Acute renal failure

Medical Management
Fluid balance is managed based on daily weight, serial measurements of central venous pressure, serum and urine concentrations, fluid losses, BP and clinical status. Blood flow is restored to the kidneys with the use of intravenous fluids, albumin, or blood product transfusions. Dialysis (hemodialysis, hemofiltration, or peritoneal dialysis) is started to prevent complications of uremia, including Hyperkalemia, pericarditis, and seizures. Ion exchange resins (orally or by retention enema) Intravenous glucose and insulin or calcium glutamate as an emergency and temporary measure to treat hyperkalemia. Sodium biacarbonate to elevate plasma pH Parenteral erythropoietin (Epogen) to treat reduced erythropoietin production and prevent anemia. Shock and infection are treated if present. Areterial blood gasses are monitored when severe acidosis is present. If respiratory problems develop, ventilatory measures are started. Phosphate binding agents such as aluminium hydrochloride to control elevated serum phosphate concentrtions . Dietary protein is limited to about 1g/kg during oliguric phase to minimize protein breakdown and to prevent accumulation of toxic end products. Caloric requirements are metwith high carbohydrate feedings; parenteral nutrition (PN) Foods and fluids containing potassium and phosphorus are restricted; potassium intake is limited to 40 to 60mEq/d. sodium intake is restricted to 2g/d. Blood chemistries are evaluated to determine amount of replacement sodium, potassium,and water during oliguric phase.

After the diuretic phase, high-protein, high-calorie diet is given with gradual resumptionof activities.

Nursing Management
Monitoring Fluid and Electrolyte Levels Screen parenteral fluids , all oral intake, and all medications for hidden sources of poatassium. Monitor cardiac function and musculoskeletal status for signs pfhyperlakemia. Monitor serum electrolyte levels and ECG for peaked T waves. Pay careful attention to parenteral and oral intake, urine output, gastric and stool output, wound drainage and pers[iaration, changes in body weight, edema, distention of jugular veins, changes in the heart sounds, and increasing difficulty breathing. Auscultate lungs for moist crackles. Assess for generalized edema by examining presacral and pretibial areas regularly. Report indicators of deteriorating fluid and electrolyte status immediately. Prepare for emergency treatment of hyperkalemia. Prepare patient foe dialysis as indicated to correct fluid and electrolyte imbalances. Reducing Metabolic Rate Reduce excertion and metabolic rate during most acute stage with bed rest. Prevent or treat fever and infection promptly. Promoting pulmonary function Assist patient to turn, cough, and take deep breaths frequently. Encourage and assist patient to move and turn. Avoiding infection Practice asepsis when working with invasive lines and catheters. Avoid using indwelling catheter if possible. Providing skin care Perform meticulous skin care.

Massage bony prominences, turn patient frequently, encourage bathing with tepid water for comfort, and prevent skin breakdown. Providing support during dialysis Assist, explain, and support patient and family; do not overlook psychological needs and concerns. Explain rationale of treatment to patient and family. Repeat explanations and clarify answers as needed. Encourage family to touch and walk to patient during dialysis. Continually assess for complications.