How do nurses manage Acute Kidney Injury (AKI)?

Nursing Management of Acute Kidney Injury

Nurses managing AKI must focus on meticulous fluid balance monitoring, medication stewardship, hemodynamic surveillance, and early recognition of complications requiring escalation of care.

Core Nursing Responsibilities

Fluid Balance Monitoring

• Document urine output every 1-6 hours depending on AKI severity, with running hourly totals maintained continuously 1
• Calculate and record total daily fluid balance at minimum every 24 hours, comparing intake versus output 1
• Monitor for oliguria (urine output <0.5 mL/kg/hour for 6 hours), which defines AKI and requires immediate physician notification 2
• Track all fluid sources including IV medications, oral intake, and enteral feeds, as accurate monitoring reduces AKI rates by 33% 1

Hemodynamic Assessment

• Assess volume status through clinical examination including jugular venous pressure, peripheral edema, lung auscultation for crackles, and daily weights 3, 2
• Monitor blood pressure closely, particularly for systolic BP <90 mmHg which is an early warning sign requiring immediate intervention 4
• Track intravascular volume and hemodynamic status during dialysis sessions to assess for renal recovery 3

Medication Management

• Identify and hold nephrotoxic medications immediately including NSAIDs, ACE inhibitors, ARBs, and diuretics when AKI is diagnosed 5, 2
• Implement the "ABCDE" checklist: Address drugs, Boost blood pressure, Calculate fluid balance, Dip urine, Exclude obstruction 4
• Verify medication dose adjustments based on current estimated GFR, as kidney function changes dynamically during AKI 5
• Avoid the "triple whammy" combination of NSAIDs, diuretics, and ACE inhibitors/ARBs which more than doubles AKI risk 2

Laboratory Monitoring

• Check serum electrolytes, BUN, and creatinine every 4-6 hours initially in severe AKI 5, 2
• Monitor for hyperkalemia, metabolic acidosis, and uremic complications that may require urgent dialysis 2
• Perform urinalysis to detect hematuria, proteinuria, or abnormal sediment 2

Patient Surveillance and Early Recognition

Critical Warning Signs Requiring Immediate Physician Notification

• Serum creatinine rise ≥0.3 mg/dL within 48 hours or ≥50% increase from baseline within 7 days 2
• Urine output <500 mL in 24 hours or <0.5 mL/kg/hour for 6 hours 4, 2
• Systolic blood pressure <90 mmHg indicating inadequate renal perfusion 4

Signs of Fluid Overload

• Monitor for peripheral edema, pulmonary congestion, weight gain, and respiratory distress 2
• Recognize that fluid overload worsens outcomes and may necessitate dialysis 3

Multidisciplinary Communication and Care Coordination

Shared Decision-Making

• Participate in discussions among caregivers, patients, and family members regarding treatment goals and recovery expectations 3
• Facilitate communication between primary team, nephrology, and rehabilitation services 3

Discharge Planning and Follow-Up

• Ensure discharge plans include documentation of renal function and clear follow-up arrangements 3
• Educate patients about medication avoidance, particularly over-the-counter NSAIDs 2
• Coordinate transfer to rehabilitation/skilled nursing facilities with close monitoring protocols 3
• Verify nephrology follow-up is scheduled within 3 months for AKI resolution assessment 3, 2

Renal Replacement Therapy (RRT) Support

For Patients Requiring Dialysis

• Monitor hemodynamic status, intravascular volume, and urine output during dialysis to assess for renal recovery 3
• Track ultrafiltration rates and intradialytic hypotensive episodes, as these associate with non-recovery of kidney function 3
• Reassess need for continued RRT daily with the medical team 2

Patient and Family Education

Critical Teaching Points

• Explain the importance of avoiding nephrotoxic medications, especially over-the-counter NSAIDs 2
• Teach recognition of symptoms requiring medical attention: decreased urine output, swelling, shortness of breath 2
• Emphasize adherence to fluid restrictions when prescribed 2

Common Nursing Pitfalls to Avoid

• Incomplete fluid balance documentation leads to missed AKI recognition; completion rates must exceed 70% for effectiveness 1
• Continuing nephrotoxic medications during AKI recovery causes ongoing kidney damage 5
• Overly aggressive fluid administration in non-hypovolemic patients worsens outcomes 5, 2
• Delayed escalation when clear indications for RRT exist increases mortality 2
• Failure to adjust medication dosages as kidney function changes during recovery 5