Nursing Care Plans for Acute Renal Failure; Acute renal failure is a syndrome of varying causation that results in a sudden decline in renal function. It is frequently associated with an increase in BUN and creatinine, oliguria (less than 500 ml urine/24 hours), hyperkalemia, and sodium retention (Williams & Wilkins, 2006).
Acute renal failure (ARF) is a sudden and almost complete loss of kidney function (decreased Glomerular filtration rate GFR) over a period of hours to days. Acute Renal Failure ARF manifests with oliguria, anuria, or normal urine volume. Oliguria (less than 400 ml/day of urine) is the most common clinical situation seen in Acute Renal Failure ARF; anuria (less than 50 ml/day of urine) and normal urine output are not as common. Regardless of the volume of urine excreted, the patient with ARF experiences rising serum creatinine and BUN levels and retention of other metabolic waste products (azotemia) normally excreted by the kidneys (Brunner and Suddarth,2003 ).
Acute renal failure (ARF) is the abrupt deterioration of renal function that results in the accumulation of fluids, electrolytes, and metabolic waste products. The sudden interruption of renal function resulting from obstruction, reduced circulation, or renal parenchymal disease. This condition is classified as prerenal, intrarenal, or postrenal and normally passes through three distinct phases: oliguric, diuretic, and recovery. It’s usually reversible with medical treatment. If not treated, it may progress to end-stage renal disease, uremia, and death.
Causes for Acute Renal Failure
Prerenal conditions occur as a result of impaired blood flow that leads to hypoperfusion of the kidney and a drop in the Glomerular filtration rate GFR.
- Volume depletion resulting from: Hemorrhage Renal losses (diuretics, osmotic diuresis) Gastrointestinal losses (vomiting, diarrhea, nasogastric suction)
- Impaired cardiac efficiency resulting from: Myocardial infarction Heart failure Dysrhythmias Cardiogenic shock
- Vasodilation resulting from: Sepsis Anaphylaxis Antihypertensive medications or other medications that cause Vasodilation
Intrarenal causes of ARF are the result of actual parenchymal damage to the glomeruli or kidney tubules. Intrarenal causes result from injury to renal tissue and are usually associated with intrarenal ischemia, toxins, immunologic processes, systemic and vascular disorders.
- Prolonged renal ischemia resulting from: Pigment nephropathy (associated with the breakdown of blood cells containing pigments that in turn occlude kidney structures) Myoglobinuria (trauma, crush injuries, burns) Hemoglobinuria (transfusion reaction, hemolytic anemia)
- Nephrotoxic agents such as: Aminoglycoside antibiotics (gentamicin, tobramycin) Radiopaque contrast agents Heavy metals (lead, mercury) Solvents and chemicals (ethylene glycol, carbon tetrachloride, arsenic) Nonsteroidal anti-inflammatory drugs (NSAIDs) Angiotensin-converting enzyme inhibitors (ACE inhibitors)
- Infectious processes such as: Acute pyelonephritis Acute glomerulonephritis
Postrenal causes of ARF are usually the result of an obstruction somewhere distal to the kidney. Pressure raises in the kidney tubules eventually, the Glomerular filtration rate GFR decreases.
Urinary tract obstruction, including: Calculi (stones), Tumors, Benign prostatic hyperplasia, Strictures, Blood clots.
Pathophysiology of Acute Renal Failure
There are four clinical phases of Acute Renal Failure ARF:
|Pathophysiology of Acute Renal Failure|
- The initiation period begins with the initial insult and ends when oliguria develops.
- The oliguria period is accompanied by a rise in the serum concentration of substances usually excreted by the kidneys (urea, creatinine, uric acid, organic acids, and the intracellular cations [potassium and magnesium]). The minimum amount of urine needed to rid the body of normal metabolic waste products is 400 ml. In this phase uremic symptoms first appear life-threatening conditions such as hyperkalemia develop.
- The diuresis period, the third phase, the patient experiences gradually increasing urine output which signals that Glomerular filtration has started to recover. Laboratory values stop rising and eventually decrease. Although the volume of urinary output may reach normal or elevated levels, renal function may still be markedly abnormal. Because uremic symptoms may still be present, the need for expert medical and nursing management continues.
- The recovery period signals the improvement of renal function and may take 3 to 12 months. Laboratory values return to the patient’s normal level. Although a permanent 1% to reduction in the GFR is common, it is not clinically significant.
