Acute Kidney Injury - Essay Example

Acute Kidney Injury Introduction Female patient by Jean was admitted to Accident and Emergency (A&E) ward of the hospital with complaints of breathing troubles. Four hours after admission, she showed the symptoms of Myocardial Infarction (MI); she underwent Coronary artery bypass graft (CABG). On the second day of the Post operative care, based on the clinical assessment and monitoring, the patient was diagnosed for Acute Kidney Injury (AKI). Monitoring and Nursing Care requirements for the patient and her family need to be discussed. The medical history of the patient reveals that she suffers from Down’s syndrome. Therefore, it is difficult to gather information from the patient due to her intellectual and physical disability. The patient requires specialised attention by the nursing staff; their coordination between the carer of the patient and medical practitioner is the prime task in the medical and nursing intervention. The present discussion is limited to the post-operative monitoring the patient for 24 hours. The patient monitoring requires assessment, nursing and medical intervention. Assessment includes gathering medical information of the patient’s medical history of the past, and pre and post operative stages. Nursing care should satisfy the DIMOND 2008-LEGAL ASPECTS OF NURSING, MASON AND LAURIES – LEGAL ASPECTS OF MENTAL CAPACITY and NICE GUIDLINE. Medical interventions are clinical assessment of patient’s condition, medical tests and examinations and medication in consonance with the medical practitioner. Patient assessment & nursing Collecting and recording of information about the patient upon admission to hospital is one of the criteria of assessment known as Audit which includes: name, date of birth, address, dependents, medication and details of medical practitioner referred by, power of attorney / advocate of patient, risk and holistic assessment signed by nursing coordinator and the patient/carer, evidence of patient/carer involvement, crisis plan signed by nursing coordinator and the patient/carer/advocate, recording of intervention daily/every shift signed, dated and designated, recording of medical practitioners’ finding/comments and tests results enclosed appropriately, reviews of care plan and regular evaluation, identification of care coordinator and other agencies involved and included with contact details (NICE, 2002) Nursing Care planning includes ASSESS, PLAN, IMPLEMENT and EVALUATE (cmft.nhs.uk, n.d ). Nursing care: Since the patient is with Down’s syndrome, her family or carers should also be given information about the kind of medical care proposed following the principles of Mental Capacity Act 2005. The consent should be obtained from the carer about the medical intervention proposed. The nursing care should include, Specific communication, Drugs and nutritional plan, Investigation plan, Psychological and emotional requirements and Physical and rehabilitation requirement. The principles of the Mental Capacity Act 2005: Every adult has the right to make his or her own decisions and must be assumed to have capacity to make them unless it is proved otherwise. A person must be given all practicable help before anyone treats them as not being able to make their own decisions. Just because an individual makes what might be seen as an unwise decision, they should not be treated as lacking capacity to make that decision. Anything done or any decision made on behalf of a person who lacks capacity must be done in their best interests. Anything done for or on behalf of a person who lacks capacity should be the least restrictive of their basic rights and freedoms (legislation.gov.uk, 2005). Assessment Assessment requires good communication skill. It is the right of patient and carer in need. This can be analysed using Assessment Tools and the ability to observe and document Physical, Social and Psychological changes. Tract and trigger system is a useful tool in assessment. Track and trigger systems rely on periodic measurement of observations (tracking) of patient, with predetermined action care till certain thresholds are reached (triggering). Care plan: primary requirement include recording patient’s details in the case sheet. The patient’s name, sex and age are recorded first. Recording, past history prior to post operative care and events, give valuable input in assessing the nursing and medical care requirements. Patient’s details: Name of patient: Jean Sex: Female Age: 42 years Patient’s history: 1. Medical history prior to admission to A&E: Down’s syndrome, hypertension, uncontrolled type2 diabetes mellitus, hypercholesterolemia 2. Subsequent history after admission: Myocardial infarction diagnosed; immediate traditional Cardiac Artery Bypass Grafting done using Heart-Lung Bypass Machine which keeps blood and oxygen circulating the body; heart was stopped for one hour using medicine; which allows surgeon to operate on still heart. Heart Function restored after surgery. Present admission: Present