Acute Kidney Injury Nursing Care Plan
Sudden loss of renal function; fluid balance, electrolyte control and nephrotoxin avoidance.
Quick answer
A Acute Kidney Injury nursing care plan centers on identify and reverse the cause quickly, before intrinsic damage becomes established; maintain fluid and electrolyte balance, above all potassium; prevent further kidney injury from drugs, contrast and hypotension. Priority nursing diagnoses are Excess fluid volume, Risk for electrolyte imbalance, Impaired urinary elimination. The plan below gives assessment cues, measurable goals, 6 intervention sets with rationales, and patient teaching.
Overview
Acute kidney injury is an abrupt decline in renal function over hours to days, marked by rising creatinine and BUN, with or without decreased urine output. Unlike chronic kidney disease it is often reversible if the cause is corrected quickly, which makes early recognition a nursing responsibility rather than a laboratory afterthought.
Causes are classified by location. Prerenal injury is a perfusion problem — hypovolemia, hemorrhage, shock, heart failure, sepsis or renal artery narrowing — and the kidney itself is intact, so it avidly conserves sodium and water. Intrarenal injury damages the nephron directly, most often acute tubular necrosis from prolonged ischemia or nephrotoxins such as aminoglycosides, contrast dye, NSAIDs or myoglobin from rhabdomyolysis. Postrenal injury is obstruction below the kidney: stones, tumor, clots, strictures or benign prostatic hyperplasia. Prerenal and postrenal causes progress to intrarenal damage if left uncorrected.
The classic course has four phases. Onset begins with the insult. The oliguric phase, lasting roughly one to three weeks, brings urine output below 400 mL per day, rising nitrogenous wastes, hyperkalemia, metabolic acidosis and fluid overload — the most dangerous period. The diuretic phase follows as tubules begin to recover but cannot yet concentrate urine, producing outputs of several liters a day with risk of dehydration, hypokalemia and hyponatremia. The recovery phase can take months, and some patients never regain full baseline function.
Key numbers to know
Oliguria definition
Urine output below 400 mL in 24 hours, or under 0.5 mL/kg/hr — report it immediately rather than at the end of shift.
Most lethal complication
Hyperkalemia. Watch for peaked T waves, widened QRS, bradycardia, muscle weakness and paresthesias; treat with calcium gluconate, then insulin with dextrose, and dialysis for definitive removal.
BUN-to-creatinine ratio
A ratio above about 20:1 suggests a prerenal cause; a ratio near 10:1 with high creatinine suggests intrarenal damage.
Contrast protection
Hydrate before and after contrast studies as ordered, hold nephrotoxic drugs and metformin per protocol, and recheck creatinine 48 to 72 hours later.
Diuretic phase trap
Large urine volumes look like recovery but cause hypovolemia and potassium loss — keep monitoring intake, output and electrolytes closely.
Nursing priorities
- Identify and reverse the cause quickly, before intrinsic damage becomes established.
- Maintain fluid and electrolyte balance, above all potassium.
- Prevent further kidney injury from drugs, contrast and hypotension.
- Support nutrition despite protein and electrolyte restrictions.
- Prevent infection, a leading cause of death in acute kidney injury.
- Prepare for renal replacement therapy when indicated.
Nursing assessment
Subjective data
- Decreased urination, or in the diuretic phase, unusually frequent large voids
- Fatigue, weakness, nausea and loss of appetite
- Shortness of breath or difficulty lying flat
- Confusion, drowsiness or difficulty concentrating
- Flank pain or difficulty starting a urine stream when obstruction is the cause
Objective data
- Rising serum creatinine and BUN with a falling estimated GFR
- Urine output below 0.5 mL/kg/hr, or several liters daily in the diuretic phase
- Hyperkalemia with peaked T waves and a widening QRS on ECG
- Metabolic acidosis with Kussmaul respirations; hyperphosphatemia and hypocalcemia
- Weight gain, edema, crackles, jugular venous distention and hypertension in the oliguric phase
- Hypotension, tachycardia and poor skin turgor in the diuretic phase
- Anemia, bleeding tendency and uremic symptoms as wastes accumulate
- Urinalysis findings: casts and tubular cells in intrarenal injury, concentrated urine with low sodium in prerenal injury
- Bladder distention or hydronephrosis on bedside ultrasound in obstruction
Related factors
- Renal hypoperfusion from hypovolemia, hemorrhage, sepsis or heart failure
- Nephrotoxic exposure to aminoglycosides, NSAIDs, contrast media or myoglobin
- Urinary tract obstruction raising back pressure into the nephron
- Impaired excretion of potassium, phosphate, hydrogen ions and nitrogenous waste
- Catabolic stress from surgery, trauma, burns or infection
- Invasive lines and catheters increasing infection risk
Key nursing diagnoses
Goals and expected outcomes
- Urine output returns to at least 0.5 mL/kg/hr and creatinine trends downward.
