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Acute Renal Failure

Acute renal failure (ARF) refers to the abrupt loss of kidney function. Over a period of
hours to a few days, the Glomerular filtration Rate (GFR) falls, accompanied by concomitant
rise in serum creatinine and urea nitrogen.
A healthy adult eating a normal diet needs a minimum daily urine output of approximately
400 ml to excrete the bodys waste products through the kidneys. An amount lower than this
indicates a decreased GFR.
ARF affects approximately 1% of patients on admission to the hospital, 2% to 5% during the
hospital stay, 4% to 15% after cardiopulmonary bypass surgery and 10% of cases acute
renal failure occurs in isolation (i.e. single organ failure).
Acute renal failure (ARF) has four well-defined stages: onset, oliguric or anuric, diuretic, and
convalescent. Treatment depends on stage and severity of renal compromise. ARF can be
divided into three major classifications, depending on site:
Prerenal: Prerenal failure is caused by interference with renal perfusion (e.g., blood volume
depletion, volume shifts [third-space sequestration of fluid], or excessive/too-rapid volume

expansion), manifested by decreased glomerular filtration rate (GFR). Disorders that lead to
prerenal failure include cardiogenic shock, heart failure (HF), myocardial infarction (MI),
burns, trauma, hemorrhage, septic or anaphylactic shock, and renal artery obstruction.
Renal (or intrarenal): Intrarenal causes for renal failure are associated with parenchymal
changes caused by ischemia or nephrotoxic substances. Acute tubular necrosis (ATN)
accounts for 90% of cases of acute oliguria. Destruction of tubular epithelial cells results
from (1) ischemia/hypoperfusion (similar to prerenal hypoperfusion except that correction of
the causative factor may be followed by continued oliguria for up to 30 days) and/or (2)
direct damage from nephrotoxins.
Postrenal: Postrenal failure occurs as the result of an obstruction in the urinary tract
anywhere from the tubules to the urethral meatus. Obstruction most commonly occurs with
stones in the ureters, bladder, or urethra; however, trauma, edema associated with infection,
prostate enlargement, and strictures also cause postrenal failure.

Statistics

In the United States, the annual incidence of acute renal failure is 100 cases for
every million people. Its diagnosed in 1% of hospital admissions. Hospitalacquired acute renal failure occurs in 4% of all admitted patients and 20% of
patients who are admitted to critical care units.

Each year an estimated 120 Filipinos per million population (PMP) develop kidney
failure. This means that about 10,000 Filipinos need to replace their kidney
function each year.

The leading cause of kidney failure in the Philippines is diabetes (41%), according
to the Philippine Renal Disease Registry Annual Report in 2008, followed by an
inflammation of the kidneys (24%) and high blood pressure (22%). Patients were
predominantly male (57%) with a mean age of 53 years.

Pathophysiology

Sudden decrease in kidney function, which may or may not be associated with a
decrease in urine output and results in a buildup of toxic wastes, such as urea
and creatinine in the blood

Stages

Initiation period initial insult and oliguria.

Oliguric period Urine output less than 400 mL/day. Uremic symptoms first
appear and hyperkalemia may develop.

Diuresis period gradual increase in urine output signaling beginning of


glomerular filtration recovery.

Recovery period improving renal function that may take 3 months to 12 months.

Causes

Prerenal

Hypovolemia

Heart failure

Hemorrhage

Excessive diarrhea

Vomiting

Diuresis

Intrarenal

Acute tubular necrosis

Postrenal

Kidney stones

Tumor

Spinal cord injury

Benign Prostatic Hypertrophy

Manifestations

Critical illness and lethargy with persistent nausea, vomiting, and diarrhea.

Skin and mucous membranes are dry.

Central nervous system manifestations: drowsiness, headache, muscle twitching,


seizures.

Urine output scanty to normal; urine may be bloody with low specific gravity.

