Acute Kidney Injury Nursing Care Plan

What is an Acute Kidney Injury Nursing Care Plan template?

An AKI Nursing Care Plan Template is a document that guides healthcare professionals in delivering personalized and effective care for patients with a sudden decline in kidney function.

The template typically includes several key components:

• Assessment: This section involves a thorough evaluation of the patient's condition, including vital signs, laboratory results (such as serum creatinine and blood urea nitrogen levels), urine output, and fluid balance. It helps in identifying the underlying cause and severity of AKI.
• Diagnosis: Based on the assessment findings, nurses can diagnose the stage and cause of AKI. This step is crucial for developing targeted interventions.
• Goals and outcomes: Establishing realistic and measurable goals is critical to the care plan. These goals include improving renal function, managing fluid balance, and addressing the underlying cause of AKI.
• Interventions: This section outlines the nursing actions and medical interventions required to address the identified issues. These may involve close monitoring of vital signs, medication administration, implementation of dietary restrictions, and collaboration with other healthcare professionals.
• Evaluation: Regular evaluation of the patient's response to interventions is essential. It helps determine the effectiveness of the care plan and make adjustments as needed.
• Patient education: Educating the patient and their family about AKI, its causes, and the importance of adherence to the care plan is crucial for promoting self-management and preventing complications.
• Discharge planning: As the patient progresses, discharge planning involves preparing the individual for continued care at home or in another healthcare setting.

The AKI Nursing Care Plan Template provides a systematic approach to care delivery, facilitating communication and collaboration among healthcare team members. It ensures that care is evidence-based, patient-centered, and continuously evaluated to achieve optimal outcomes for individuals experiencing acute kidney injury and prevent kidney failure.

How does it work?

Step 1: Download our template and fill out patient information

Download our printable Acute Kidney Injury Nursing Care Plan template above and fill out your patient's information (e.g., age, gender, medical record number, etc.) to establish their identity for their care plan.

Step 2: Assessment and diagnosis

Conduct a comprehensive assessment of the patient. Record vital signs (blood pressure, heart rate, respiratory rate) and lab values (serum creatinine, blood urea nitrogen, urine output, fluid balance) from the assessment.

Then, using the results, identify and document the primary diagnosis of the acute kidney injury, specifying the underlying cause and stage. This information will guide your treatment goals and interventions.

Step 3: Establish measurable treatment goals and provide appropriate treatment

Establish measurable goals for the patient, such as achieving specific renal function improvements, maintaining fluid balance, and addressing the root cause of AKI.

Manage the treatment plan effectively by closely monitoring vital signs, administering medications, implementing dietary restrictions, and coordinating with healthcare professionals.

Step 4: Patient evaluation

Regularly assess and document the patient's response to interventions. This step involves comparing current status to established goals, allowing for adjustments to the care plan as needed.

Continuously monitor the patient's progress, making any necessary adjustments to the care plan based on changes in the patient's condition or response to interventions.

Distribute copies of the care plan to relevant healthcare team members involved in the patient's care. Ensure that the plan is implemented consistently and updated as needed.

Step 5: Patient education

Include a section to educate patients and families on AKI (e.g., causes, symptoms, signs of potential complications), care plan adherence, medication, and dietary restrictions.

Step 6: Discharge planning

Plan for the patient's transition from the healthcare facility. Include instructions for continued care at home or in another setting, emphasizing follow-up appointments and ongoing monitoring.

Step 7: Review and sign-off

Before finalizing, review the completed care plan for accuracy and completeness. Obtain necessary signatures from healthcare professionals involved in the patient's care.

When would you use this template?

The Acute Kidney Injury Nursing Care Plan Template is a valuable resource for healthcare practitioners managing patients experiencing sudden and potentially reversible kidney dysfunction. This template is handy in the following scenarios:

• Diagnosis of acute kidney injury (AKI): Use the template when a patient is diagnosed with AKI, whether in an inpatient or outpatient setting. It is a structured tool to guide the development of an individualized care plan based on the patient's condition and contributing factors.
• Hospital admissions: When a patient with AKI is admitted, the care plan template becomes instrumental. It ensures a standardized approach to care and facilitates communication among multidisciplinary healthcare teams, including nurses, physicians, and specialists.
• Emergency department presentations: In emergencies where AKI is identified, the template can be quickly employed to initiate timely and appropriate interventions. This is crucial in addressing the acute nature of the condition and preventing further complications.
• Outpatient clinics: The template aids patients with AKI receiving care in outpatient settings, such as renal clinics or specialized nephrology practices, in developing a comprehensive plan for ongoing monitoring, management, and patient education.
• Transitions of care: When patients with AKI transition between care settings, such as from the hospital to home or from one healthcare provider to another, the template ensures continuity of care by providing a clear and concise summary of the patient's needs and interventions.
• Chronic kidney disease (CKD) management: In cases where AKI is a manifestation of underlying chronic kidney disease, the template can be adapted for long-term care planning. This is especially relevant for practitioners involved in managing CKD and its complications.‍
• Collaborative care: Healthcare practitioners, including nurses, physicians, dietitians, and pharmacists, can use this template collaboratively to ensure a holistic and coordinated approach to AKI management. It fosters communication and promotes consistency in care delivery.

