Você está na página 1de 8
Acute kidney failure (ARF) occurs when your kidneys suddenly become unable to filter waste products from

Acute kidney failure (ARF) occurs when your kidneys suddenly become unable to filter waste products from your blood. When your kidneys lose their filtering ability, dangerous levels of wastes may accumulate, and your blood's chemical makeup may get out of balance.

Acute kidney failure also called acute renal failure or acute kidney injury develops rapidly, usually in less than a few days. Acute kidney failure is most common in people who are already hospitalized, particularly in critically ill people who need intensive care.

Acute kidney failure can be fatal and requires intensive treatment. However, acute kidney failure may be reversible. If you're otherwise in good health, you may recover normal or nearly normal kidney function.

Acute kidney failure can occur when:

Pre-renal ARF - You have a condition that slows blood flow to your kidneys

Intrarenal ARF -You experience direct damage to your kidneys

Postrenal ARF -Your kidneys' urine drainage tubes (ureters) become blocked and wastes can't leave your body through your urine

Risk factors

Acute kidney failure almost always occurs in connection with another medical condition or event. Conditions that can increase your risk of acute kidney failure include:

Being hospitalized, especially for a serious condition that requires intensive care

Liver diseases

Advanced age

Blockages in the blood vessels in your arms or legs (peripheral artery disease)

Diabetes

High blood pressure

Heart failure

Kidney diseases

Certain cancers and their treatments

As for Patient Rio’s case, he is 90 years old which means he is in the advanced age. He was also diagnosed with Acute Renal Failure secondary to Hypertension, which means that the cause of his ARF was due to high blood pressure. Over time, uncontrolled high blood pressure can cause arteries around the kidneys to narrow, weaken or harden. These damaged arteries are not able to deliver enough blood to the kidney tissue.

Symptoms

Signs and symptoms of acute kidney failure may include:

Decreased urine output, although occasionally urine output remains normal

Fluid retention, causing swelling in your legs, ankles or feet

Shortness of breath

Fatigue

Confusion

Nausea

Weakness

Irregular heartbeat

Chest pain or pressure

Seizures or coma in severe cases

As for Patient Rio’s case, he manifested fluid retention as evidence by pitting edema

on both upper and lower extremities, weakness, and tachycardia. Although he had a normal urine output.

Complications

Potential complications of acute kidney failure include:

Fluid buildup. Acute kidney failure may lead to a buildup of fluid in your lungs, which can cause shortness of breath.

Chest pain. If the lining that covers your heart (pericardium) becomes inflamed, you may experience chest pain.

Muscle weakness. When your body's fluids and electrolytes your body's blood chemistry are out of balance, muscle weakness can result.

Permanent kidney damage. Occasionally, acute kidney failure causes permanent loss of kidney function, or end-stage renal disease. People with end-stage renal disease require either permanent dialysis a mechanical filtration process used to remove toxins and wastes from the body or a kidney transplant to survive.

Death. Acute kidney failure can lead to loss of kidney function and, ultimately, death.

ARF staging

Guidelines for staging ARF

* Stage 1: SCr 1.5-1.9 times baseline or greater than/equal to 0.3 mg/dL increase with urine output of less than 0.5 mL/kg/h for 6-12 hours.

* Stage 2: SCr 2.0-2.9 times baseline and urine output of less than 0.5 mL/kg/h for greater than/equal to 12 hours.

* Stage 3: SCr 3.0 times baseline or increase in SCr to greater than/equal to 4.0 mg/dL; or initiation of RRT; or in patients <18 years, decrease in estimated glomerular filtration rate (eGFR) to <35 mL/min per 1.73 m 2 and urine output less than 0.3 mL/kg/h for 24 hours or more; or anuria for 12 hours or more.

Phases of ARF

Phase

Characteristic features

Duration

Kidney injury

Symptoms of the underlying illness causing AKI may be

Hours to

present.

days

Oliguric or

Progressive deterioration of kidney function

 

anuric phase

Reduced urine production (oliguria) Increased retention of urea and creatinine Complications: fluid retention (pulmonary edema), hyperkalemia, metabolic acidosis, uremia, lethargy, asterixis

Generally < 2 weeks

Polyuric

Glomerular filtration returns to normal, thus increasing

Complications: loss of electrolytes and water

3 weeks

phase

urine production (polyuria), while tubular reabsorption

remains disturbed.

Recovery

Kidney function and urine production normalize.

Up to 2 years

phase

 

Patients have a higher risk of secondary infection throughout all phases (most common reason for a fatal outcome).