- Prerenal decreased tissue turgor, dryness of mucous membranes, weight loss, hypotension, oliguria or anuria, flat neck veins, tachycardia
- Postrenal obstruction to urine flow, obstructive symptoms of BPH, possible nephrolithiasis
- Intrarenal presentation based on cause; edema usually present
- Changes in urine volume and serum concentrations of BUN, creatinine, potassium, and so forth, as described above
Assessment and Diagnostic Findings Nursing Care Plans for Acute Renal Failure:
- Changes in urine
- Change in kidney contour
- Increased bun and creatinine levels (azotemia)
- Metabolic acidosis
- Calcium and phosphorus abnormalities
- Arrhythmias due to hyperkalemia
- Electrolyte (sodium, potassium, calcium, phosphorus) abnormalities
- GI bleeding due to stress ulcers
- Multiple organ systems failure
Nursing Assessment Nursing Care Plans for Acute Renal Failure
- Determine if there is a history of cardiac disease, malignancy, sepsis, or intercurrent illness.
- Determine if patient has been exposed to potentially nephrotoxic drugs (antibiotics, NSAIDs, contrast agents, solvents).
- Conduct an ongoing physical examination for tissue turgor, pallor, alteration in mucous membranes, blood pressure, heart rate changes, pulmonary edema, and peripheral edema.
- Monitor intake and output
Nursing Diagnosis Nursing Care Plans for Acute Renal Failure
Common nursing diagnosis found in Nursing Care Plans for Acute renal failure:
- Excess Fluid Volume related to decreased glomerular filtration rate and sodium retention
- Risk for Infection related to alterations in the immune system and host defenses
- Imbalanced Nutrition: Less Than Body Requirements related to catabolic state, anorexia, and malnutrition associated with acute renal failure
- Risk for Injury related to GI bleeding
- Disturbed Thought Processes related to the effects of uremic toxins on the central nervous system (CNS)
Nursing Intervention, Evaluation, Out Come, Patient Teaching and Home Healthcare Guidelines Nursing Care Plans For Acute Renal Failure. Nursing interventions with nursing diagnosis; Excess Fluid Volume, Risk for Infection, Imbalanced Nutrition: Less Than Body Requirements, Risk for Injury, Disturbed Thought Processes.
Excess fluid volume related to decreased Glomerular filtration rate and sodium retention
Achieving fluid and electrolyte balance
· Monitor acid base balance.
Blood pressure stable, no edema or shortness of breath
Risk for infection related to alterations in the immune system and host defenses
No signs of infection
Imbalanced nutrition: less than body requirements related to catabolic state, anorexia, and malnutrition associated with acute renal failure
Maintaining adequate nutrition
Food intake adequate, maintaining weight
Risk for injury related to GI bleeding
Preventing GI bleeding
Stools heme negative
Disturbed thought processes related to the effects of uremic toxins on the central nervous system (CNS)
Preserving neurologic function
Appears more alert, sleeps less during the day
Nursing Key outcomes Nursing Care Plans for Acute Renal Failure
Key outcomes for ARF, Patient will:
- Perform activities of daily living without excessive fatigue or exhaustion.
- Maintain hemodynamic stability.
- Achieving fluid and electrolyte balance.
- Preserving neurological function
- Remain free from signs or symptoms of circulatory overload.
- Verbalize the importance of balancing activities with adequate rest periods.
- Discuss fears or concerns.
- Preventing Gastro intestinal GI bleeding
- Verbalize appropriate food choices according to his prescribed diet.
- Patient’s oral mucous membrane will remain intact.
- The patient’s skin integrity will remain intact.
- Demonstrate skill in managing the urinary elimination problems.
- Maintain adequate urine output.
- The patient will remain free from signs or symptoms of infection.
- Family members will verbalize the effect the patient’s condition has on the family unit.
- The patient will avoid or minimize complications.
Patient Teaching and Home Healthcare Guidelines Nursing Care Plans for ARF
Every patient with Acute Renal Failure ARF need to understanding of renal function, signs and symptoms of Acute Renal Failure. Patients who have not recovered viable renal function need to understand that their condition may persist and even become chronic. And who have recovered viable renal function still need to be monitored by a nephrologists and If chronic renal failure is suspected, further outpatient treatment and monitoring are needed
- Explain that she or he may be more susceptible to infection than previously.
- Reassure the patient and family by clearly explaining all diagnostic tests, treatments, and procedures
- Teach the patient or significant others about all medications, including dosage, potential side effects, and drug interactions.
- Explain that the patient should tell the healthcare professional about the medications if the patient needs treatment such as dental work or if a new medication is added.
- Explain that ongoing medical assessment is required to check renal function.
- Explain all dietary and fluid restrictions. Note if the restrictions are life-long or temporary.
- Discuss with significant others the lifestyle changes that may be required with chronic renal failure
- Tell the patient about his prescribed medications, and stress the importance of complying with the regimen.
- Stress the importance of following the prescribed diet and fluid allowance.
- Instruct the patient to weigh him daily and report sudden increase of weight.
- Advise the patient against overexertion. If he becomes dyspneic or short of breath during normal activity, tell him to report it to his physician.
- Teach the patient how to recognize edema, and report this finding to the physician.