stream of the patient (Dirkes, 2011). The nursing interventions in relation to pathphysiology The nursing interventions that are required in Anita Browns case will range from medical ones to therapeutic ones. Simple interventions include volume repletion as well as avoiding or totally discontinuing agents that are potentially harmful like nephrotoxic agents (Fry & Farrington, 2006). These may cause acute renal injury to progress rapidly. The medication doses may also be required to be adjusted in order to remove or to minimise the levels of nephrotoxins. It is in fact advisable that the patient must not be given any nephrotoxin agents unless there is no other alternative (Brincat & Hilton, 2008). Only the electrolyte level and the acid-base balance should be optimised to patient-friendly levels. The kinds of treatment that can be given to manage the disease in the next 48 hours are varying. According to the National Health Service, they include processes such as hemodialysis, hemofiltration and peritoneal dialysis. These processes are used to filter fluids and other wastes from the body, especially the blood stream in an attempt to manage the primary condition (Hilton, 2011). If the case is severe, it may then require therapeutic intervention. Hemodyalisis Application of hemodialysis must be done within the first 48 hours. This is the basic procedure by which potassium is removed from the body. It is usually very effective as it has an immediate effect once it is started. The maximum amounts of potassium are removed within the first one hour. The process is a medical procedure in which the blood of the patient is circulated outside the body through an external tube called the extracorporeal circuit (ECC) (Dirkes, 2011). It is plastic tubing and works together with an artificial kidney which called a dialyzer and a dialysis machine that is used to monitor and maintain the blood flow in the body (Glasgow & Mulvihill, 2006). In this process, waste products are removed from the body while electrolytes and other chemicals are also added into the blood. The result is blood that is more purified and chemically-balanced (Murphy & Byrne, 2010). This is now returned to the body. The typical procedure can run for about three to four hours and this largely depends on the physical condition of the patient or the size of the dialyzer that is used. It can prove to be very helpful in the first 48 hours but is highly recommended that it runs for several times in a week. In this manner, then acute kidney injury can be reversed. The doctor must be aware for changes that are associated with the blood pressure of the patient. Hemofiltration This may also be administered in the form of continuous renal replacement therapy abbreviated as CRRT (Praught & Shlipak, 2005). Even though it is a slow and fairly long process, it can be used to control acute renal injury in patients that are critically ill. In this case Anita Brown will be put under the use of ECC just like in hemodialysis although a hollow fibre is now used instead of a dialyzer. It will be inserted to remove fluids and toxins. Her high pressure condition is very suitable for hemofiltration. A pump- like machine is used to make the blood flow to the ECC. Pure blood then is generated in the body (Field, Pollock & Harris, 2010). The process will continue until the kidney failure condition is reversed. Peritoneal dialysis This can be the most suitable way of managing the acute kidney injury in Anita Brown’s case as she seems not to be in immediate crisis. For this process, it is the lining of the patients own abdomen that acts as a blood filter (Praught & Shlipak, 2005). A catheter will be inserted in the patient’s abdomen which during the process it will be used to fill the abdominal cavity with the fluid/dialysate. The catheter must be a flexible tube. The excess fluids that are in the patient’s abdomen and the waste products as well are drained from the blood stream to the dialysate. After some time, the dirtified dialysate is then drained from the abdomen and replaced with a clean one (Ronco, Levin, Warnock et al, 2007). Nurses should also note that it is very essential to avoid pre-operative and peri-operative hypovolaemia in the process of patient management. The rationale behind this is to ensure that the correct intravenous fluids are prescribed and after a very careful assessment. A lot of consideration has to be followed also in relation to the fluid that has been lost. This will help the doctor to consider on the nature of the fluid that has to be replaced. In order to select the most appropriate fluid, a thorough clinical assessment within the safety limits has to be done (Dirkes, 2011). It is also very essential for the doctor to continuously monitor the volume of the patient. This will help in determining when to right stop the intake of the intravenous fluids. The rate of fluid replacement