Steady rise in blood urea nitrogen (BUN) may occur depending on degree of
catabolism; serum creatinine values increase with disease progression.

Hyperkalemia may lead to dysrhythmias and cardiac arrest.

Progressive acidosis, increase in serum phosphate concentrations, and low


serum calcium levels may be noted.

Anemia from blood loss due to uremic GI lesions, reduced red blood cell lifespan,
and reduced erythropoietin production.

Complications
The following are the complications of acute renal failure

Volume overload. Due to non-functional excretion system.

Pulmonary edema. Due to fluid overload.

Electrolyte imbalance. Since excess electrolytes are not excreted.

Metabolic acidosis due to dramatic decrease of kidneys excretory function.

Assessment Methods

Urine output measurements

fluid intake and output

Assessment
ACTIVITY/REST

May report: Fatigue, weakness, malaise

May exhibit: Muscle weakness, loss of tone

CIRCULATION

May exhibit: Hypotension or hypertension (including malignant hypertension,


eclampsia/pregnancy-induced hypertension)

Cardiac dysrhythmias

Weak/thready pulses, orthostatic hypotension (hypovolemia)

Jugular venous distension (JVD), full/bounding pulses (hypervolemia); flat neck


veins (diuretic phase)

Generalized tissue edema (including periorbital area, ankles, sacrum)

Pallor (anemia); bleeding tendencies

ELIMINATION

May report: Change in usual urination pattern: Increased frequency, polyuria


(early failure and early recovery), or decreased frequency/oliguria (later phase)

Dysuria, hesitancy, urgency, and retention (inflammation/obstruction/infection)

Abdominal bloating, diarrhea, or constipation

History of benign prostatic hyperplasia (BPH), or kidney/bladder stones/calculi

May exhibit: Change in urinary color, e.g., absence of color, deep yellow, red,
brown, cloudy

Oliguria (may last 1221 days and occurs in 70% of patients); polyuria (26 L/day
of urine, lacking concentration and regulation of waste products)

FOOD/FLUID

May report: Weight gain (edema), weight loss (dehydration)

Nausea, anorexia, heartburn, vomiting

Metallic taste

Use of diuretics

May exhibit: Changes in skin turgor/moisture

Edema (generalized, dependent)

NEUROSENSORY

May report: Headache, blurred vision

Muscle cramps/twitching; restless leg syndrome; numbness, tingling

May exhibit: Altered mental state, e.g., decreased attention span, inability to
concentrate, loss of memory, confusion, decreasing level of consciousness (LOC)
(azotemia, electrolyte and acid-base imbalance)

Twitching, muscle fasciculations, seizure activity

PAIN/DISCOMFORT

May report: Flank pain, headache

May exhibit: Guarding/distraction behaviors, restlessness

RESPIRATION

May report: Shortness of breath

May exhibit: Tachypnea, dyspnea, increased rate/depth (Kussmauls respiration);


ammonia breath

Cough productive of pink-tinged sputum (pulmonary edema)

SAFETY

May report: Recent transfusion reaction

May exhibit: Fever (sepsis, dehydration)

Petechiae, ecchymotic areas on skin

Pruritus, dry skin

TEACHING/LEARNING

May report: Family history of polycystic disease, hereditary nephritis, urinary


calculus, malignancy

History of exposure to toxins, e.g., drugs, environmental poisons; substance


abuse

Current/recent use of nephrotoxic drugs, e.g., aminoglycoside antibiotics,


amphotericin B; anesthetics; vasodilators; nonsteroidal anti-inflammatory drugs
(NSAIDs)

Recent diagnostic testing with radiographic contrast media

Concurrent conditions: Tumors in the urinary tract, Gram-negative sepsis;


trauma/crush injuries, hemorrhage, disseminated intravascular coagulation (DIC),
burns, electrocution injury; autoimmune disorders (e.g., scleroderma, vasculitis),
vascular occlusion/surgery, diabetes mellitus (DM), cardiac/liver failure

Diagnostic Procedures
Urine:

Volume: Usually less than 100 mL/24 hr (anuric phase) or 400 mL/24 hr (oliguric
phase), which occurs within 2448 hr after renal insult. Nonoliguric (more than
400 mL/24 hr) renal failure also occurs when renal damage is associated with
nephrotoxic agents (e.g., contrast media or antibiotics).

