In Class

Nursing Notes

Acute Kidney Injury (AKI)

Definition:

• Sudden loss of kidney function over hours to days.

Types:

1. Pre-renal AKI – Problem before the kidney (blood flow issue)

   • Causes: Dehydration, blood loss, low BP, heart failure

2. Intrinsic (Intra-renal) AKI – Problem inside the kidney

   • Causes: Glomerulonephritis, toxins, drugs (e.g., NSAIDs, antibiotics)

3. Post-renal AKI – Problem after the kidney (urine blockage)

   • Causes: Kidney stones, enlarged prostate, tumors

Signs & Symptoms:

• Decreased urine output (oliguria)

• Swelling (edema)

• High creatinine and urea levels

• Nausea, confusion, fatigue

Nursing Care:

• Monitor fluid balance (input/output)

• Check blood tests (creatinine, urea, electrolytes)

• Avoid nephrotoxic drugs (NSAIDs, contrast dye)

• Manage BP

• Prepare for dialysis if needed (CRRT)

Chronic Kidney Disease (CKD)

Definition:

• Progressive, irreversible damage to the kidneys over months to years.

Causes:

• Diabetes (main cause)

• High blood pressure

• Glomerulonephritis

• Polycystic kidney disease

Diagnosis:

• Blood test: eGFR (estimated Glomerular Filtration Rate)

• Urine test: uACR (albumin-to-creatinine ratio)

Stages:

• Stage 1: Kidney damage with normal GFR (>90)

• Stage 5: Kidney failure (GFR <15 = dialysis or transplant)

Signs & Symptoms (Late stages):

• Fatigue

• Itchy skin (pruritis)

• Nausea/vomiting

• Fluid overload → swelling (legs, lungs)

• High BP

• Anaemia (low blood count)

Nursing Care:

• Monitor blood pressure, weight, and fluid balance

• Educate on low-salt, low-protein, low-potassium diet

• Administer renal-safe medications

• Prepare for dialysis or transplant when needed

Dialysis Overview

Purpose:

• Removes waste, extra water, and toxins from the blood when kidneys can’t

Two Main Types:

1. Hemodialysis (HD):

   • Blood taken out, filtered by machine, and returned to body.

   • Usually done 3 times a week at a dialysis centre.

2. Peritoneal Dialysis (PD):

   • Body’s peritoneum (lining of abdomen) acts as the filter using special fluid.

   • Can be done at home, often daily.

Peritoneal Dialysis (PD)

How It Works:

• Dialysis fluid put into abdomen through a catheter → absorbs waste → fluid drained out.

Types:

• CAPD (Continuous Ambulatory PD): Manual fluid exchanges throughout the day.

• APD (Automated PD): Machine does exchanges overnight while sleeping.

Complications:

• Peritonitis (infection of peritoneum) → cloudy fluid, fever, abdominal pain

Nursing Care:

• Strict aseptic technique with catheter

• Monitor for signs of infection

• Educate patient on hand hygiene and exit site care

• Record input/output accurately

Continuous Renal Replacement Therapy (CRRT)

Definition:

• A continuous 24-hour dialysis treatment for critically ill patients (mostly ICU)

Purpose:

• Gently remove fluid and waste without dropping BP too much (important for unstable patients)

Types of CRRT:

• CVVH: Continuous venovenous hemofiltration

• CVVHD: Continuous venovenous hemodialysis

Nursing Care:

• Monitor vital signs and hemodynamic status closely

• Monitor blood results (electrolytes, clotting, blood gases)

• Maintain machine settings

• Prevent clotting of dialysis circuit (may use anticoagulants)

✅ Extra Tips for Memory:

Clinical Reasoning Cycle: Nat Moore (CKD Stage 5, Hypertension Crisis)

1⃣ Consider the patient situation:

• Nat Moore, 33-year-old female

• Stage 5 CKD, on hemodialysis 3x/week

• History of Type 1 Diabetes, hypertension, ex-smoker (quit 1 month ago)

• Presenting with:

  • Severe headache (pain 10/10)

  • High BP (195/100 ➔ 190/90)

  • Vision changes

  • Shortness of breath

  • Chest pressure

  • Peripheral oedema

• Missed antihypertensive medication (Amlodipine) for 3 days.

