ACUTE RENAL FAILURE

Description
Is a sudden decline in renal function, usually marked by increased concentrations of blood urea nitrogen (BUN; azotemia) and creatinine; oliguria (less than 500 ml of urine in 24 hours); hyperkalemia; and sodium retention.

Acute renal failure are classified into following: o Prerenal failure results from conditions that interrupt the renal blood supply; thereby reducing renal perfusion (hypovolemia, shock, hemorrhage, burns impaired cardiac output, diuretic therapy). Postrenal failure results from obstruction of urine flow. Intrarenal failure results from injury to the kidneys themselves (ischemia, toxins, immunologic processes, systemic and vascular disorders).

o o

The disease progresses through three clinically distinct phase which is oliguricanuric, diuretic, and recovery, distinguished primarily by changes in urine volume and BUN and creatinine levels. Complication of ARF include dysrhythmias, increased susceptibility to infection, electrolyte abnormalities, GI bleeding due to stress ulcers, and multiple organ failure. Untreated ARF can also progress to chronic renal failure, end-stage renal disease, and death from uremia or related causes.

Assessment: 1. Oliguric-anuric phase: urine volume less than 400 ml per 24 hours; increased in
2. 3. 4. 5. 6. 7. serum creatinine, urea, uric acid, organic acids, potassium, and magnesium; lasts 3 to 5 days in infants and children, 10 to 14 days in adolescents and adults. Diuretic phase: begins when urine output exceeds 500 ml per 24 hours, end when BUN and creatinine levels stop rising; length is availabe. Recovery phase: asymptomatic; last several months to 1 year; some scar tissue may remain. In prerenal disease: decreased tissue turgor, dryness of mucous membranes, weight loss, flat neck veins, hypotension, tachycardia. In postrenal disease: difficulty in voiding, changes in urine flow. In Intrarenal disease: presentation varies; usually have edema, may have fever, skin rash. Nausea, vomiting, diarrhea, and lethargy may also occur.

Diagnostic Evaluation: 1. Urinalysis shows proteinuria, hematuria, casts. Urine chemistry distinguishes various
forms of ARF(prerenal, postrenal, intrarenal). 2. Serum creatinine and BUN levels are elevated; arterial blood gas (ABG) levels, serum electrolytes may be abnormal. 3. Renal untrasonography estimates renal size and rules out treatable obstructive uropathy.

Primary Nursing Diagnosis

Fluid volume deficit related to excessive urinary output,vomiting,hemorrhage

Other Diagnoses that may occur in Nursing Care Plans For Acute Renal Failure Ineffective tissue perfusion (renal) Excess fluid volume Risk for infection

Therapeutic and Pharmacologic Interventions:

Ensure adequate intravascular volume & adequate cardiac output - Goals aimed at treating the underlying cause & preserving as much kidney fx as possible Pharmacology Volume replacement- fluid challenges to increase renal blood flow Loop diuretics Low-dose dopamine- to increase blood flow to the kidney & increases BP Kayexalate (if hyperkalemia) Sodium bicarbonate (if metabolic acidosis) Avoid NSAIDs & ace inhibitors- used to help ARF from nephrotoxic ATN Use nephrotoxic drugs sparingly.

Nutrition Adequate calories to prevent catabolism calories average 30 35 kcal/kg of body weight 30-40% total calories from fat Monitor protein intake control nitrogenous waste production limit starvation ketosis about 0.6 2 grams/kg/day can add essential Amino Acid supplements Restrict potassium, phosphate, & sodium potassium and sodium depends on plasma levels and symptoms of edma, hypertension, and CHF limit phoshates and give calcium supplements and/or phosphate-binding agents Give calcium supplements/phosphate binding agents Fluid Balance Assess edema, CHF, & pulmonary edema Accurate I & O, daily weights Restrict fluid if hyponatremic Problems that occur Hyperkalemia Hyponatremia Metabolic acidosis

Nursing Diagnosis:
Excess fluid volume related to compromised regulatory mechanisms Imbalanced nutrition: Less than body requirements r/t dietary restrictions Ineffective protection related to abnormal blood profiles

Nursing Interventions: 1. Monitor 24-hour urine volume to follow clinical course of the disease.
2. 3. 4. 5. Monitor BUN, creatinine, and electrolyte. Monitor ABG levels as necessary to evaluate acid-base balance. Weigh the patient to provide an index of fluid balance. Measure blood pressure at various times during the day with patients in supine, sitting, and standing positions. 6. Adjust fluid intake to avoid volume overload and dehydration. 7. Watch for cardiac dysrhythmias and heart failure from hyperkalemia, electrolyte imbalance, or fluid overload. Have resuscitation equipment available in case of cardiac arrest. 8. Watch for urinary tract infection, and remove bladder catheter as soon as possible. 9. Employ intensive pulmonary hygiene because incidence of pulmonary edema and infection is high. 10. Provide meticulous wound care. 11. Offer high-carbohydrate feedings because carbohydrates have a greater proteinsparing power and provide additional calories.

12. Institute seizure precautions. Provide padded side rails and have airway and suction equipment at the bedside. 13. Encourage and assist the patient to turn and move because drowsiness and lethargy may reduce activity. 14. Explain that the patient may experience residual defects in kidney function for a long time after acute illness. 15. Encourage the patient to report routine urinalysis and follow-up examinations. 16. Recommend resuming activity gradually because muscle weakness will be present from excessive catabolism.

Documentation Guidelines
Physical findings:Urinary output and description of urine, fluid balance, vital signs, findings related to original disease process or insult,presence of pain or pruritus,mental status,GI status, and skin integrity Condition of peritoneal or vascular access sites Nutrition: Response to dietary or fluid restrictions, tolerance to food, maintenance of body weight Complications:Cardiovascular,integumentary infection