- Serum potassium stays within the ordered range with no ECG changes.
- Weight, blood pressure and edema remain within the individualized target.
- The patient stays free of infection during the admission.
- Nutritional intake meets the prescribed calorie target without excess protein, potassium or phosphorus.
- The patient and family describe nephrotoxic drugs to avoid before discharge.
Nursing interventions and rationales
Monitor renal function and fluid balance
- Record strict hourly or shift intake and output, including all IV flushes, oral fluids and drainage, and report oliguria immediately.
- Weigh the patient daily on the same scale at the same time; a kilogram of weight change equals roughly a liter of fluid.
- Assess for overload each shift — crackles, jugular distention, edema, orthopnea, rising blood pressure — and for depletion during the diuretic phase.
- Follow creatinine, BUN, GFR and urinalysis trends and correlate them with clinical findings rather than treating single values.
- Titrate fluid replacement to the ordered plan, which in oliguria is often the previous day's output plus insensible losses.
Prevent electrolyte and acid-base emergencies
- Review potassium with every draw and place the patient on a cardiac monitor when it is elevated.
- Recognize hyperkalemia clinically: muscle weakness, cramping, paresthesias, bradycardia and irregular rhythm.
- Give calcium gluconate, insulin with dextrose, sodium bicarbonate or potassium binders exactly as ordered, and recheck levels after treatment.
- Restrict dietary potassium and eliminate potassium-containing salt substitutes and supplements.
- Give phosphate binders with meals and monitor for tetany when acidosis is corrected in a hypocalcemic patient.
Protect the kidneys from further injury
- Review every medication for nephrotoxicity and renal dosing, and question NSAIDs, aminoglycosides and combined nephrotoxic regimens.
- Maintain adequate perfusion pressure; treat hypotension promptly because each hypotensive episode extends tubular damage.
- Follow hydration protocols before and after contrast imaging and hold metformin per policy.
- Monitor drug levels for renally cleared agents such as vancomycin and digoxin, and watch for toxicity at previously safe doses.
- Relieve obstruction promptly: assess for bladder distention, ensure catheter patency, and report anuria, which often signals blockage.
Support nutrition and comfort
- Coordinate with a renal dietitian for adequate calories with controlled protein, potassium, phosphorus and sodium.
- Offer small frequent meals, treat nausea before eating, and provide oral care to reduce metallic taste and uremic fetor.
- Manage uremic pruritus with emollients, cool baths, short nails and prescribed antipruritics.
- Track weight, albumin and prealbumin as objective nutrition markers in a catabolic patient.
Prevent infection and complications of immobility
- Remove urinary catheters and central lines as soon as they are no longer required and use strict aseptic technique for those that remain.
- Monitor temperature, white count and all invasive sites; uremia blunts the immune response so signs may be subtle.
- Encourage early mobility, incentive spirometry and prescribed thromboprophylaxis.
- Provide pressure injury prevention for edematous, poorly perfused skin.
Prepare for renal replacement therapy
- Anticipate dialysis for refractory hyperkalemia, fluid overload, severe acidosis, uremic pericarditis or encephalopathy.
- Explain the procedure and expected sensations, and address fear that dialysis is permanent — in acute injury it is often temporary.
- Hold dialyzable medications until after treatment when ordered and monitor pre- and post-treatment weight and vital signs.
- Protect any vascular access and monitor for disequilibrium symptoms after the first treatments.
Patient and family teaching
- Never take ibuprofen, naproxen or other NSAIDs without checking with your provider — they can damage recovering kidneys.
- Drink the amount of fluid your provider prescribes and weigh yourself daily.
- Avoid salt substitutes and high-potassium foods until you are told otherwise.
