ACUTE RENAL FAILURE CLINICAL COURSE
ONSET: begins when the kidney is injured and lasts from hours to
● a syndrome of varying causation that results in a sudden
days.
decline in renal function. It is frequently associated with an
increase in BUN and creatinine, oliguria (less than 500 mL
OLIGURIC-ANURIC PHASE: (urine volume less than 400 to 500
urine/24 hours), hyperkalemia, and sodium retention.
mL/24 hours).
● Results in retention of toxins, fluids, and end products of
a. Accompanied by rise in serum concentration of elements
metabolism
usually excreted by the kidney (urea, creatinine, organic
● Usually reversible with medical treatment.
acids, and intracellular cations- potassium and magnesium).
● also called Acute Kidney injury
b. There can be a decrease in renal function with increasing
nitrogen retention even when the patient is excreting more
ETIOLOGY
than 2-3 L of urine daily- called non-oliguric or high-output
● Prerenal- result from conditions that decrease renal blood
renal failure.
flow such as:
○ Hypovolemia, shock, blood loss, embolism, burns,
DIURETIC PHASE: begins when the 24-hour urine volume exceeds
cardiovascular disorders, sepsis
500 mL and ends when the BUN and serum creatinine levels stop
rising.
● Intrarenal – result from injury to renal tissue and are usually
associated with:
RECOVERY PHASE:
○ Nephrotoxic agents, infections, ischemia and
a. Usually lasts several months to 1 year.
blockages, polycystic kidney disease
b. Probably some scar tissue remains, but the functional loss is
not always clinically significant.
● Postrenal- arise from obstruction or disruption to urine flow
anywhere along the urinary tract.
CLINICAL MANIFESTATIONS
○ Stones, blood clots, BPH, urethral edema from
1. Prerenal
invasive procedures
● Decreased tissue turgor
● Dryness of mucous membranes
Other major causes:
● Weight loss
● Vascular Disease
● Hypotension
● Glomerular Disease
● Oliguria or anuria
● Interstitial/Tubular Disease
● Flat neck veins
● Obstructive Uropathy
● Tachycardia
2. Intrarenal
● Edema usually present
3. Postrenal
● Obstruction to urine flow
● Obstructive symptoms of BPH (Benign Prostatic
Hyperplasia or Hypertrophy)
● Possible nephrolithiasis
4. Changes in urine volume and serum concentrations of
BUN, creatinine, potassium
Subjective symptoms
● Nausea
● Loss of appetite
● Headache
● Lethargy
● Tingling in extremities
DIAGNOSTIC EVALUATION
● Urinalysis- reveals proteinuria, hematuria, casts
● Rising serum creatinine and BUN levels
● Urine chemistry examinations to distinguish various forms of
acute renal failure; decreased sodium
● Renal Ultrasonography- for estimate of renal size and to
exclude a treatable obstructive uropathy
PATHOPHYSIOLOGY
NURSING ASSESSMENT 3. Avoid exposure to nephrotoxins. Be aware that the majority
1. Determine if there is a history of cardiac disease, malignancy, of drugs or their metabolites are excreted by the kidneys.
sepsis, or intercurrent illness.
2. Determine if a patient has been exposed to potentially ● DRUG ALERT: Nonsteroidal anti-inflammatory drugs
nephrotoxic drugs (antibiotic, NSAIDs, contrast agents, (NSAID’s) including COX-2 inhibitors, may reduce glomerular
solvents). filtration rate
3. Conduct ongoing physical examination for tissue turgor,
pallor, alteration in mucous membranes, blood pressure, 4. Monitor chronic analgesic use-some drugs may cause
heart rate changes, pulmonary edema, and peripheral interstitial nephritis and papillary necrosis. .
edema. 5. Prevent and treat shock with blood and fluid replacement.
4. Monitor intake and output. Prevent long periods of hypotension.
6. Monitor urinary output and CVP hourly in critically ill patients
NURSING DIAGNOSES to detect onset of renal failure at the earliest moment.