medical status: Post-operative care after CABG after admission to A&E ward for chest tightness and shortness of breath. Significant events: Event Observed: First day: nil Second day: Oliguria, elevated creatinine Diagnosis: Acute Kidney Injury Probable cause: hypotension, diabetes, cardiac surgery, radio contrast dye Medical intervention during next 24 hrs: Monitoring (LO 1 & 4) and Nursing Care (LO 2 & 3). Acute Kidney Injury diagnosed for Jean, the patient is intrinsic renal and it is the post operative event. It is impairment of kidney function the consequence of which result in electrolyte derangement and retention of substances which are secreted in the blood. Common cause of hospitalised patient is Acute Tubular Necrosis. Physiological deterioration leads to Critical Illness. Track and trigger systems shall help in assessing the score of illness by the parameters, such as: heart rate, respiratory rate, systolic blood pressure, level of consciousness, oxygen saturation, temperature. STAGING OF AKI is important for initiating medical treatment: Staging is done in accordance to the level of blood creatinine and urine output. Stage 1: creatinine: ≥ 0.3mg/dl; urine output: < 0.5 ml/kg/h for 6–12 hours Stage 2: creatinine: 2.0-2.9 times base line; urine output: < 0.5 ml/kg/h for ≥ 24 hours Stage 3: creatinine: ≥ 4.0mg/dl; urine output: < 0.3 ml/kg/h for ≥ 12 hours Functions of kidney: They are : Secretion of hormones such as erythropoietin, rennin, vitamin D, prostaglandins, Synthesis of glucose, glycerol and glutamine, Balancing the level of urea, glucose, proteins, sodium, chloride, bicarbonate, potassium, calcium, magnesium, phosphate and water level etc , Filtration and reabsorption, Excretion of toxic substances and Regulation of blood pressure, red blood cell and acid level. Diagnosis and monitoring Abrupt deterioration of kidney function leads to Acute kidney injury, diagnosed as a result of enhanced serum creatinine along with reduction in urine output. The severity of injury may require renal replacement therapy. The examination will reveal the AKI as either “pre-renal, intrinsic renal, or post-renal” (p1). The patient history can identify the cause of renal impairment or poor renal perfusion; Medicines with nephro-toxicity if consumed can result in impaired renal function. Physical examination is to be made to measure volume of blood in the patient’s circulatory system and identification of dermatological signs that may indicate systemic disorders followed by preliminary lab testing for serum creatinine, blood count, urinalysis and sodium excretion at fractional levels. Ultrasound based diagnostic imaging of kidneys is ideally carried out to ensure there is no obstruction. Treatment of AKI involves replacement of fluid, eschewing medicines with known nephrotoxicity, keeping off contrast media exposure, and maintenance of electrolyte imbalances (Rahman, Shad, & Smith, 2012). Dialysis is resorted to in the case of condition of high levels of potassium ions in blood known as Refractory hypokalaemia i.e 5.5 mmol/L, excessive urine output characterized as volume overload, metabolic acidosis of intractable condition, organic brain disorder called Uremic encephalopathy, inflammation of pericardium known as pericarditis, and toxins removal (Rahman, Shad, & Smith, 2012). Risk factors involved are senility, sepsis, shock, history of heart surgery etc. Team-based management is necessary for improving patient’s condition. Prevention, early diagnosis, and aggressive management are critical approaches. Symptoms of Acute Kidney Injury which require monitoring for medical intervention. Oedema in lower limbs, Pulmonary odema, Blood pressure changes, Oliguria and annuria, Back ache, Potassium imbalance and Irregular heart rate, tachycardia. Diabetes mellitus: Since the patient is admitted with the history of diabetes mellitus, its cumulative effect on AKI should be considered. Diabetes Mellitus is the condition where high blood glucose level increases the load of kidney in eliminating glucose from the body. Since the patient Jean is Type 2 Diabetic, her HbA1c and Blood Glucose level are to be monitored. HbA1c provides information how the Blood sugar level have been over a longer-term trend, over a period of time. An HbA1c reading can be taken from a blood specimen drawn from the arm. Blood glucose level is the concentration of glucose in the blood at a single point in time. Pre prandial is measured while the stomach is empty. Post prandial is measure 2 hours after meals. This is measured using a fasting plasma glucose test, which can be carried out using blood taken from a finger or can be taken from a blood sample from the arm. However, fasting glucose tests indicates the current glucose levels only, whereas the HbA1c test shows the average levels are over a period of 2-3 months. HbA1c is expressed as a percentage (DCCT unit) or as a value in mmol/mol (IFCC unit). Note that the HbA1c value, which is measured in mmol/mol, should not be confused with a blood glucose