Diagnosis

Kidney biopsy

If your signs and symptoms suggest that you have

acute kidney failure, your doctor may recommend certain tests and procedures to verify your diagnosis. These may include:

Phases of ARF Phase Characteristic features Duration <a href=Kidney injury Symptoms of the underlying illness causing AKI may be Hours to present. days Oliguric or Progressive deterioration of kidney function anuric phase Reduced urine production (oliguria) Increased retention of urea and creatinine Complications: fluid retention (pulmonary edema) , hyperkalemia, metabolic acidosis, uremia, lethargy, asterixis Generally < 2 weeks Polyuric Glomerular filtration returns to normal, thus increasing Complications: loss of electrolytes and water ∼ 3 weeks phase urine production (polyuria), while tubular reabsorption remains disturbed. (dehydration, hyponatremia, and hypokalemia) Recovery Kidney function and urine production normalize. Up to 2 years phase Patients have a higher risk of secondary infection throughout all phases (most common reason for a fatal outcome). Diagnosis Kidney biopsy If your signs and symptoms suggest that you have acute kidney failure, your doctor may recommend certain tests and procedures to verify your diagnosis. These may include:  Urine output measurements. Measuring how much you urinate in 24 hours may help your doctor determine the cause of your kidney failure.  Urine tests. Analyzing a sample of your urine (urinalysis) may reveal abnormalities that suggest kidney failure.  Blood tests. A sample of your blood may reveal rapidly rising levels of urea and creatinine — two substances used to measure kidney function. " id="pdf-obj-2-113" src="pdf-obj-2-113.jpg">

Urine output measurements. Measuring how much you urinate in 24 hours may help your doctor determine the cause of your kidney failure.

Urine tests. Analyzing a sample of your urine (urinalysis) may reveal abnormalities that suggest kidney failure.

Blood tests. A sample of your blood may reveal rapidly rising levels of urea and creatinine two substances used to measure kidney function.

Imaging tests. Imaging tests such as ultrasound and computerized tomography may be used to help your doctor see your kidneys.

Removing a sample of kidney tissue for testing. In some situations, your doctor may recommend a kidney biopsy to remove a small sample of kidney tissue for lab testing. Your doctor inserts a needle through your skin and into your kidney to remove the sample.

Treatment

Treatment for acute kidney failure typically requires a hospital stay. Most people with acute kidney failure are already hospitalized. How long you'll stay in the hospital depends on the reason for your acute kidney failure and how quickly your kidneys recover.

In some cases, you may be able to recover at home.

Treating the underlying cause of your kidney injury

Treatment for acute kidney failure involves identifying the illness or injury that originally damaged your kidneys. Your treatment options depend on what's causing your kidney failure.

Treating complications until your kidneys recover

Your doctor will also work to prevent complications and allow your kidneys time to heal. Treatments that help prevent complications include:

Treatments to balance the amount of fluids in your blood. If your acute kidney failure is caused by a lack of fluids in your blood, your doctor may recommend intravenous (IV) fluids. In other cases, acute kidney failure may cause you to have too much fluid, leading to swelling in your arms and legs. In these cases, your doctor may recommend medications (diuretics) to cause your body to expel extra fluids.

Medications to control blood potassium. If your kidneys aren't properly filtering potassium from your blood, your doctor may prescribe calcium, glucose or sodium

polystyrene sulfonate (Kionex) to prevent the accumulation of high levels of potassium in your blood. Too much potassium in the blood can cause dangerous irregular heartbeats (arrhythmias) and muscle weakness.

Medications to restore blood calcium levels. If the levels of calcium in your blood drop too low, your doctor may recommend an infusion of calcium.

Dialysis to remove toxins from your blood. If toxins build up in your blood, you may need temporary hemodialysis often referred to simply as dialysis to help remove toxins and excess fluids from your body while your kidneys heal. Dialysis may also help remove excess potassium from your body. During dialysis, a machine pumps blood out of your body through an artificial kidney (dialyzer) that filters out waste. The blood is then returned to your body.

Treatment is focused on removing the cause of the kidney failure.

Medications and other products the patient ingests will be reviewed. Any that might harm the kidneys will be eliminated or the dose reduced.

Other treatments will be offered, with the following goals:

Correct dehydration: Intravenous fluids, with electrolyte replacement if needed

Fluid restriction: For those types of kidney failure in which excess fluid is not

appropriately eliminated by the kidneys

Increase blood flow to the kidney: Usually related to improving heart function or

increasing blood pressure

Correct chemical (electrolyte) abnormalities: Keeps other body systems working

properly

Meds given to pt:

Erythropoietin 4000 units (Tuesday)

Biofluid 500ml x 12hrs

Human Albumin 25% + 40mg Furosemide 30mg q12

Lactulose 30ml ODHS + vit 10ml q8 x3

Clopidogrel 75mg tab ODPC

Enoxaprin Na 0.2cc SQ OD

N-Acetyl Cysteine OD HS

Duavent q8 PRN

Rosuvastatine 30mg/tab ODHS

Paracetamol tab q8 PRN

Peptamen 6 scoops in H2O TID

Nursing Interventions and Rationales:

  • 1. Strict intake and output measurement

o

It is important if the kidney’s are not functioning to measure the patient’s

I&Os. Notify the physician if there is a deficit greater than 5-10%.

  • 2. Medications to watch: Statins, NSAIDS, Aspirin

o

Be mindful of medications that can become toxic when the kidneys aren’t

functioning at their prime.