● Excessive Fluid Volume related to decreased glomerular 7. Schedule diagnostic studies require dehydration so there are
filtration rate and sodium retention “rest days”, especially in aged who may not have adequate
● Risk for infection related to alterations in immune system renal reserve.
and host defenses 8. Pay special attention to draining wounds, burns, which can
● Imbalanced Nutrition: Less Than Body Requirements related lead to dehydration and sepsis and progressive renal
to catabolic state, anorexia, and malnutrition associated with damage.
acute renal failure. 9. Avoid infection; give meticulous care to patients with
● Risk for Injury related to GI Bleeding indwelling catheter or [Link].
● Disturbed Thought Processes related to the effects of uremic
toxins on the central nervous system(CNS). MANAGEMENT
Corrective and Supportive Measures
MEDICAL MANAGEMENT 1. Corrective reversible cause of acute renal failure (e.g, improve
● Fluid and dietary restrictions renal perfusion, maximize cardiac output, surgical relief of
● Maintain Electrolytes obstruction).
● May need dialysis to jump start renal function 2. Be alert for and correct underlying fluid excesses or deficits .
● May need to stimulate production of urine with IV fluids, 3. Correct and control biochemical imbalances-treatment of
Dopamine, diuretics, etc. hyperkalemia.
4. Restore and maintain blood pressure.
MANAGEMENT 5. Maintain nutrition.
Preventive Measures
1. Identify patients with preexisting renal disease.
2. Initiate adequate hydration before, during, and after any
procedure requiring NPO status.
COMPLICATIONS ● If antibiotics are administered, care must be taken to adjust
1. Infection the dosage for renal impairment.
2. Arrhythmias due to hyperkalemia
3. Electrolyte (sodium, potassium, calcium, phosphorus) 3. MAINTAINING ADEQUATE NUTRITION
abnormalities ● Work collaboratively with dietitians to regulate protein intake
4. GI Bleeding due to stress ulcers according to impaired renal function.
5. Multiple organ systems failure ● Offer high carbohydrate feedings because carbohydrates
have a greater protein-sparing power and provide additional
NURSING INTERVENTIONS calories.
1. ACHIEVING FLUID AND ELECTROLYTE BALANCE ● Weigh daily
● Monitor for signs and symptoms of hypovolemia or ● Be aware that food and fluids containing large amounts of
hypervolemia potassium, sodium, and phosphorus may need to be
● Monitor urinary output and urine specific gravity; measure restricted.
and record intake and output including urine, gastric
suction, stools, wound drainage, perspiration. 4. PREVENTING GI BLEEDING
● Monitor serum and urine specific concentrations. ● Examine all stools and emesis for gross and occult blood.
● Weigh patients daily to provide an index of fluid balance; ● Administer H2-receptor antagonist, such as cimetidine
expected weight loss is ½ to 1 Ib (0.25- 0.5 kg) daily. (Tegamet) or ranitidine (Zantac), or nonaluminum or
● Adjust fluid intake to avoid volume overload and magnesium antacids as prophylaxis for gastric stress ulcers.
dehydration. ● Prepare for endoscopy when GI bleeding occurs.
● Evaluate for signs and symptoms of hyperkalemia and
monitor serum potassium levels. (Notify health care provider
of value above 5.5mg/L) 5. PRESERVING NEUROLOGIC FUNCTION
● Watch for cardiac arrhythmia and heart failure from ● Speak to the patient in simple orienting statements, using
hyperkalemia, electrolyte imbalance, or fluid overload. Have repetition when necessary.
resuscitation equipment on hand in case of cardiac arrest. ● Maintain a predictable routine, and keep change to a
● Instruct patients about the importance of following minimum.
prescribed diet, avoiding foods high in potassium. ● Watch for and report mental status changes-somnolence,
● Administer blood transfusions during dialysis to prevent lassitude, lethargy, and fatigue progressing to irritability,
hyperkalemia from stored blood. disorientation, twitching, seizures.
● Correct cognitive distortions.
2. PREVENTING INFECTION ● Use seizure precautions-padded side rails, airway and
● Monitor for all signs of infection. Be aware that renal failure suction equipment at bedside.
patients do not always demonstrate fever and leukocytosis. ● Encourage and assist patients to turn and move because
● Remove bladder catheter as soon as possible; monitor for drowsiness and lethargy may prevent activity.
UTI. ● Use music tapes to promote relaxation.