Color: Dirty, brown sediment indicates presence of RBCs, hemoglobin, myoglobin,


porphyrins.

Specific gravity: Less than 1.020 reflects kidney disease, e.g., glomerulonephritis,
pyelonephritis with loss of ability to concentrate; fixed at 1.010 reflects severe
renal damage.

pH: Greater than 7 found in urinary tract infections (UTIs), renal tubular necrosis,
and chronic renal failure (CRF).

Osmolality: Less than 350 mOsm/kg is indicative of tubular damage, and


urine/serum ratio is often 1:1.

Creatinine (Cr) clearance: Renal function may be significantly decreased before


blood urea nitrogen (BUN) and serum Cr show significant elevation.

Sodium: Usually increased if ATN is cause for ARF, more than 40 mEq/L if kidney
is not able to resorb sodium, although it may be decreased in other causes of
prerenal failure.

Fractional sodium (FeNa): Ratio of sodium excreted to total sodium filtered by the
kidneys reveals inability of tubules to reabsorb sodium. Readings of less than 1%
indicate prerenal problems, higher than 1% reflects intrarenal disorders.

Bicarbonate: Elevated if metabolic acidosis is present.

Red blood cells (RBCs): May be present because of infection, stones, trauma,
tumor, or altered glomerular filtration (GF).

Protein: High-grade proteinuria (34+) strongly indicates glomerular damage


when RBCs and casts are also present. Low-grade proteinuria (12+) and white
blood cells (WBCs) may be indicative of infection or interstitial nephritis. In ATN,
proteinuria is usually minimal.

Casts: Usually signal renal disease or infection. Cellular casts with brownish
pigments and numerous renal tubular epithelial cells are diagnostic of ATN. Red
casts suggest acute glomerular nephritis.

Blood:

BUN/Cr: Elevated and usually rise in proportion with ratio of 10:1 or higher.

Complete blood count (CBC): Hemoglobin (Hb) decreased in presence of anemia.


RBCs often decreased because of increased fragility/decreased survival.

Arterial blood gases (ABGs): Metabolic acidosis (pH less than 7.2) may develop
because of decreased renal ability to excrete hydrogen and end products of
metabolism. Bicarbonate decreased.

Sodium: Usually increased, but may vary.

Potassium: Elevated related to retention and cellular shifts (acidosis) or tissue


release (red cell hemolysis).

Chloride, phosphorus, and magnesium: Usually elevated.

Calcium: Decreased.

Serum osmolality: More than 285 mOsm/kg; often equal to urine.

Protein: Decreased serum level may reflect protein loss via urine, fluid shifts,
decreased intake, or decreased synthesis because of lack of essential amino
acids.

Radionuclide imaging: May reveal calicectasis, hydronephrosis, narrowing, and


delayed filling or emptying as a cause of ARF.

Kidney, ureter, bladder (KUB) x-ray: Demonstrates size of


kidneys/ureters/bladder, presence of cysts, tumors, ad kidney displacement or
obstruction (stones).

Retrograde pyelogram: Outlines abnormalities of renal pelvis and ureters.

Renal arteriogram: Assesses renal circulation and identifies extravascularities,


masses.

Voiding cystoureterogram: Shows bladder size, reflux into ureters, retention.

Renal ultrasound: Determines kidney size and presence of masses, cysts,


obstruction in upper urinary tract.

Nonnuclear computed tomography (CT) scan: Cross-sectional view of kidney


and urinary tract detects presence/extent of disease.

Magnetic resonance imaging (MRI): Provides information about soft tissue


damage.

