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NUR251
AU
Charles Darwin University
First of all, it is important for a nurse to identify the patient correctly and then perform a routine head to toe assessment for understanding the current condition of the patient. Routine head to assessment is considered an extremely important nursing interventions since it provides comprehensive data regarding the patient’s response to implemented treatment and also helps to tract an early sign of deterioration. Baseline data including patient’s health needs can be obtained through this process and evaluation of the patient’s condition becomes easier for a nursing professional in charge of the patient. In case this assessment remains incomplete, it will result into failure to misdiagnosis of serious health conditions and would also affect provision of quality of care to the patient on- time. Head- to- toe assessment checklist can be used in order to perform this assessment.
Secondly, considering the chief diagnosis of the patient i.e., acute kidney injury, monitoring the fluid balance should be prioritized by the nurse. Mary’s fluid input and output both were impacted due to the progression of the clinical condition of AKI, however she was placed on intravenous fluid therapy for restoration of fluid balance. In order to evaluate the effectiveness of the implemented therapy and to avoid the risk of hypovolemia or dehydration of the patient (Chapman et al.,2021). It necessary to perform fluid balance monitoring in accurately (Moore, Hsu & Liu, 2018). Skin turgor, appearance of the mucous membrane, sings of pitting oedema and change in skin colour might be considered as potential indicators for fluid imbalance state in Mary. Based on this assessment, required interventions can be prompted. In case a nurse misses out or avoid assessment of fluid balance in this patient, evaluation of the implemented intervention on patients will remain incomplete leading to failure in quality-of-care provision. In this context, use of a fluid balance chart would be appropriate for a nurse.
Thirdly, a nurse should consider performing vital signs measurement for the patient. Vital signs are considered the most powerful and potential indicators for assessing the deuteriation of an individual at an early stage (Bansal et al., 2018). According to the initial assessment report, it was indicated that the patient was hypertensive and showing bradycardia. Along with that increased respiratory rate was also remarked for the patient. All these vital cues might lead to cardiopulmonary failure and might impose greater risk of heart failure or cardiac arrest on Mary. Considering the complications of the AKI on the patient’s current health status, it would be highly essential to measure the vital signs of the patient at a regular time interval and avoid the risk of clinical complications. In case, a nurse fails to measure vial signs of the patient from time to time, early signs of cardiopulmonary system breakdown will remain undiagnosed. As a consequence, Mary’s condition might become more critical and difficult to manage. In order to perform the assessment and document the records, a nurse must utilize the vital sign assessment chart.
| Nursing problem: Risk of fluid volume deficit | |||
| Related to: Acute kidney injury, decreased fluid intake due to nauseous feeling and reduced glomerular filtration rate. | |||
| Goal of care | Nursing interventions | Rationale | Evaluation |
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Ensuring restoration of fluid homeostasis in patient.
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· Assessment of physical signs and symptoms which may related to deficient fluid volume. · It is important promote hydration in the patient. · The effect of fluid deficit on the patient’s health should be discussed.
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· Physical signs of dehydration might include decreased skin turgor, capillary refill time of more than 3 seconds, dry appearance of oral mucosa. All of these can be considered as the direct outcomes of vasoconstriction and limited perfusion to the periphery of the body (Cosentino et al., 2019). · Promoting hydration may help to maintain fluid intake of the patient and thus might contribute to restoration of fluid balance. · Increasing the awareness regarding dehydration in the patient might improve her understanding and promote drinking water. |
· The capillary refill time is maintained less than 3 seconds. · The patient shows normal thirst. · GFR would shoe normal range. |
| Nursing problem: Risk of electrolyte imbalance | |||
| Related to: Decreased urinary output. | |||
| Goal of care | Nursing interventions | Rationale | Evaluation |
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Restoration of normal electrolyte balance in the patient.
| · Administration of electrolyte replacements as per the recommended doses should be promoted. · It is important to considered measured which are helpful in reducing excess electrolytes. | · For individuals at risk of electrolyte imbalances, oral or IV electrolyte therapy may be given to maintain electrolyte balance (Serin et al., 2017). · Patients with end-stage renal illness are more likely to have hyperkalemia, which can cause severe electrocardiographic abnormalities. In many individuals, dialysis is the only way to cure their hyperkalemia (Nash et al., 2019). To keep the myocardium stable, intravenous calcium is administered. Patients at risk of electrolyte excesses, such as potassium, may benefit from kayexalate. | Blood sodium potassium level would show normal level. Urine appears normal in colour and smell.
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| Nursing problem: Risk of unstable blood glucose level | |||
| Related to: Medical history of type 2 diabetes mellitus. | |||
| Goal of care | Nursing interventions | Rationale | Evaluation |
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Maintaining the blood glucose level at normal level is important.
