1. Planning
1.1. Pt. pain will have decreased/ or free of pain
1.1.1. pt. temperature will revert back to normal
1.1.1.1. pt. will have reduce anxiety level
1.1.1.1.1. Pt. urine will be clear and no presence of blood
2. Priority Assessment
2.1. Vital Sign, Pain, Fever, Bloody Urine, anxiety.
2.1.1. Assess Skin for any areas of edema and evaluate the degree
2.1.1.1. Auscultate for heart and lung sounds+ assess LOC -level of consciousness
3. Nursing Dx. Impaired Urinary Elimination r/t AKI+ hematuria + infection evidenced by decreased urine output, urgency + fever.
4. Ms. Smith 25 y/o female, walked in anxiously at the emergency at TEGH and presents c/o flank pain, fever, bloody urine, decrease urine output,and urgency for the past 48 hours.
4.1. MD Dx. Acute Kidney Injury r/t infection
4.1.1. MD intervention- CBC w/ diff., Blood Cultures, Urine C & S, Urinalysis, Vital Signs q4h, IV therapy- antibiotics, IV fluid therapy.
4.1.2. Rationale for MD interventions
4.1.2.1. CBC & diff. to detect hemoglobin loss, increase WBC confirms active infection, Blood Cultures test to determine if local or systemic infection & to rule out any bacterial infection, Urine C & S test to find bacteria that caused infection, Urinalysis Test to identify any abnormalities,to detect variety of disorders and to interpret quality of urine including appearance, concentration and content of urine. IV therapy- antibiotics to treat bacterial infection(eg. Septra), IV fluid therapy to flush the kidneys.
5. Implementation
5.1. administer pain, antipyretic, antibiotic meds as ordered, Monitor Urine output (note characteristics, colour, consistency, odor). Monitor for urine specific gravity
5.1.1. Encourage pt. to perform deep breathing exercises, meditation & muscle relaxation to reduce anxiety.
5.1.1.1. Maintain calm manner when working with the pt.
5.1.1.1.1. establish rapport to build trust with pt. using silence and listening actively, demonstrating empathy, respecting client's personal space
6. Evaluation
6.1. pt. will state that he is free of pain
6.1.1. Pt. vital signs & temperature normal
6.1.1.1. pt will be at ease and level of anxiety decreased
6.1.1.1.1. pt. will void clear urine
7. Acute Kidney Injury
7.1. Initiating stage:
7.1.1. pt presents bloody urine & flank pain for the past 48 hours.
7.1.1.1. Oliguric Stage: (last 5 days to over 15 days)
7.1.1.1.1. Renal changes occur: decrease tubular transport, decrease urine formation, low GFR. (note pt. presents decreased urine output upon admission.) During this stage, bleeding+ infection is common.