Excretory urography (intravenous urogram or pyelogram): Radiopaque


contrast concentrates in urine and facilitates visualization of KUB.

Endourology: Direct visualization may be done of urethra, bladder, ureters, and


kidney to diagnose problems, biopsy, and remove small lesions and/or calculi.

Electrocardiogram (ECG): May be abnormal, reflecting electrolyte and acidbase imbalances.

Urine tests

Urinalysis: Analysis of the urine affords enormous insight into the function of the
kidneys.

Twentyfourhour urine tests: This test requires you to collect all of your urine
for 24 consecutive hours. The urine may be analyzed for protein and waste
products (urea nitrogen and creatinine). The presence of protein in the urine
indicates kidney damage. The amount of creatinine and urea excreted in the urine
can be used to calculate the level of kidney function and the glomerular filtration
rate (GFR).

Glomerular filtration rate (GFR): The GFR is a standard means of expressing


overall kidney function. As kidney disease progresses, GFR falls. The normal
GFR is about 100140 mL/min in men and 85115 mL/min in women. It
decreases in most people with age. The GFR may be calculated from the amount
of waste products in the 24hour urine or by using special markers administered
intravenously. Patients are divided into five stages of chronic kidney disease
based on their GFR.

Urine Specific Gravity This is a measure of how concentrated a urine sample


is. A concentrated urine sample would have a specific gravity over 1.030 or 1.040

Blood tests

Creatinine and urea (BUN) in the blood: Blood urea nitrogen and serum
creatinine are the most commonly used blood tests to screen for, and monitor
renal disease.
o Creatinine is a breakdown product of normal muscle breakdown.
o Urea is the waste product of breakdown of protein.
o The level of these substances rises in the blood as kidney function
worsens.

Electrolyte levels and acidbase balance: Kidney dysfunction causes


imbalances in electrolytes, especially potassium, phosphorus, and calcium.
o High potassium (hyperkalemia) is a particular concern.
o The acidbase balance of the blood is usually disrupted as well.

Decreased production of the active form of vitamin D can cause low levels of
calcium in the blood. Inability to excrete phosphorus by failing kidneys causes its
levels in the blood to rise.

Blood cell counts: Because kidney disease disrupts blood cell production and
shortens the survival of red cells, the red blood cell count and hemoglobin may be
low (anemia). Some patients may also have iron deficiency due to blood loss in
their gastrointestinal system. Other nutritional deficiencies may also impair the
production of red cells.

Other tests

Ultrasound: Ultrasound is often used in the diagnosis of kidney disease. An


ultrasound is a noninvasive type of test.
o In general, kidneys are shrunken in size in chronic kidney disease,
although they may be normal or even large in size in cases caused by
adult polycystic kidney disease, diabetic nephropathy, and amyloidosis.

Biopsy: A sample of the kidney tissue (biopsy) is sometimes required in cases in


which the cause of the kidney disease is unclear. Usually, a biopsy can be
collected with local anesthesia only by introducing a needle through the skin into
the kidney.

Gerontologic Considerations

Half of all patients who develop acute renal failure during hospitalization are older
than 60 years. The etiology of ARF in older clients include prerenal causes, such

as dehydration, intrarenal causes such as nephrotoxic agents, and complications


of major surgery.

Thirst suppression, enforced bed rest, lack of access to water and confusion all
contribute to elder patients failure to consume adequate fluids.

All medications need to be monitored for potential side effects that could result in
damage to the kidney either through reduced circulation or nephrotoxicity.

Outpatient procedures that require fasting or a bowel preparation may cause


dehydration and therefore require careful monitoring.

Care Settings
Clients with acute renal failure are treated in inpatient medical or surgical care unit.

Nursing Priorities
1. Reestablish or maintain fluid and electrolyte balance.
2. Prevent complications.
3. Provide emotional support for client and significant other (SO).
4. Provide information about disease process, prognosis, and treatment needs.

