Acute tubular necrosis • Dry mucous membranes

Overview • Uremic breath

• Injury to the nephron's tubular segment resulting • Cardiac arrhythmia, if hyperkalemic
from ischemic or • Muscle weakness
nephrotoxic injury and causing renal failure and Diagnostic test results
uremic syndrome Laboratory
• Also known as intrinsic renal azotemia • Urinary sediment contains red blood cells (RBCs)
Pathophysiology and casts.
• In ischemic injury, circulatory collapse, severe • Urine specific gravity is 1.010.
hypotension, trauma, • Urine osmolality is less than 400 mOsm/kg.
hemorrhage, dehydration, cardiogenic or septic • Urine sodium level is 40 to 60 mEq/L.
shock, surgery, • Blood urea nitrogen and serum creatinine levels are
anesthetics, and reactions to transfusions may cause elevated.
disruption of blood • Anemia is present.
flow to the kidneys. • Platelet adherence is defective.
• Nephrotoxic injury may follow ingestion of certain • Metabolic acidosis is present.
chemical agents, such • Hyperkalemia is found.
as contrast medium or antibiotics, or result from a Diagnostic procedures
hypersensitive reaction • Electrocardiography may show arrhythmias and,
of the kidneys. with hyperkalemia, a
Causes widening QRS complex, disappearing P waves, and
• Diseased tubular epithelium tall, peaked T waves.
• Ischemic or toxic injury to glomerular epithelial • Renal ultrasound, computed tomography scanning,
cells or vascular or magnetic resonance
endothelium imaging measures kidney size and excludes
• Obstructed urine flow obstruction
Incidence
• Acute tubular necrosis accounts for about 75% of Treatment
acute renal failure cases. General
• This disorder is the most common cause of acute Acute phase
renal failure in critically • Vigorous supportive measures until normal kidney
ill patients. function resumes
Complications Long-term management
• Heart failure • Daily replacement of projected and calculated fluid
• Uremic pericarditis loss (including
• Pulmonary edema insensible loss)
• Uremic lung • Peritoneal dialysis or hemodialysis if the patient is
• Anemia catabolic or if
• Anorexia, intractable vomiting hyperkalemia and fluid volume overload aren't
• Poor wound healing due to debilitation controlled by other
Warning measures
Fever and chills may signal the onset of an infection, Diet
the leading cause • Fluid restriction
of death in acute tubular necrosis. • Low-sodium, low-potassium
Assessment Activity
• Diagnosis usually delayed until the condition has • Rest periods when fatigued
progressed to an Medications
advanced stage • Diuretics
History • Transfusion of packed RBCs
• Ischemic or nephrotoxic injury • Epoetin alfa
• Urine output less than 400 ml/24 hours • Antibiotics
• Fever and chills • Emergency I.V. administration of 50% glucose,
Physical findings regular insulin, and sodium
• Evidence of bleeding abnormalities, such as bicarbonate (for hyperkalemia)
petechiae and ecchymosis • Sodium polystyrene sulfonate with sorbitol by
• Dry, pruritic skin mouth or by enema (for
hyperkalemia) Selected references
Nursing considerations Dirkes, S.M., and Kozlowski, C. “Renal Assist
Nursing diagnoses Device Therapy for
• Acute pain Acute Renal Failure,” Nephrology Nursing Journal
• Decreased cardiac output 30(6):611-14,
• Excess fluid volume December 2003.
• Fatigue
• Imbalanced nutrition: Less than body requirements
• Ineffective tissue perfusion: Renal
• Risk for infection
• Risk for injury
Expected outcomes
The patient will:
• express feelings of comfort and decreased pain
• maintain hemodynamic stability
• maintain fluid balance
• demonstrate energy conservation skills
• consume required caloric intake
• maintain urine specific gravity within the
designated limits and have
improved kidney function
• remain free from all signs and symptoms of
infection
• remain free from injury.
Nursing interventions
• Give prescribed drugs and blood products.
• Restrict food containing high sodium and potassium
levels.
• Use aseptic technique, particularly when handling
catheters.
• Perform passive range-of-motion exercises.
• Provide meticulous skin care.
Monitoring
• Intake and output
• Vital signs
• Laboratory studies
• Complications
Patient teaching
General
Be sure to cover:
• the disorder, diagnosis, and treatment
• signs of infection and when to report them to the
practitioner
• dietary restrictions
• how to set goals that are realistic for the patient's
prognosis.
Discharge planning
• Refer the patient to appropriate supportive resources
or social services.
Resources
Organizations
American Association of Kidney Patients:
www.aakp.org
National Institute of Diabetes & Digestive & Kidney
Diseases:
www.niddk.nih.gov