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· A nurse should promote medical adherence of the patient. · Self-monitoring devices should be introduced · The patient should be encouraged to maintain healthy lifestyle and incorporate healthy diet, exercise regularly.
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· Regular intake of antihyperglycemic medications is beneficial for improving insulin sensitivity and thereby increases glucose utilization. This ultimately helps to maintain the blood sugar level (Ko et al., 2017). · According to a study done by Machry et al. (2018), the use of Self-Monitoring of Blood Glucose (SMBG) is advantageous in terms of lowering blood glucose concentration in type 2 diabetes mellitus patients. · Lifestyle modifications are considered one of the most appropriate and most recommended interventions for managing type 2 diabetes mellitus. Dietary changes and regular physical exercises have been associated with improved insulin functioning for diabetic patients and thus might be recommended to this patient as well. With this intervention, the patient should also be able to maintain her body weight which is considered one of the main causes underlying development of this metabolic disorder. | · HbA1C measurement should reflect normal ranges. · The patient showing willingness to overcome the risk factors. · Patient efficiently uses self-monitoring devices. |
Discharge planning is considered one of the major responsibilities that are relied on the nursing professionals (Thoma & Waite, 2018). Providing health education to the patient should start from the beginning of the hospitalization. the discharge planning of Mary should include detailed description and awareness of her condition and also management of her comorbidities. First of all, the patient must be made aware of the gravity of her present condition. Along with this it is important to make the patient understand the risk factors that may impact her condition. The patient must be able to recognise underlying causes of her present illness and would show her proactiveness in addressing those risk factors. While educating the patient, self- monitoring techniques should be introduced to her so that she can participate actively in her own treatment. The process of using the self-monitoring devices should be demonstrated to the patient so that she feels confident in using them after discharge. This will eventually promote her adherence to medical treatment. Promoting self- care should be an integral part of Mary’s discharge planning. Along with understanding the risk factors, the patient must be referred to dietician and physiotherapist so that she can explore the ways to mitigate the risk factors as well. A dietician might help her to get a dietary plan suitable for her while the physiotherapist might promote regular physical exercise in the patient and also may promote mobility of the patient.
The second thing that must be prioritized in her discharge planning is developing her knowledge regarding the early signs and symptoms of acute kidney injury (Siew et al., 2019). The patient should be advised to maintain her daily fluid intake balance so that the risk of dehydration can be avoided. Educating the patient about keeping count of the frequency of daily urinary output may be incorporated. The patient should be able to assess change in the colour and smell of urine at the time of discharge and based on that she must be able to reach out to medical assistance for avoiding critical condition.
Since high blood pressure and increased blood glucose concentration are considered two major risk factors for developing and progression of acute kidney injury, the patient should take management of both these comorbidities under consideration. According to the research conducted by Machry et al. (2018), it was indicated that utilization of Self-Monitoring of Blood Glucose (SMBG) is beneficial in terms of reducing blood glucose concentration among type 2 diabetes mellitus patient. In order to prevent the severe outcomes associated with diabetes induced acute kidney injury, the patient might be introduced to self- monitoring devices such as glucometer and blood- pressure monitor. These devices would eventually help the patient to keep tract of her own conditions. Obesity being another potential risk factor may also be targeted in this process as well. There are other strategies for example dietary modification, quitting alcoholism and performing regular physical exercise which might be helpful in achieving a desired weight. The patient should also be supported from a nurse’s end in the aspects of planning short term and long- term goals.
The compound sodium lactate (CSL) has been advised to the patient at a dose of 500 mls for a period of 2 hours. In this case, the hourly rate of the intravenous fluid administration is 250 ml per hour. The formula is 500 mls/ 2 hours = 250 mls per hour.
Again, intravenous sodium chloride was charged at a rate of 1000mls/8 hourly, hence the hourly rate of sodium chloride/ potassium chloride infusions is 1000mls/ 8 hours = 125 mls per hour.
Compound Sodium Lactate solution is one of the fluid therapies that has been recommended to the patient. This compound is helpful in restoration of electrolyte balance in the body. There are different components of the solutions which include sodium, calcium, potassium as well as chloride. D-lactate and L-lactate have comparable pharmacokinetics. Lactate in Compound Sodium Lactate solution is metabolised by oxidizing and hepatic glucose production, mostly in the liver, and bicarbonate is made by these processes over the course of 1-2 hours. When this compound is added to Compound Sodium Lactate Fluid, the solution's overall pharmacokinetics are governed by the kind of medication utilised. Undesirable effects associated with administration of such therapy may include Acute hyponatraemic encephalopathy, metabolic as well as nutritional problems including hyperkalaemia which is often referred as hospital acquired hyperkalaemia. Cardiovascular and pulmonary insufficiency may also be observed and can be manifested by bradycardia, increased blood pressure, Angioedema, chest discomfort, flushing, shortness of breath, bronchospasm, cough and immune system disorders for example urticaria and rash as well.
