Understanding AKI Through John's Story

Jack Smith

Hey everyone, welcome to AKI, where we walk through real nursing case studies and try to make the complex a little more manageable. I'm Jack Smith—I've been a nurse for about fifteen years, most of that time on the med-surg floors. Let me tell you, today's story is one I think a lot of you will relate to. We're diving into the case of John Matthews, a 68-year-old guy with a medical history that honestly reads like a pretty common admission—hypertension, type 2 diabetes, and osteoarthritis.

Jack Smith

John came in with decreased urine output, fatigue, and pretty bad swelling in both legs that'd gotten worse over three days. Think about it—he's showing up to the ED feeling weak, kinda nauseous, not peeing much, and you notice his legs are puffy. When you check his vitals? Elevated blood pressure, like 160 over 95, and dry mucous membranes. It’s almost textbook for someone whose kidneys aren’t happy.

Jack Smith

Lab-wise, we saw the usual suspects: his serum creatinine and BUN were up, which if you’ve been on the floor longer than a week, you know is big evidence the kidneys are struggling. His urinalysis? Proteinuria and—you guessed it—muddy brown casts. He also had hyperkalemia and a low eGFR. You start adding that up and your mind just jumps straight to acute kidney injury, right?

Jack Smith

What’s interesting though, and what really matters for nurses is the “why.” In John’s case, it turns out he’d been popping ibuprofen like candy for his joint pain. This is where medication histories really mean everything. It actually reminds me of a guy I had on the surgical floor—also took a bunch of NSAIDs and crashed his kidneys almost overnight. I guess the point here is, even something that sounds so harmless… you know, over-the-counter NSAIDs, can really pack a punch. Where was I going with this? Oh right, so often we focus on the new meds and forget about what people grabbed at home. It’s a lesson I try not to forget.

Jack Smith

Now, let’s talk meds, because this is where things can get tricky. For someone like John, you can’t just throw diuretics at them and hope for the best. We used furosemide—Lasix—to help with the fluid overload, but carefully, because you really don’t wanna tip the balance and cause even more kidney injury.

Jack Smith

Hyperkalemia was a big red flag for him—it was high enough that he needed multiple interventions. Sodium polystyrene sulfonate, which, if you work in a hospital, you know as Kayexalate, was used to bring his potassium down. But that's not always the fastest. So in cases when that potassium is really stubborn, insulin with dextrose is given to shift the potassium into the cells. For severe cases, there’s IV calcium gluconate to kinda “buy time” and protect the heart while you work on the underlying problem.

Jack Smith

One thing we really drilled into the plan—stop all nephrotoxic drugs, which means NSAIDs go out the window. And this brings up a frequent challenge for nursing: managing pain in elderly patients when you can’t reach for NSAIDs. Sometimes you’ve got to be creative, and honestly, it’s about working with pharmacy and providers to find what works. I remember a shift where a new pain med was ordered during change of shift, and renal labs had just started tanking. Thanks to a quick hallway huddle with pharmacy and the doc, we caught it in time before anything was given. It’s that interdisciplinary teamwork that keeps our patients safe, especially when kidneys are involved and you’re juggling so many moving parts.

Jack Smith

So after you get the meds sorted, what’s left? A whole lot, honestly. Nursing interventions are where we really shine in AKI cases. At the bedside, you’re glued to the chart, tracking every drop in and out—monitoring I&Os is your bread and butter. Daily weights? Absolutely critical. It’s one of the best early warning systems for fluid retention. And vital signs—can’t stress this enough. Watch for hypertension, and, if you start to find tachycardia or shortness of breath, get ready to act.

Jack Smith

It’s also on us to catch fluid overload early. All those little subtle signs—crackles in the lungs, new or worsening edema, a patient just feeling off. That’s where your assessment skills really make a difference. And of course, education, education, education. If I could print a sticker to put on everyone’s badge, it’d just say: “Ask about NSAIDs and teach about hydration.” But we go a step further—we talk about dietary restrictions, low potassium, low sodium, and the importance of coming back when things don’t feel right.

Jack Smith

I had a patient a while ago—very similar to John—who was using a ton of over-the-counter meds. We sat down and went over what those pain meds could do to the kidneys, and you know what? He brought in a whole grocery bag of bottles for review at his next appointment. That kind of buy-in, that self-advocacy, it just sticks with you. For John, the educational piece meant shifting away from NSAIDs, getting connected to nephrology, and having that follow-up plan nailed down.

Jack Smith

And that kind of wraps us up for today. AKI can be overwhelming, but breaking it down to labs, meds, interventions, and patient education? That’s how we make it manageable. Thanks for tuning in. In the meantime, keep asking questions and advocating for your patients—they really need us.