level which is measured in mmol/l. Use our HbA1c conversion tool to help with switching between the two measurement units. An HbA1c of 5.6% or less is normal. The following are the values when the HbA1c is being used to diagnose diabetes: Normal: Less than 5.7% Pre-diabetes: 5.7% to 6.4% Diabetes: 6.5% or higher Diabetes mellitus type 2. This is in contrast to diabetes mellitus type 1, in which there is an absolute lack of insulin due to breakdown of islet cells in the pancreas  Test values for Type 2 diabetes: pre prandial 4 to 7 mmol/L; post prandial under 8.5mmol/L (Lewington & Kanagasundaram, 2011) Hypercholesterolemia: It is also called Hyperlipidemia where the level of cholesterol in the blood is high. High cholesterol level is the predisposing factor cardiac disease. Normal value of Total Cholesterol in blood is 200 mg/dL (5, 17 mmol/L) The patient has been admitted with history of Hypercholesterolemia. The patient was administered radio contrast dye before cardiac surgery. Long term Hypercholesterolemia and administration of contrast induces Acute Kidney injury. Use of Statin on patient may aggravate the condition of AKI. (Carney, 2013) Other investigation suggested for monitoring the patient with AKI: Full Blood Count (FBC) throws full picture of Blood Components. FBC is a very common blood test done for specific conditions, such as anaemia. The number of red cells, white cells and platelets in the blood are checked. Red cells carry oxygen around the body and haemoglobin makes up part of the red cells. White cells are used by the body to fight infections. Platelets are important for clotting blood and stopping bleeding. Low haemoglobin suggests a person has anaemia. High haemoglobin could indicate lung disease or bone marrow problems. Low white blood cell count. Bone marrow problems, including bone marrow cancer, may be indicated if the test shows a low white blood cell count. It could also be due to a viral infection or be down to a person’s genetic make-up and of no clinical significance. It is also important to monitor the white cell count during chemotherapy treatment for cancer. High white blood cell counts may suggest the body is fighting off an infection, or in rare cases, it might be a sign of leukaemia or blood cancer. Low platelet counts could also signify a viral infection. It could also be due to an autoimmune condition in which the bodys immune system turns on itself attacking healthy tissue. High platelet counts can mean inflammatory conditions, an infection, or bone marrow conditions (Leach,2014). (HSE, n.d.) When oxygen is deprived of adequate oxygen, the condition is called hypoxia (Hypoxiation or Anoxemia). Hypoxia may affect the whole body or a region may be affected. Hypoxia refers condition where deficiency of oxygen is diagnosed, whereas hypoxemia refers specifically to states that have low arterial oxygen supply. Hypoxia in which there is complete deprivation of oxygen supply is referred to as "anoxia". Ischemia, meaning insufficient blood flow to a tissue, can also result in hypoxia. This is called ischemic hypoxia.  Haemoglobin is the carrier of oxygen in the body. It delivers oxygen to tissues of the body. Haemoglobin increases the oxygen-carrying capacity of blood. Hypoxic state result, when the ability of haemoglobin to carry oxygen is interfered. Iron is used in the synthesis of haemoglobin, when haemoglobin is low there is less iron, due to insufficient intake, or poor absorption. Anemia is typically a chronic process that is compensated over time by increased levels of red blood cells via upregulated erythropoietin. Erythropoietin is a hormone secreted by the kidneys that increases the rate of production of red blood cells when the levels of oxygen in the tissues become low. Blood test is done to measure Full Blood Count of the blood. A blood sample is taken from a vein in the arm. All kinds of blood cells from the specimen are evaluated. Anaemia is detected when the level of haemoglobin comes down. Limited number of blood cells caused deficiency of haemoglobin. Lower level ferritin an indicator for inadequate quantity of iron in the body and it results in iron deficiency and a test for the amount of ferritin is done. Vitamin B12 and foliate deficiency: Anaemia may also be because of paucity of vitamin B12 and folic acid. Folic acid and vitamin B12 are administered to enable one’s body to generate red blood cells. This type of iron deficiency is widely prevalent in older people (Davey, 2011). (NHSDirectWales, 2014) (knowsleyccg.nhs.uk, 2014) (BootsWebMed, 2014) Metabolic acidosis (MA) is a condition in which there is too much acid in the body fluids. Causes: Metabolic acidosis takes place in the conditions of body producing excessive acid, or in a condition of kidneys not being able to discharge adequate acid from the body. The above condition occurs in different kinds such as diabetic, hyperchloremic and lactic acidosis In type 1 diabetes, the acidic ketone bodies builds up to form what is characterized as Diabetic acidosis. Too