Recognising Acute Kidney Injury & Hyperkalaemia | Renal Nursing Scenario for Student Nurses

🚨 WHAT WOULD YOU DO?

“He Just Kept Saying He Felt Sick…”

You’re on placement on a renal ward. Your patient was admitted two days ago with a worsening acute kidney injury (AKI), he has a background of chronic kidney disease (CKD). He’s been feeling generally unwell for days with poor oral intake, vomiting and reduced urine output.

At handover this morning he was described as:

• tired but alert
• independent with care
• eating small amounts
• awaiting repeat blood results
• fluid balance being closely monitored

Now it’s mid-afternoon. You head into the bay to repeat his observations and update the fluid balance chart.

At first, he just looks exhausted. But then he says, “I feel really sick… something just feels off.”

You notice the untouched sandwich beside him. His water jug is still nearly full. The cardboard vomit bowl beside the bed has fluid in it. He looks grey, sweaty and somehow more drowsy than he did this morning. Your attention sharpens.

 

1. Assess: What doesn’t fit?

Future nurse thinking means not brushing things off as simple fatigue. You start speaking to him instead of just doing his obs and leaving, and you look at him properly:

• he seems slower answering questions
• his speech is slightly slurred
• he keeps closing his eyes mid-conversation
• his breathing looks deeper and heavier than earlier
• he complains of nausea again
• You ask if he is in any pain. “No pain… just feel awful.”
  

That vague, non-specific presentation matters on a renal ward. Kidney deterioration often whispers subtly through metabolic changes before observations become severely abnormal.

 

2. Verify: Check the observations and fluid balance

You repeat a full set of observations to gather objective data:

• BP: 98/62 (hypotensive)
• HR: 118 (tachycardic)
• RR: 26 (tachypnoeic)
• SpO₂: 97% on room air
• Temp: 37.4°C

Then you review the fluid balance chart and start looking at the trend across the shift:

Input: minimal oral fluids today and the prescribed IV fluids are running slowly

Output: urine output steadily dropping throughout the shift, with only 120 mL passed over the last 4 hours

Now the full picture starts building: worsening nausea, drowsiness, poor intake, reduced urine output, tachycardia and falling blood pressure. This no longer feels like simple tiredness.

 

3. Think: Review the blood results

Earlier, you checked his latest blood results on the computer with your staff nurse. “The blood results suddenly start matching the patient in front of you.”

Creatinine: This waste product is normally filtered out by healthy kidneys. His rising creatinine level indicates the kidneys are no longer filtering effectively, confirming worsening kidney injury.

Urea: This is another waste product normally removed through the kidneys. As kidney function worsens, urea builds up in the bloodstream and can directly cause symptoms like nausea, vomiting, fatigue, confusion and that “washed out” feeling many renal patients describe.

Potassium: Potassium is an important electrolyte regulated by the kidneys. His potassium is climbing dangerously high, moving toward severe hyperkalaemia.

Now your brain connects the full clinical pattern: the worsening nausea, the drowsiness, the poor intake, the reduced urine output, the worsening blood results and the rising potassium. This is becoming a serious metabolic problem.

 

4. Escalate: Use the pattern clearly

You find your staff nurse immediately. You don’t just say, “He feels sick.” Instead, you link your observations together clearly:

 “Can you review Bed 23, please? He seems much more drowsy than this morning; his urine output has dropped significantly to around 30 mL an hour, he’s tachycardic at 118, and his blood results show worsening renal function with a rising potassium level.”

That wording works because you are escalating the trend, the functional change, the objective findings, and the clinical concern, not just one isolated symptom.

 

5. Respond: The “Clinical Why” behind the urgency

Your nurse reviews him immediately and the medical team are contacted for an urgent bedside review. A repeat urgent blood sample and a 12-lead ECG are requested. His ECG is reviewed urgently because hyperkalaemia can deteriorate quickly even before the patient appears critically unwell.

While setting up the monitoring equipment, the doctor explains the physiology behind the concern.

The Clinical Why: The kidneys help regulate fluid balance, waste removal and electrolyte levels. When kidney function deteriorates, potassium can rise rapidly in the bloodstream. High potassium levels (hyperkalaemia) interfere with the heart’s electrical activity and can quickly lead to dangerous cardiac arrhythmias or cardiac arrest if left untreated.

The ECG later shows peaked T waves, one of the classic cardiac signs of hyperkalaemia. Suddenly, the urgency around urine output, repeat bloods, cardiac monitoring and fluid balance makes complete sense.

Treatment is started immediately to stabilise the heart, lower potassium levels, review fluid management and support kidney function.

 

6. Document & Handover

You document the deterioration chronologically in the nursing notes: worsening nausea, reduced urine output, updated observations, blood result changes, escalation times, ECG findings and the medical review and treatment plan.

At handover, you keep it clear and professional:

“Bed 23 became increasingly drowsy and nauseated during the shift with worsening urine output and rising renal blood markers. Escalated following concerns regarding deteriorating AKI and hyperkalaemia. Repeat bloods, ECG and urgent medical review completed, with potassium-lowering treatment now underway.”

 

🏥 Real-World Reflection

This scenario was inspired by how subtly renal deterioration can initially appear in practice. Renal patients do not always present as critically unwell. Sometimes the first signs are:

• nausea
• reduced appetite
• increasing fatigue
• worsening drowsiness
• reduced urine output
• a patient simply “not looking right” anymore

Because these symptoms can appear vague, deterioration is easy to underestimate on a busy ward. One of the biggest learning moments for many students during a renal placement is realising that fluid balance charts are not just paperwork. They are an active clinical tool.

When urine output starts falling alongside worsening blood results and increasing drowsiness, the entire clinical picture changes. It reinforces something really important: nursing is not just about recording observations, it’s about understanding what those observations are telling you physiologically.

🧠 Bleepbook Takeaway

Renal Deterioration Whispers First: Nausea, fatigue, drowsiness and a poor appetite can all indicate worsening kidney function and metabolic imbalance.

Fluid Balance Charts Save Lives: Reduced urine output is a major clinical finding, not just a number to write down at the end of a shift.

Potassium Can Become Dangerous Quickly: Worsening kidney injury can lead to hyperkalaemia, which directly threatens the electrical stability of the heart.

Escalate the Pattern, Not the Symptom: One isolated symptom may seem minor. Together, the pattern tells the real story.

Future Nurse Thinking is Connecting the Dots: Sometimes deterioration starts with a single quiet realisation: “This patient just doesn’t look like themselves anymore.”

“Have you ever had a patient who couldn’t clearly tell you they were deteriorating? What subtle signs helped you recognise the change?”

 

Bleepbook Disclaimer:

These scenarios are written to help UK student nurses connect theory to real-world clinical thinking. While based on realistic practice situations, they are educational resources only and should never replace local policy, supervision or professional clinical judgement. Patient conditions can deteriorate quickly and every clinical situation is different. Always follow your Trust guidelines, NICE recommendations and the NMC Code and escalate concerns to your mentor or senior clinician if you are worried about a patient.