Try to limits these drugs, watch labs and antibiotic troughs. Look out for signs

  • 3. Statins NSAIDS Aspirin Acetaminophen Insulin Some antibiotics Herbal supplements

o

Be mindful of medications that can become toxic when the kidneys aren’t

functioning at their prime.

Try to limits these drugs, watch labs and antibiotic troughs. Look out for signs and symptoms of overdose.

Here are the most common signs and symptoms of overdose. *note this is not a comprehensive list*

Statins: muscle pain and weakness.

NSAIDS: N/V, headache, dizziness and blurred vision.

Aspirin: ringing in the ears (tinnitus), decreased hearing.

Acetaminophen: N/V/D, irritability, convulsions, coma.

Insulin: Hyperinsulinemia from the body building up resistance to insulin.

Some antibiotics: Neuro symptoms like seizures, confusion, neuropathy.

Herbal supplements: Various, depends on the herbal supplement.

  • 4. Monitor lung sounds and edema You want to make sure fluid balance is carefully monitored. A backup in the lungs would cause crackles and a back up systemically would cause pitting edema in the legs.

o

  • 5. Diuretic administration: Furosemide (Lasix) Bumetanide (Bumex) Spironolactone (Aldactone)

o

This is very important… diuretics are going to make the patient PEE… lots

and lots of PEE. Do not under any circumstances administer a diuretic without a bathroom plan. And a word to the wise, have a backup plan. Meaning if you have a walkie talkie patient with functioning arms and a

strong call light finger, I still would set up a bedside commode just.in.case.

I walk them to the bathroom or assist them in any way needed, but it is possible that they do not know how urgent their situation is and I can clean

up pee, but you can’t clean up that patients dignity.

Diuretics work on different parts of the nephrons. The goal of diuretics is to

help the kidneys rid the body of salt (notice I didn’t say sodium (Na+)?)

and fluids. It is important to note for every Na+ molecule there is a compound of one water (H20) that follows it. Psssst: potassium is a salt ...

There are three kinds of diuretics: Loop, Thiazide, and potassium sparing.

Loop: works on the loop of henle and excretes Na+, K+, and Ca-. (Yikes!

Watch your patient’s electrolytes!)

Thiazide: Works on the distal convoluted tubule and blocks the Na+/Cl-

symporter (which reabsorbs

...

you

guessed it Na+ and Cl-). This symporter

is responsible for about 5% of Na+ reabsorption. So monitor your patient’s

sodium and chloride. Oh, and your K+ have direct relationships!

...

Why?

Because K+, Cl- and Na+

Potassium-Sparing: Works on the Na+/K+ pumps in the collecting ducts of the kidney by blocking the effects of aldosterone at that site. Aldosterone has the collecting ducts reabsorbing Na+ and thus water, and for ever Na+ absorbed, one molecule of K+ is excreted. So this diuretic does the opposite of that, saves a K+ and excretes a Na+ and H20.

Most commonly used diuretics in acute kidney failure:

-Furosemide: Loop -Bumetanide: Loop -Spironolactone: Potassium-Sparing

  • 6. Monitor Potassium Potassium (K+) Normal range: 3.5 - 5.0 mEq/L

o

As Furosemide is the front line and best treatment for kidney failure,

nurses must be careful to watch the patient’s potassium levels

(Remember: Furosemide is potassium wasting).

Potassium (K+): is the most abundant intracellular cation and plays a vital role in the transmission of electrical impulses in cardiac and skeletal muscle. It plays a role in acid base equilibrium. In states of acidosis hydrogen with enter the cell as this happens it will force potassium out of the cell, a 0.1 decrease in pH will cause a 0.5 increase in K+

  • 7. Diet changes and control Fluid restriction Salt restriction Educating the patient on decreased sodium intake as well as strict fluid intake is vital when in any sort of kidney failure.

o

However, if patient is on a potassium wasting diuretic, educate about potassium (bananas, sweet potatoes, etc.)

  • 8. Monitor Kidney Labs Blood Urea Nitrogen (BUN) Normal Range: 7-20 mg/dL Creatinine (Cr) Normal Range: 0.7-1.4 mg/dL This measures how well treatment is working, you want the labs to be moving back to normal limits.

o

Blood Urea Nitrogen (BUN): measures the amount of urea in the blood. When protein is broken down ammonia is formed. Ammonia is converted to urea in the liver and is eventually excreted in the kidneys.

Creatinine (Cr): is a byproduct of creatine metabolism, and it is excreted by the kidneys. Creatinine is created in proportion to muscle mass and usually stays stable.

Possible Nursing Diagnosis for ARF

Fatigue related to decreased Hgb count.

Excess fluid volume related to inability of the kidney to excrete waste products

Knowledge deficit related to disease condition

Imbalanced nutrition less than body requirements related to disease condition

Impaired urinary elimination related to disease condition

Fluid Volume Excess related to inability of the kidney to excrete waste products