Nursing Diagnosis

Excess fluid Volume related to compromised regulatory mechanism.

Risk for Decreased Cardiac Output (RF may include: fluid overload, fluid shifts,
fluid deficit).

Risk for Imbalanced Nutrition: Less than Body Requirements

Risk for Infection

Deficient Knowledge

Nursing Care Plans


Main Article: 6 Acute Renal Failure Nursing Care Plans

Medical Management
I. Promote fluid and Electrolyte and Acid Base Balance
A. Fluid Balance

Monitor fluid volume status

Weight most accurate indicator (daily)

Input and Output monitoring

Assessment of skin turgor and mucous membrane

fluid restrictions. Amount of fluids to be taken per day (400 ml (insensible fluid
loss) + previous days urine output.

Moisten the lips, give ice chips

Diuretic therapy. Furosemide and Mannitol are often use

B. Electrolyte Balance
1. Hyperkalemia impaired potassium excretion; indication for dialysis; result from
metabolic acidosis

If there is Emergency Hyperkalemia give 50% dextrose and regular insulin

Can give sodium bicarbonate for acidosis

Client can be given with Sodium Polystyrene Sulfonate (Kayexalate) can be


given with Sorbitol to promote evacuation; can be given orally or rectally

Avoid salt substitutes

2. Hyponatremia restriction of fluids

fluid restrictions

3. Hypocalcemia decreased activation of Vit. D; hyperphosphatemia

Calcium Carbonate, Calcium Lactate and Vitamin D

Emergency Hypocalcemia give Calcium Gluconate IV

4. Hyperphosphatemia impaired excretion of Phosphate by the kidneys in the urine

Phosphate binders they bind phosphate in the GI tract for excretion

o Aluminum hydroxide cause constipation so stool softener maybe


given
o Aluminum Carbonate if use for a long period, this can caused
dementia

Calcium base phosphate binders excrete phosphorus but


increased Ca.

Calcium Carbonate

Calcium Acetate

5. Hypermagnesemia impaired excretion of Magnesium by the kidneys


Magnesium mainly excreted in the urine; seen in antacids or enemas

Diuretic therapy

Avoid magnesium containing antacids or enemas

Emergence Hypermagnesemia Give Calcium Gluconate

C. Acid Base Balance


Metabolic Acidosis

Impaired hydrogen ion excretion

Increased excretion of bicarbonate

Accumulation of urea, creatinine and uric acid

Hyperkalemia
o Give Sodium Bicarbonate alkalinic meds
o Give Sodium Lactate alkalinic meds
o Give Shohls solution treatment of metabolic acidosis; caused
stomatitis

II. Reserve Renal Function

Dopamine Hydrochloride to dilate renal arteries promoting renal perfusion

Control of hypertension with the use of ACE inhibitors, diet and weight control

III. Optimal Nutrition

High CHO diet to spare CHON metabolism

Low CHON diet but with essential amino acids (50 proteins); 50 mg/day

Serve foods in small amount because of nausea, anorexia and stomatitis

IV. Improve Body Chemistry

Dialysis
o Hemodialysis
o Peritoneal dialysis

Kidney Transplantation

Nursing Management

Monitor for potential complications.

Assist in emergency treatment of fluid and electrolyte imbalances.

Assess progress and response to treatment; provide physical and emotional


support.

Keep family informed about condition and provide support.

Monitoring fluid and Electrolyte Balance

Screen parenteral fluids, all oral intake, and all medications for hidden sources of
potassium.

Monitor cardiac function and musculoskeletal status for signs of hyperkalemia.

Pay careful attention to fluid intake (IV medications should be administered in the
smallest volume possible), urine output, apparent edema, distention of the jugular
veins, alterations in heart sounds and breath sounds, and increasing dif- ficulty in
breathing.

Maintain daily weight and intake and output records.

Report indicators of deteriorating fluid and electrolyte status immediately. Prepare


for emergency treatment of hyperkalemia. Prepare patient for dialysis as indicated
to correct fluid and electrolyte imbalances.