Furosemide is another medication which has also been prescribed to Mary. This is one of the most potential diuretics which work effectively by promoting elimination of excessive water from the body. This diuretic agent works by facilitating the process of diuresis by the kidney. Basically, the mechanism of action of this drug includes sodium-potassium-2 chloride (Na+-K+-2 Cl−) co-transporter inhibition. These symporters are usually located on the ascending limb of the loop of Henle which is considered one of the main segments of the renal tubule through which reabsorption of fluid is mediated. The pharmacokinetic property of the drug includes excretion through urine by almost 80% of a single dose, plasma half-life of the medicine is around 30 minutes and the drug is minimally metabolized through the hepatic system. Adverse effect of this medication might include nausea, constipation, abdominal cramping, blurred vison, dizziness and vertigo as well.
Bansal, N., Matheny, M. E., Greevy Jr, R. A., Eden, S. K., Perkins, A. M., Parr, S. K., ... & Siew, E. D. (2018). Acute kidney injury and risk of incident heart failure among US veterans. American Journal of Kidney Diseases, 71(2), 236-245. https://doi.org/10.1053/j.ajkd.2017.08.027
Chapman, C. L., Johnson, B. D., Vargas, N. T., Hostler, D., Parker, M. D., & Schlader, Z. J. (2020). Both hyperthermia and dehydration during physical work in the heat contribute to the risk of acute kidney injury. Journal of Applied Physiology, 128(4), 715-728. https://doi.org/10.1152/japplphysiol.00787.2019
Cosentino, N., Genovese, S., Campodonico, J., Bonomi, A., Lucci, C., Milazzo, V., ... & Marenzi, G. (2019). High-sensitivity C-reactive protein and acute kidney injury in patients with acute myocardial infarction: a prospective observational study. Journal of clinical medicine, 8(12), 2192. https://doi.org/10.3390/jcm8122192
Ko, S. H., Hur, K. Y., Rhee, S. Y., Kim, N. H., Moon, M. K., Park, S. O., ... & Kim, J. H. (2017). Antihyperglycemic agent therapy for adult patients with type 2 diabetes mellitus 2017: a position statement of the Korean Diabetes Association. Diabetes & metabolism journal, 41(5), 337-348. https://doi.org/10.4093/dmj.2017.41.5.337
Machry, R. V., Rados, D. V., de Gregorio, G. R., & Rodrigues, T. C. (2018). Self-monitoring blood glucose improves glycemic control in type 2 diabetes without intensive treatment: A systematic review and meta-analysis. Diabetes research and clinical practice, 142, 173-187. https://doi.org/10.1016/j.diabres.2018.05.037
Moore, P. K., Hsu, R. K., & Liu, K. D. (2018). Management of acute kidney injury: core curriculum 2018. American Journal of Kidney Diseases, 72(1), 136-148. https://doi.org/10.1053/j.ajkd.2017.11.021
Nash, D. M., Markle-Reid, M., Brimble, K. S., McArthur, E., Roshanov, P. S., Fink, J. C., ... & Garg, A. X. (2019). Nonsteroidal anti-inflammatory drug use and risk of acute kidney injury and hyperkalemia in older adults: a population-based study. Nephrology Dialysis Transplantation, 34(7), 1145-1154. https://dx.doi.org/10.1093%2Fndt%2Fgfz062
Serin, S. O., Karaoren, G., Okuturlar, Y., Unal, E., Ahci, S., Karakoc, E., & Ucak, S. (2017). Thiamin and folic acid deficiency accompanied by resistant electrolyte imbalance in the re-feeding syndrome in an elderly patient. Asia Pacific journal of clinical nutrition, 26(2), 379-382. https://search.informit.org/doi/abs/10.3316/ielapa.688319035474763
Siew, E. D., Parr, S. K., Wild, M. G., Levea, S. L., Mehta, K. G., Umeukeje, E. M., ... & Cavanaugh, K. L. (2019). Kidney disease awareness and knowledge among survivors ofacute kidney injury. American journal of nephrology, 49(6), 449-459. https://doi.org/10.1159/000499862
Thoma, J. E., & Waite, M. A. (2018). Experiences of nurse case managers within a central discharge planning role of collaboration between physicians, patients and other healthcare professionals: A sociocultural qualitative study. Journal of clinical nursing, 27(5-6), 1198-1208. https://doi.org/10.1111/jocn.14166
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