- Tell every provider, dentist and imaging center that you had kidney injury, especially before contrast dye studies.
- Keep follow-up lab appointments; kidney recovery is tracked with blood tests, not by how you feel.
- Report decreased urination, swelling, shortness of breath, muscle weakness or palpitations right away.
- Manage blood pressure and diabetes tightly to protect remaining kidney function.
How to build this plan
- 1Assess the patient. Collect subjective and objective data through interview, physical assessment, labs and chart review. Complete, accurate data is the foundation of every later step.
- 2Analyze and cluster the data. Group related cues, compare them with normal findings, and identify patterns that point to actual or potential problems.
- 3Formulate nursing diagnoses. Write the problem statement using a recognized diagnostic label plus related factors and evidence (problem related to cause as evidenced by signs).
- 4Set priorities. Rank diagnoses as high, medium or low using ABCs, Maslow's hierarchy and the patient's own stated priorities. Life-threatening problems come first.
- 5Establish goals and outcomes. Write SMART, patient-centered outcomes: specific, measurable, attainable, realistic and time-bound (short-term and long-term).
- 6Select nursing interventions. Choose independent, dependent and collaborative actions that are safe, evidence-based and matched to the outcome.
- 7Provide rationales. State the scientific reason each intervention works. Rationales are what turn a task list into clinical reasoning.
- 8Evaluate the plan. Compare the patient's actual response with the expected outcome: met, partially met or not met — then continue, revise or discontinue.
- 9Document and communicate. Record the plan and the patient's response in the health record so the whole team works from the same information.
Summarized for study use. Always follow your school's or facility's approved care plan format and current clinical policy.
Practice Acute Kidney Injury questions
These concepts are tested on the ATI proctored exams below — every set has answers and rationales.
More Urinary & Renal care plans
Plans that share these nursing diagnoses
Care plan writing guides
Common questions
What are the nursing diagnoses for Acute Kidney Injury?
Priority nursing diagnoses for Acute Kidney Injury: Excess fluid volume; Risk for electrolyte imbalance; Impaired urinary elimination.
What are the nursing interventions for Acute Kidney Injury?
Record strict hourly or shift intake and output, including all IV flushes, oral fluids and drainage, and report oliguria immediately. Weigh the patient daily on the same scale at the same time; a kilogram of weight change equals roughly a liter of fluid. Assess for overload each shift — crackles, jugular distention, edema, orthopnea, rising blood pressure — and for depletion during the diuretic phase. Follow creatinine, BUN, GFR and urinalysis trends and correlate them with clinical findings rather than treating single values. Titrate fluid replacement to the ordered plan, which in oliguria is often the previous day's output plus insensible losses. Review potassium with every draw and place the patient on a cardiac monitor when it is elevated.
What are the nursing care goals for Acute Kidney Injury?
Urine output returns to at least 0.5 mL/kg/hr and creatinine trends downward. Serum potassium stays within the ordered range with no ECG changes. Weight, blood pressure and edema remain within the individualized target. The patient stays free of infection during the admission. Nutritional intake meets the prescribed calorie target without excess protein, potassium or phosphorus. The patient and family describe nephrotoxic drugs to avoid before discharge.
What should you assess in a patient with Acute Kidney Injury?
Decreased urination, or in the diuretic phase, unusually frequent large voids; Fatigue, weakness, nausea and loss of appetite; Shortness of breath or difficulty lying flat; Confusion, drowsiness or difficulty concentrating; Flank pain or difficulty starting a urine stream when obstruction is the cause; Rising serum creatinine and BUN with a falling estimated GFR; Urine output below 0.5 mL/kg/hr, or several liters daily in the diuretic phase; Hyperkalemia with peaked T waves and a widening QRS on ECG; Metabolic acidosis with Kussmaul respirations; hyperphosphatemia and hypocalcemia; Weight gain, edema, crackles, jugular venous distention and hypertension in the oliguric phase; Hypotension, tachycardia and poor skin turgor in the diuretic phase; Anemia, bleeding tendency and uremic symptoms as wastes accumulate; Urinalysis findings: casts and tubular cells in intrarenal injury, concentrated urine with low sodium in prerenal injury; Bladder distention or hydronephrosis on bedside ultrasound in obstruction