and the nature of the fluid to be replaced must always be tailored to conform to the needs of the patient (Praught & Shlipak, 2005). For instance, a lot of solutions that contain potassium should not be used in large amounts for the terminally ill patients. There is likelihood that they may develop exacerbating hyperkalaemia. Prognosis may not apply to Anita Brown’s case because it is not recommended for her age. Other nursing interventions collectively include observing the clients level of metabolic acidosis in order to identify any complications associated with renal failure (Brincat & Hilton, 2008). The nurse must see to it that enough fluids are provided to replace any urine outputs. This prevents conditions like oedema which arises out of excessive intake of fluids. Moreover, Anita Brown’s diet should be monitored in those 48 hours. The patient must take a lot of carbohydrates, vitamins and fewer proteins. Proteins are not advisable because they are not easily broken down and are only essential for body repair and growth (Ronco, Levin, Warnock et al, 2007 pp.375). Significantly, it is important to provide frequent oral hygiene to the patient which prevents tissue irritation as well as formation of ulcers in the stomach (Field, Pollock & Harris, 2010). Ulcers are likely to be caused by urea and other acidic waste products which are excreted through the membranes. Even though not very essential, Anita Brown can also be provided with chewing gum or candy which helps in stimulating the flow of saliva thus reducing thirst. The skin of the patient can also be maintained in order to avoid pruritis and to remove any uremic frost. Most importantly, Anita Brown ought to be given all sorts of emotional reassurance (Glasgow & Mulvihill, 2006). This decreases the anxiety levels and the psychological trauma that accompanies the disease. The pathophysiology associated with acute kidney injury involves very complex factors that result in inflammation. This must also be taken into consideration as they can easily result in the progress of the kidney failure. The inflammatory response must be regulated to avoid the worsening of the condition (Murphy & Byrne, 2010). Conclusion In the recent years, acute kidney injury (AKI) has been associated with high rates of mortality and morbidity. Anita Brown will not be an exception if no adequate approaches are taken to counter or reverse her condition in the first 48 hours. It is therefore of paramount importance that as a nurse in charge, I ought to put right my priorities of care and administer the correct nursing interventions. The priorities of care include adequate fluid replacement, assessment of any potential risk factors and a thorough examination in order to identify the root cause of the condition. The first 24-48 hours following admission of the patient are the most important hours of the patient’s time. This will determine whether the patient will recover or succumb to the illness. The nursing interventions should focus on attempts to limit the risk of the more damage to the kidneys. Since the condition is associated with an abrupt decrease in the functioning of the kidney, all measures should be put in place to reverse the condition. Notably, Anita Brown is 45 years. Hence the kidney failure could be associated with her advancing age. Nonetheless, obtaining a very detailed history of the patient is very essential. It helps in determining the kind of medications that will be administered to the patient. In a nutshell, acute kidney injury (AKI) is a manageable condition all together. Patient care demands that the patient be monitored closely and carefully. If the fluid imbalance could be reversed promptly, the risks that the patient is exposed to are reduced (Field, Pollock & Harris, 2010). Moreover, cardiovascular monitoring is another essential element in managing the condition (Brincat & Hilton, 2008). Moreover, psychological considerations and the diet of the patient should not be left out. I rest my case. References Brincat, S., Hilton, R. (2008) Prevention of acute kidney injury: British Journal of Hospital Medicine Vol. 69, No. 8, pp. 450-454. Dirkes, S. (2011) Acute kidney injury: not just acute renal failure anymore? Critical Care Nurse Vol. 31, No. 1, pp. 37-50. Field, M., Pollock, C., Harris, D. (2010) The Renal System (2nd edition) Oxford: Churchill Livingstone.pp.315-325 Fry, A., Farrington, K. (2006) Management of acute renal failure Postgraduate Medical Journal Vol. 82, pp. 106-116. Glasgow RE, Mulvihill SJ (2006). Treatment of gallstone disease. 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National clinical guideline for early identification and management in adults in primary and secondary care London: Royal College of Physicians. Yaklin, K. (2011) Acute kidney injury: an overview of pathophysiology and treatments: Nephrology Nursing Journal Vol. 38, No. 1, pp. 13-19. Read More