much depletion of sodium bicarbonate can result Hyperchloremic acidosis sometimes with severe diarrhoea. Too much secretion of lactic acid results in lactic acidosis. The MA can also be caused by dysfunctional kidneys, aspirin, ethylene glycol or methanol poisoning and high levels of dehydration (Davenport & Tolwani, 2009). Itchy skin can be a symptom of decreased kidney function, especially in cases of kidney failure (Kidney-cares.org, 2012). Investigation: Blood count TC/DC (FBC), GFR (to find out the stage of AKI), blood urea, creatinine, potassium (U&E – urea and electrolyte), Urological obstruction, Biochemical analysis, and Arterial pH. Medication and intervention: Intravenous infusion like isotonic sodium bicarbonate or sodium chloride, Insulin therapy and prophylactic intermittent haemodialysis (IHD) or hemofiltration (HF) for contrast-media removal Medications to be avoided: ACE inhibitors and ARBs if eGFR is low, Loop diuretic, Low dose dopamine, Theophylline, and Fenoldopam Intravascular Volume Assessment in the critically ill Patient: Clinical assessment of intravascular volume is importance in the management of critically ill patients. Intravascular volume assessment is relied on physical examination findings: weight measurements, and urine output as a means of determining a patient’s fluid status (Marsh & Brown, 2012). (Begin, 2013) (McGrawHill, n.d.), Conclusion It will be clear that acute kidney injury origianlly known as acute renal failure deals with not only kideny failure but also variety of injuries to the kidney with the change of defintion of AKI in the past. Diagnosis is mainly on the basis of monitoring of creatinine levels either with or without urine output. AKI is now one of the priorities of primmary care as it is found in people without any incidence of acute illness. NICE guidelines advoacte early intervention with the objective risk assesment and prevention by eraly recogntion and treatment. NICE guidelnes also recoomends certain drugs which have not received marketing authorisation as there is good evidence of efficacy. The summary of monitoring includes the use of drugs with Non-steroidal anti-inflammatory drugs, diuretics, antibiotics, cardiac drugs for hypertension, statins, anticoagulants, Monitoring patient for event or adverse reaction, Assessing pain using pain tool, Symptoms of Hypovolaemia, hypoxia, Investigation of glomerular filtration rate and Investigation of blood urea, haemoglobin, References Begin, L. (2013). The Nursing Students Practical Guide to Writing Care Plans . www.scribd.com/.../The-Nursing-Student’s-Practical-Guide-to-Writing-C...‎. BootsWebMed. (2014). Anaemia, vitamin B12 or folate deficiency - Introduction. Retrieved May 1, 2014, from Boots Web Med : http://www.webmd.boots.com/a-to-z-guides/tc/anaemia-vitamin-b12-or-folate-deficiency-introduction Carney, E. (2013). Acute kidney injury: High-potency statin therapy and risk of acute kidney injury. Nat Rev Nephrol , 9 (6), 309. cmft.nhs.uk. Nursing Process . www.cmft.nhs.uk/.../Assessingplanningimplementingandevaluatingcare_. Davenport, A., & Tolwani, A. (2009). Citrate anticoagulation for continuous renal replacement therapy (CRRT) in patients with acute kidney injury admitted to the intensive care unit. CKJ Clinical Kidney Journal , 2 (6), 439-447. Davey, P. (2011). HSE. (n.d.). Anaemia, iron deficiency. Retrieved May 2, 2014, from HSE: http://www.nehb.ie/eng/health/az/A/Anaemia,-iron-deficiency/Symptoms-of-iron-deficiency-anaemia.html Kidney-cares.org. (2012). Itchy Skin and Kidney Function. Retrieved May 1, 2014, from Kidney Cares Community : http://www.kidney-cares.org/kidney-failure-symptoms-complications/223.html knowsleyccg.nhs.uk. (2014). Anaemia, vitamin B12 or folate deficiency . Retrieved May 1, 2014, from knowsleyccg.nhs.uk: http://www.knowsleyccg.nhs.uk/health-a-to-z/a/anaemia-vitamin-b12-or-folate-deficiency/ Leach, M. (2014). Interpretation of the full blood count in systemic disease – a guide for the physician. Journal of Royal College of Physicians of Edinburg , 44 (1), 36-41. legislation.gov.uk. (2005). Mental Capacity Act . http://www.legislation.gov.uk/ukpga/2005/9/contents. Lewington, A., & Kanagasundaram, S. (2011). Acute Kidney Injury Practice Guidelines . http://www.renal.org/guidelines/modules/acute-kidney-injury#sthash.EiJQnCwr.dpbs. Marsh, C., & Brown, J. (2012). Perioperative fluid therapy. Anaesthesia & intensive care medicine , 13 (12), 594-597. McGrawHill. (n.d.). Introduction to the care planning process. www.mcgraw-hill.co.uk/openup/chapters/9780335237326.pdf‎. NHSDirectWales. (2014). Anaemia, vitamin B12 and folate deficiency. Retrieved May 1, 2014, from NHS Direct Wales : http://www.nhsdirect.wales.nhs.uk/encyclopaedia/ch/article/anaemia,vitaminb12andfolatedeficiency/?print=1 NICE. (2002). Principles for Best Practice in Clinical Auidt. Oxon, UK: Redcliffe Medical Press. Rahman, M., Shad, F., & Smith, M. (2012). Acute kidney injury: a guide to diagnosis and management. Am Fam Physician , 86 (7), 631-9. Read More