Reducing Metabolic Rate

Reduce exertion and metabolic rate with bed rest.

Prevent or treat fever and infection promptly.

Promoting Pulmonary Function

Assist patient to turn, cough and take deep breaths frequently.

Encourage and assist patient to move and turn.

Preventing Infection

Practice asepsis when working with invasive lines and catheters.

Avoid indwelling catheters if possible.

Providing Skin Care

Perform meticulous skin care

Bath the patient with cool water, turn patient frequently, keep the skin clean and
well moisturized and fingernails trimmed for patient comfort and to prevent skin
breakdown.

Discharge Goals
1. Homeostasis achieved.
2. Complications prevented or minimized.
3. Dealing realistically with current situation.
4. Disease process, prognosis, and therapeutic regimen understood.
5. Plan in place to meet needs after discharge.

3. Risk for Imbalanced Nutrition


Nursing Diagnosis

Nutrition: imbalanced, risk for less than body requirements

Risk factors may include

Protein catabolism; dietary restrictions to reduce nitrogenous waste products

Increased metabolic needs

Anorexia, nausea/vomiting; ulcerations of oral mucosa

Possibly evidenced by

Not applicable. A risk diagnosis is not evidenced by signs and symptoms, as the
problem has not occurred and nursing interventions are directed at prevention.

Desired Outcomes

Maintain/regain weight as indicated by individual situation, free of edema.


Nursing Interventions

Rationale
Aids in identifying deficiencies and dietary

Assess and document dietary intake.

needs. General physical condition, uremic


symptoms (nausea, anorexia), and multiple
dietary restrictions affect food intake.
Minimizes anorexia and nausea associated

Provide frequent, small feedings.

with uremic state and/or diminished


peristalsis.

Give patient/SO a list of permitted foods or

Provides patient with a measure of control

fluids and encourage involvement in menu

within dietary restrictions. Food from home

choices.

may enhance appetite.


Mucous membranes may become dry and
cracked. Mouth care soothes, lubricates,

Offer frequent mouth care or rinse with

and helps freshen mouth taste, which is

diluted acetic acid solution. Give gums, hard

often unpleasant because of uremia and

candy, breath mints between meals.

restricted oral intake. Rinsing with acetic


acid helps neutralize ammonia formed by
conversion of urea.
The fasting or catabolic patient normally

Weigh daily.

loses 0.20.5 kg/day. Changes in excess of


0.5 kg may reflect shifts in fluid balance.

Monitor laboratory studies: BUN, albumin,

Indicators of nutritional needs, restrictions,


and necessity for and effectiveness of

Nursing Interventions
transferrin, sodium, and potassium.

Rationale
therapy.
Determines individual calorie and nutrient

Consult with dietitian support team.

needs within the restrictions, and identifies


most effective route and product (oral
supplements, enteral or parenteral nutrition).
The amount of needed exogenous protein is
less than normal unless patient is on

Provide high-calorie, low to moderate protein


diet. Include complex carbohydrates and fat
sources to meet caloric needs and essential
amino acids. Avoid concentrated sugar
sources. Give anorectic patients small,
frequent meals.

dialysis. Carbohydrates meet energy needs


and limit tissue catabolism, preventing keto
acid formation from protein and fat oxidation.
Carbohydrate intolerance mimicking DM
may occur in severe renal failure. Essential
amino acids improve nitrogen balance and
nutritional status, stimulate repair of tubular
epithelial cells, and enhance patients ability
to fight systemic complications.

Maintain proper electrolyte balance by


strictly monitoring levels.

Medications and decrease in GFR can


cause electrolyte imbalances and may
further cause renal injury.
Restriction of these electrolytes may be

Restrict potassium, sodium, and phosphorus

needed to prevent further renal damage,

intake as indicated.

especially if dialysis is not part of treatment,


and/or during recovery phase of ARF.

