Question 1. Define acute kidney injury.

Acute renal failure (ARF) has been replaced by the term acute kidney injury (AKI) and is recognized as a clinical syndrome rarely with a sole or distinct pathophysiology (Davies 2009: Makris & Spanou 2016). Acute kidney injury (AKI) is a clinical spectrum manifested as being abrupt (within hours) sustained decrease in kidney function, encompassing injury (structural damage) and impairment (loss of function) resulting in raised serum creatinine and/or decrease in urine output from baseline (Mehta et al. 2007). RIFLE criteria for classification and staging adapted for paediatrics has been further enhanced as a diagnostic tool, by proposed modifications of staging by Acute Kidney Injury Network (AKIN 2007), Kidney Disease Improving Global Outcomes (KDIGO 2012) and NICE guidelines (2019), to standardise practice.

Paediatric – modified RIFLE (pRIFLE)

• R Risk
  
• I Injury
  
• F Failure
  
• L Loss – need for renal replacement therapy (RRT) >4 weeks
  
• E End-stage renal disease (ESRF), requiring dialysis >3 months

(Bellomo et al. 2004)

Ricci et al. (2008), have shown that this classification is a good predictor of outcome, showing that mortality increased with worsening Rifle class. It is hoped that these new guidelines will standardise and improve diagnoses and outcomes for renal patients. Currently no studies have been able to determine exactly at what point ‘renal replacement therapy’ (RRT) should be initiated. This can differ widely between units and even individual practitioners.

Question 2. With reference to a model of care, identify the immediate problems when planning Jack’s care.

Nursing prevention strategies, recognition of risk factors and management of AKI depend on nurse’s knowledge of pathophysiology, pharmacological agents together with therapeutic clinical measures.

Activity of living: elimination (Roper et al. 1990).

Assess: Jack is anuric.

Activity of living: eating and drinking.

Assess: Jack has continued nausea and vomiting leading to dehydration. This could lead to potential problems such as:

• Over hydration – if IV fluids commenced and fluid balance is not regularly reviewed or an inability to adhere to 24-hour fluid allowance.
  
• Catabolism – due to reduced calorie intake and inability to tolerate oral nutrition.
  
• May require dietetic involvement, for example nasogastric feed, supplements/enteral feeds.

Activity of living: maintaining a safe environment.

Assess: Jack has the potential problem of fluid excess related to anuria, excessive fluid administration, and sodium and water retention.

Potential electrolyte imbalance due to:

↓ renal potassium excretion (hyperkalaemia)

↓ renal sodium excretion (hypernatraemia) Decreased sodium due to excess hydration (hyponatraemia)

Activity of living: breathing and circulation (importance of compliance & consequences of non-adherence).

Assess: Jack has the potential problem of pulmonary oedema due to fluid overload, and fluid retention. He has the potential problem of hypertension due to fluid overload.

Activity of living: controlling body temperature.

Assess: Jack has the potential problem of infection due to compromised nutritional status and complications due to underlying pathology

Activity of living: communication (Casey 1988).

Assess: Jack and his family are anxious due to the suddenness, severity of his illness, the potential for long-term kidney damage. Jack is almost a teenager with the potential problem of compliance/concordance.

Question 3. Continuing with the nursing process and model of care, discuss in further detail the immediate problems identified in Jack’s care plan.

Activity of living: elimination.

Plan:

• To find cause of anuria and if possible restore renal function
  
• To prevent fluid overload

Implement:

• Weigh twice daily – morning and evening.
  
• Ensure bloods are taken on a daily basis to review kidney function – increase frequency if indicated – assist with same.
  
• 
  

  Record minimum four hourly vital signs – heart rate (HR), blood pressure (BP), respiratory rate (RR). Paediatric vital signs are individualised specific to age, size and underlying medical condition:

  
  
  
  
  • Assess fluid status from results
    
  • Decreased BP, increased HR continued dehydration
    
  • Increased BP fluid overload

Increased RR pulmonary oedema

• Calculate individual fluid requirement and ensure accurate record completion.

Activity of living: eating and drinking.

Plan:

• To ensure required nutritional and fluid intake and prevent a catabolic state
  
• To reduce uraemia
  
• To minimise nausea and vomiting

Implement:

• Record a minimum daily weight.
  
• Give IV fluids as prescribed – adhere to local hospital policies and procedures for administration of intravenous fluids.
  
• Assist with venepuncture to retain daily bloods or more frequently as indicated.
  
• Liaise with dietician for daily dietetic assessment.
  
• Give prescribed anti-emetics as per local hospital policy for administration of medicines and monitor effect.
  
• Record accurate hourly intake and output to account for insensible loss (approx. 400 ml/m²) + previous 24 hours’ output and other losses.
  
• Offer small amounts of high calorie, low salt, low potassium, calculated protein foods – take into account personal likes and dislikes.
  
• Consider the need for supplementary/enteral feeding if oral nutrition cannot be tolerated.
  
• Provide parent and child information and explanation of dietary needs.
  
• Consider parental or child involvement in recording diet and oral intake.

Activity of living: maintaining a safe environment.

Plan: monitor serum potassium and reduce to a safe level.

Implement:

• Assist with the collection of a minimum of daily bloods – increase frequency if clinically indicated.
  
• Liaise with dietician and ensure dietary potassium restriction is adhered to in diet.
  
• Give prescribed medications as per hospital policy and monitor effects/side effects, for example sodium bicarbonate drives potassium from blood into the cells.
  
• Consider the need for ECG monitoring, depending upon serum electrolyte levels.
  
• Provide parental and child information on diet and potassium containing foods.
  
• If potassium remains elevated give explanation and information in preparation for dialysis.

Activity of living: breathing and circulation.

Plan: to reduce BP to a safe level.

Implement:

• Record a minimum of four hourly BP and HR (increase frequency if condition indicates).
  
• Give anti-hypertensives as prescribed as per local hospital policy and monitor effects/side effects.Withold regular ACEi/ARB if taking pre admission as may cause further deterioration of renal function. ACE/ARB should not be given as a treatment for acutely elevated blood pressure in the setting of a patient with AKI.
  
• Ensure parents and child are aware of their fluid allowance and the importance of compliance.
  
• Consider child and parents’ involvement in the recording of oral fluid intake.
  
• Weigh to assess hydration status, that is, fluid overload may contribute to increased BP.
  
• If BP remains elevated provide parents and child with information and explanation if dialysis is considered. Consider age appropriate and developmental needs when providing written and verbal information.
  
• Involve play therapist – distraction.

NB when administering prescribed medications, the frequency and/or dose may need adjusted due to the child’s reduced renal function.