2⃣ Collect Cues / Information:

✅ Vital signs:

• BP 190/90 (hypertensive crisis range)

• HR 87 bpm (normal)

• RR 23 (mild tachypnoea)

• SpO2 94% (slightly low)

• Temp 36.8°C

• GCS 14 (alert but headache impacts)

✅ Investigations:

• Severe anemia: Hb 8.1, Hct 23%, RBC 2.9

• Thrombocytopenia: Platelets 81

• Elevated inflammatory markers: CRP 285

• Worsening kidney function: BUN 103, Cr 12 (both much higher than usual baseline)

• Low albumin: 26 (hypoalbuminemia)

• Electrolyte abnormalities:

  • Low sodium (Na 134)

  • Low calcium (Ca 6.9)

  • High phosphorus (10.8) → severe hyperphosphatemia

• UA/FWT positive for:

  • Protein (++++)

  • Blood (+++)

  • Leucocytes (+)

  • Glucose (+)

✅ Symptoms & Background:

• Missed BP meds → uncontrolled hypertension

• Symptoms suggestive of hypertensive emergency (target organ damage: vision, brain, chest)

3⃣ Process Information:

✅ Link data:

• Headache, vision changes, chest pressure + BP 190/90 → Hypertensive Emergency (severe BP + end-organ symptoms).

• Severe kidney dysfunction worsens BP control (fluid overload + toxin buildup).

• Missed Amlodipine for 3 days — leading to loss of BP control.

• Evidence of fluid overload (peripheral oedema, chest pressure, breathlessness).

✅ Consider possible complications:

• Hypertensive encephalopathy (headache, confusion)

• Pulmonary oedema (SOB, chest pressure)

• Risk of stroke, MI, further kidney injury

✅ Why blood and protein in urine?

• Reflects ongoing glomerular damage due to CKD worsening.

✅ Anemia?

• CKD-related anemia (decreased erythropoietin production by kidneys).

4⃣ Identify Problems / Nursing Priorities:

Top 5 Nursing Problems:

5⃣ Establish Goals:

• Lower BP safely to reduce risk of organ damage.

• Manage fluid overload to prevent pulmonary oedema.

• Correct metabolic imbalances (electrolytes, acidosis).

• Stabilize kidney function (prepare for urgent dialysis).

• Treat and prevent further complications (infection, bleeding due to low platelets).

6⃣ Take Action:

✅ Immediate priorities:

• Administer antihypertensives IV or orally (as prescribed, e.g., hydralazine, labetalol).

• Urgent dialysis session to remove fluid and toxins.

• Supplemental oxygen if SpO2 drops further.

• Diuretics (Frusemide if tolerated) to manage overload — careful with electrolytes.

• Monitor neuro status (risk of hypertensive encephalopathy).

• Monitor cardiac rhythm (hypocalcemia can cause arrhythmias).

• Administer erythropoiesis-stimulating agents later to address anemia (not immediately).

• Investigate underlying infections (high CRP suggests possible infection).

✅ Monitoring:

• Continuous BP monitoring

• Hourly neuro assessments (GCS, PEARL)

• Strict input/output charting

• Regular bloodwork (FBE, UEC, CRP, VBG)

7⃣ Evaluate Outcomes:

✅ Positive signs would include:

• Gradual and safe BP lowering (avoid too rapid drop — risk of ischemia).

• Reduced headache and vision improvement.

• Improved respiratory effort and SpO2.

• Good urine output post-dialysis.

• Stabilization of electrolytes and improved kidney markers over time.

• No progression to stroke, MI, or pulmonary oedema.

🧠 Reflection:

• Key learning:

  • Medication adherence (e.g., missing Amlodipine) can rapidly lead to a hypertensive crisis, especially with CKD.

  • Managing fluid overload carefully is critical in CKD patients.

  • Watch closely for signs of neurological deterioration during hypertensive emergencies.

• Future focus:

  • Patient education about never missing BP meds, especially with chronic disease.

  • Early recognition of hypertensive emergencies saves lives.

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