Acute Kidney Injury and Dialysis-Related Nursing Care

Acute kidney injury is tested through its consequences rather than its causes. Fluid accumulates, potassium climbs, waste products build, and every one of those turns into a nursing observation you can act on. Access care and the dialysis assessments sit on top of that.

Fluid is the visible problem

Output falls, and what the patient drinks and receives stops leaving. That shows up on the body long before it shows up in a laboratory report.

Daily weight is the most reliable fluid measurement available to you, which surprises students who expect it to be intake and output charting. Same scale, same time of day, same amount of clothing, recorded every day without exception.

Intake and output charting still matters, and it only works if everything is counted. Oral fluids, intravenous fluids, flushes, medication volumes, drains, vomit and any measured losses all belong on the chart.

Then examine for the overload itself. Crackles at the lung bases, breathlessness lying flat, swelling in the ankles or the sacrum, raised neck veins and a rising blood pressure describe fluid that has nowhere to go.

Breathlessness in this patient is urgent. Fluid moving into the lungs is not a slow problem, and it is reported straight away rather than at the end of the round.

The phase changes and so does the risk

Kidney injury often moves through phases, and the nursing worry flips as it does. While output is low, the concern is accumulation, and the whole plan is built around restriction and monitoring.

Then output can pick up sharply. Large volumes start leaving before the kidney has recovered its ability to concentrate urine or hold on to electrolytes.

That phase catches people out. The patient improves on paper and dehydrates in reality, and potassium and sodium can swing in the opposite direction to the one you were watching for.

So keep weighing and keep charting through the recovery. The observations that mattered last week are the ones that will show you the new problem.

Potassium is the dangerous problem

MedlinePlus gives a normal serum potassium of 3.7 to 5.2 mEq/L and notes in its own words that normal value ranges may vary slightly among different laboratories, so grade the result against the range printed on your patient's report.

Damaged kidneys stop excreting potassium, so the level climbs quietly. There is no reliable symptom that tells you it is happening, which is exactly why the monitoring is the intervention.

Weakness, tingling and palpitations can appear, and by then you are late. The heart is the organ at risk, and rhythm disturbance is the mechanism.

The rate of rise matters at least as much as the number itself, which is why a stem giving you two results hours apart is telling you something more important than either value alone.

Potassium is a rhythm problem before it is a laboratory one. The low-potassium version of that story, U wave included, is worked through in hypokalemia on the ECG, the U wave is not optional.

Nursing care follows sensibly from that.

The wider reasoning behind electrolyte questions, rather than the memorised lists, is in electrolytes, understand, do not just memorise.

Urea and creatinine belong together in this picture and are best read as a pair rather than one at a time. That reading is set out in BUN and creatinine, read together not separately.

Access care is a whole item on its own

A fistula or graft is the patient's lifeline and it is fragile. The arm carrying it is protected, and protecting it is entirely nursing work.

Feel for the thrill and listen for the bruit at the start of your shift and again if anything changes. A quiet, still access is an emergency to report, not a finding to recheck later.

Nothing goes into that arm. No blood pressure cuff, no venipuncture, no intravenous line, and no tight clothing, jewellery or sleeping on it.

After dialysis, watch the needle sites for bleeding and keep the dressings intact. Teach the patient to check the thrill themselves at home, because they will notice a change sooner than anyone else.

A dialysis catheter carries its own rule. It is a direct line into the bloodstream and it is not used for anything else without a specific order, with strict aseptic technique whenever the dressing is touched.

Medications and food get reviewed, not assumed

Every medication list in a kidney stem deserves a second read. Drugs cleared by the kidney accumulate when clearance falls, and doses that were safe last month may not be safe now.

Nephrotoxic agents are the other half of that review. Anti-inflammatories, some antibiotics and contrast studies all appear in these stems for a reason, and questioning an order is a legitimate nursing action.

Diet is restricted in more than one direction. Potassium, phosphate, sodium, protein and fluid allowances are all set individually, and reinforcing the specific plan beats reciting a generic renal diet.

Phosphate binders are worth understanding rather than memorising. They work by binding phosphate in food, which is why the timing with meals is the entire point of the dose.

Before and after dialysis

Before treatment, record weight and full observations, check the access, and confirm which medications are being withheld until afterwards, since antihypertensives and drugs that dialyse out are commonly held.

Afterwards, weigh again and compare. Removing fluid drops the blood pressure, so hypotension, dizziness, nausea and muscle cramps are the expected complaints and they need reporting rather than reassurance.

Watch the neurological state too. Headache, confusion or restlessness after a treatment is reported, because shifting fluid and solutes fast affects the brain as well as the circulation.

Infection risk runs through all of it. When immune defence itself is the underlying problem, the whole unit routine changes, and that version is described in neutropenic precautions and what changes on the unit.

Uremia also affects platelet function, so these patients bruise and bleed more readily than their history suggests. The findings that mark a bleed as active are in GI bleeding and obstruction, and the red flags between them.

The short version to carry

Weigh them daily. Guard the arm. Treat every potassium result as urgent, and keep the system order from the med-surg reasoning order underneath the detail.