Nursing Management of Patient with Acute Kidney Injury probably secondary to Community Acquired Pneumonia Almira Sacdal Umali,

a 36 year old female was admitted at East Avenue Medical Center, Emergency Room accompanied by her husband with a chief complaint of abdominal pain. She was diagnosed with Acute Kidney Injury probably secondary to Community Acquired Pneumonia. Prior to admission, as stated by her husband, the client experiences flu and abdominal pain. The client was placed on a comfortable position and was referred to Dr. Danilos Kuizon, she was then seen and examined, and with orders made and carried out. Acute kidney failure also called acute renal failure or acute kidney injury develops rapidly over a few hours or a few days. Acute kidney failure occurs when your kidneys suddenly become unable to filter waste products from your blood. When your kidneys lose their filtering ability, dangerous levels of wastes may accumulate and your blood's chemical makeup may get out of balance. Acute kidney failure can be fatal and requires intensive treatment. However, acute kidney failure may be reversible. If you're otherwise in good health, you may recover normal kidney function.

Pathophysiology Acute renal failure is a rapid decrease in renal function leading to the collection of metabolic wastes in the body. ARF can result from conditions that cause inadequate kidney perfusion (prerenal failure); damage to the glomeruli, interstitial tissue, or tubules (intrarenal/intrinsic renal failure); or obstruction urine flow (postrenal falure). ARF in clients with chronic renal insufficiency (CRI) may result in end-stage renal disease (ESRD), or it may resolve to nearly the pre-ARF level of renal function. Many factors contribute to renal insults in ARF, but the acute syndrome may be reversible, especially with prompt intervention. The pathologic process of ARF is related to the cause of sudden decrease in kidney function and to the affected kidney site(s). reduced blood flow (hypoperfusion), toxins, tubular ischemia, infections and obstructions have different effects on the renal system. Any of these processes can reduce glomerular filtration rate (GFR), disrupt tubular cell membranes, an obstruct urine outflow in the renal tubules. With shock or other problems causing an acute reduction in renal blood flow (hypoperfusion), the kidney compensates with autoregulatory responses (e.g., renal blood vessel constriction, activation of rennin-angiotensin-aldosterone pathway, and release of antidiuretic hormone[ADH]). These responses increase blood volume and improve renal perfusion. However, these same responses reduce renal volume, resulting in oliguria (urine output less than 400 ml/day). Tubular cell injury is more likely to occur from the increasing ischemia related to hypoperfusion. Toxins can cause blood vessel constriction in the kidney, leading to reduced renal blood flow and renal ischemia. Kidney tissue inflammation caused by infection, drugs or cancer result in immune-mediated changes in renal tissue. With extensive tubular damage, tubular cells slough and combine with other formed element (e.g., RBC casts), which obstructs the tubular lumen and prevent urine outflow. Obstruction anywhere within the urinary tract may result in full or partial obstruction to the formation and outflow of urine.

When pressure in the renal tubules (intrarenal pressure exceeds glomerular hydrostatic pressure, glomerular filtration stops. This problem allows nitrogenous wastes to collect in the blood, increasing the blood urea nitrogen (BUN) and serum creatinine levels. When BUN rises faster than the serum creatinine level, the cause is usually related to protein breakdown or volume depletion. When both the BUN and the creatinine levels rise and the ratio between the two remains constant, renal failure is present. History Almira Sacdal Umali, a 36 year old female, born on September 8, 1973, married to Felipe Umali, lives at San Jose, Rodriguez, Rizal, was admitted last October 31, 2012, 1:10am at East Avenue Medical Center, Emergency Room. She was accompanied by her husband with a chief complaint of abdominal pain. She was diagnosed with Acute Kidney Injury probably secondary to Community Acquired Pneumonia. Prior to admission, as stated by her husband, the client experiences flu and abdominal pain which prompted them to consult at ER (East Avenue Medical Center).

Nursing Physical Assessment A.U. was lying on bed, unconscious, and weak in appearance with an ongoing IVF of PNSS 1L x 8 hrs with a side drip of D5W at 500cc level with 4 amps of dopamine regulated at 35 gtts/min at left arm, infusing well. The client has a Foley catheter connected to a urine bag, with a light yellow colored appearance of urine, moderate in amount. The client has an endotracheal tube hooked to a continuous ambubag, and an O2 with a flow rate of 10 lpm, as ordered. She has a nasogastric tube insertion in place, patent and secured. The clients temperature was 37.4 C, pulse rate was 90, respirations were 24, blood pressure was 90/60. The clients skin is dry, soft, brown and no lesions present. Presence of distended neck vein was noted. The client was non-ambulatory and was not able to perform independent activities of daily living. Related Treatment A.U. had undergone the following laboratory exams; complete blood count (CBC) is obtained to identify leukocytosis (an elevated white blood count), and other values of the blood cell components like Hgb, Hct, Platelets. Serum electrolyte, Blood urea nitrogen (BUN), and creatinine levels are also assessed, which are helpful in monitoring renal function. Changes in the following laboratory values may reflect poor renal function, in which a rising BUN, creatinine levels and abnormal blood electrolytes values are expected. The patient has an ongoing IVF of PNSS 1L x 8 hrs with a side drip of D5W at 500cc level with 4 amps of dopamine regulated at 35 gtts/min at left arm, to prevent electrolyte imbalance and to maintain adequate fluid intake to avoid dehydration.The patients medications ordered by the physician were, Ceftriaxone 1g + 90cc of PNSS once a day: cephalosporin antibiotic, indicated for lower respiratory tract infection. Sodium Bicarbonate (NaHCO3) 100g/IV; shortacting, potent systemic antacid; rapidly neutralizes gastric acid or systemic acidosis.

Recommendations Scheduled laboratory blood and urine test to monitor renal function Dietary consult is needed to modify clients diet according to the degree of renal function and ongoing nutritional requirements. Monitor the client's diet to provide high carbohydrates, adequate fats, and low protein. If client receives high calories from fat and carbohydrate metabolism, the body doesn't break down protein for energy. Protein is thus available for growth and repair. Limit foods high in potassium and sodium and to observe protein restrictions. Teach about any needed fluid intake limitations. Provide only enough fluid intake to replace urine output to avoid an edema caused by excessive fluid intake. Provide emotional reassurance to the client and family members to help decrease anxiety levels caused by the fact that the client has an acute illness with unknown prognosis. Explain treatments and progress to the client to help reduce anxiety.