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 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:

1. Hemorrhage
2. Renal losses (diuretics, osmotic diuresis)
3. Gastrointestinal losses (vomiting, diarrhea, nasogastric suction)

• Impaired cardiac efficiency resulting from:

1. Myocardial infarction
2. Heart failure
3. Dysrhythmias
4. Cardiogenic shock

• Vasodilation resulting from:

1. Sepsis
2. Anaphylaxis
3. Antihypertensive medications or other medications that cause
4. Vasodilation

Intrarenal Failure

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:

1. Pigment nephropathy (associated with the breakdown of blood cells containing pigments that in turn occlude kidney structures)
2. Myoglobinuria (trauma, crush injuries, burns)
3. Hemoglobinuria (transfusion reaction, hemolytic anemia)

• Nephrotoxic agents such as:

1. Aminoglycoside antibiotics (gentamicin, tobramycin)
2. Radiopaque contrast agents
3. Heavy metals (lead, mercury)
4. Solvents and chemicals (ethylene glycol, carbon tetrachloride, arsenic)
5. Nonsteroidal anti-inflammatory drugs (NSAIDs)
6. Angiotensin-converting enzyme inhibitors (ACE inhibitors)

• Infectious processes such as:

1. Acute pyelonephritis
2. Acute glomerulonephritis

Postrenal Failure

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:

1. Calculi (stones)
2. Tumors
3. Benign prostatic hyperplasia
4. Strictures
5. Blood clots

Pathophysiology of Acute Renal Failure

There are four clinical phases of Acute Renal Failure ARF:

1. The initiation period begins with the initial insult and ends when oliguria develops.
2. 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.
3. 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.
4. 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.

Clinical Manifestations

• 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)
• Hyperkalemia
• Metabolic acidosis
• Calcium and phosphorus abnormalities
• Anemia

Complications

• Infection
• Arrhythmias due to hyperkalemia
• Electrolyte (sodium, potassium, calcium, phosphorus) abnormalities
• GI bleeding due to stress ulcers
• Multiple organ systems failure

Nursing Process

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:

1. Excess Fluid Volume related to decreased glomerular filtration rate and sodium retention
2. Risk for Infection related to alterations in the immune system and host defenses
3. Imbalanced Nutrition: Less Than Body Requirements related to catabolic state, anorexia, and malnutrition associated with acute renal failure
4. Risk for Injury related to GI bleeding
5. Disturbed Thought Processes related to the effects of uremic toxins on the central nervous system (CNS)

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