What do the results mean?

Interpreting the results of assessments and diagnostic tests for acute kidney injury (AKI) is crucial for guiding the development and implementation of an effective care plan. Here are typical results and their meanings:

• Elevated serum creatinine: Elevated serum creatinine levels, a waste product usually filtered by the kidneys, indicate impaired kidney function. The degree of elevation correlates with the severity of AKI. A substantial increase suggests a significant decrease in glomerular filtration rate (GFR).
• Increased blood urea nitrogen (BUN): Elevated BUN levels indicate impaired kidney function, as the kidneys are responsible for excreting urea. Elevated BUN may result from decreased renal blood flow or inadequate filtration. However, BUN levels can be influenced by factors such as dehydration and protein intake.
• Decreased urine output: Oliguria (reduced urine output) or anuria (absence of urine) are common signs of AKI. It reflects the kidneys' inability to excrete waste and regulate fluid balance effectively. Monitoring urine output is essential for assessing the severity of AKI.
• Fluid and electrolyte imbalances: AKI can disrupt the body's balance of fluids and electrolytes. Hyperkalemia (elevated potassium levels), hyponatremia (low sodium levels), and fluid overload are common imbalances. These can lead to complications such as cardiac arrhythmias and edema.
• Metabolic acidosis: In severe cases of AKI, impaired kidney function can result in the accumulation of acidic byproducts in the blood, leading to metabolic acidosis. This can have systemic effects on various organ systems.‍
• Underlying causes: Identification of the underlying cause of AKI is crucial for targeted interventions. Common causes include dehydration, sepsis, medications, and obstruction of the urinary tract. Addressing the cause is essential for managing and potentially reversing AKI.

Research and evidence

Originally conceived as a structured methodology to enhance the consistency and quality of patient care, nursing care plans have garnered recognition within the healthcare profession for their pivotal role in improving patient outcomes through evidence-based care planning.

Nephrology and critical care nursing research have been instrumental in defining the components of the AKI Nursing Care Plan Template (Wagner, 2022). Numerous studies have identified optimal practices for assessing, diagnosing, and managing AKI, resulting in evidence-based guidelines that inform the structure and content of care plans. Notably, the research underscores the importance of early detection of AKI, emphasizing monitoring serum creatinine levels and urine output (Gameiro et al., 2020).

The influence of electronic health records (EHRs) and healthcare technology on care plan development is evident (Vera, 2014). Carefully designed templates, influenced by technological advancements, aim to be user-friendly, facilitating efficient documentation and communication among healthcare providers. These templates bridge research findings in AKI management and practical, standardized approaches embedded in care plans, ensuring alignment with current evidence (Goyal et al., 2022).

Ultimately, the evidence supporting the use of care plans lies in their demonstrated ability to foster systematic and standardized patient care, contributing to improved outcomes, reduced practice variability, and enhanced communication among healthcare teams.

References

Gameiro, J., Fonseca, J. A., Outerelo, C., & Lopes, J. A. (2020). Acute kidney injury: From diagnosis to prevention and treatment strategies. Journal of Clinical Medicine, 9(6), 1704. https://doi.org/10.3390/jcm9061704

Goyal, A., Daneshpajouhnejad, P., Hashmi, M. F., Bashir, K., & John, B. K. (2022). Acute kidney injury (nursing). In ncbi.nlm.nih.gov. StatPearls Publishing. https://ncbi.nlm.nih.gov/books/NBK568593/

Wagner, M. (2022, July 27). Acute kidney injury (AKI) nursing diagnosis & care plan. NurseTogether. https://www.nursetogether.com/acute-kidney-injury-nursing-diagnosis-care-plan/

Vera, M. (2014, February 27). 6 acute renal failure nursing care plans. Nurseslabs. https://nurseslabs.com/acute-renal-failure-nursing-care-plans/