Administer medications as indicated:


Iron deficiency may occur if protein is
Iron preparations

restricted, patient is anemic, or GI function is


impaired.

Calcium carbonate

Restores normal serum levels to improve

Nursing Interventions

Rationale
cardiac and neuromuscular function, blood
clotting, and bone metabolism. Note: Low
serum calcium is often corrected as
phosphate absorption is decreased in the GI
system. Calcium may be substituted as a
phosphate binder.

Vitamin D

Necessary to facilitate absorption of calcium


from the GI tract.
Vital as coenzyme in cell growth and

B complex and C vitamins, folic acid

actions. Intake is decreased because of


protein restrictions.

Antiemetics: prochlorperazine

Given to relieve N/V and may enhance oral

(Compazine), trimethobenzamide (Tigan).

intake.

4. Risk for Infection

Risk factors may include

Depression of immunologic defenses (secondary to uremia)

Invasive procedures/devices (e.g., urinary catheterization)

Changes in dietary intake/malnutrition

Possibly evidenced by

Not applicable. A risk diagnosis is not evidenced by signs and symptoms, as the
problem has not occurred and nursing interventions are directed at prevention.

Desired Outcomes

Experience no signs/symptoms of infection.

Nursing Interventions
Promote good hand washing by patient and
staff.

Rationale

Reduces risk of cross contamination.

Avoid invasive procedures, instrumentation,


and manipulation of indwelling catheters
whenever possible. Use aseptic technique
when caring and manipulating IV and
invasive lines. Change site dressings per

Limits introduction of bacteria into body.


Early detection of developing infection may
prevent sepsis.

protocol. Note edema, purulent drainage.


Provide routine catheter care and promote
meticulous perineal care. Keep urinary

Reduces bacterial colonization and risk of

drainage system closed and remove

ascending UTI.

indwelling catheter as soon as possible.


Encourage deep breathing, coughing,
frequent position changes.

Assess skin integrity.

Prevents atelectasis and mobilizes


secretions to reduce risk of pulmonary
infections.
Excoriations from scratching may become
secondarily infected.
Fever (higher than 100.4F) with increased
pulse and respirations is typical of increased

Monitor vital signs.

metabolic rate resulting from inflammatory


process, although sepsis can occur without
a febrile response.
Although elevated WBCs may indicate

Monitor laboratory studies: WBC count


with differential.

generalized infection, leukocytosis is


commonly seen in ARF and may reflect
injury within the kidney. A shifting of the
differential to the left is indicative of infection.

Obtain specimen(s) for culture and

Verification of infection and identification of

Nursing Interventions

Rationale
specific organism aids in choice of the most

sensitivity and administer appropriate


antibiotics as indicated.

effective treatment. Note: A number of antiinfective agents require adjustments of dose


and/or time while renal clearance is
impaired.

5. Risk for Deficient Fluid Volume

Risk factors may include

Excessive loss of fluid (diuretic phase of ARF, with rising urinary volume and
delayed return of tubular reabsorption capabilities)

Possibly evidenced by

Not applicable. A risk diagnosis is not evidenced by signs and symptoms, as the
problem has not occurred and nursing interventions are directed at prevention.

Desired Outcomes

Display I&O near balance; good skin turgor, moist mucous membranes, palpable
peripheral pulses, stable weight and vital signs, electrolytes within normal range.
Nursing Interventions

Rationale
Assessment can help estimate fluid
replacement needs. Fluid intake should

Measure I&O accurately. Weigh daily.

approximate losses through urine,

Calculate insensible fluid losses.

nasogastric or wound drainage, and


insensible water losses (diaphoresis,
metabolism).

Provide allowed fluids throughout 24-hr

Diuretic phase of ARF may revert to oliguric

Nursing Interventions

Rationale
phase if fluid intake is not maintained or

period.

nocturnal dehydration occurs.

Monitor BP (noting postural changes) and

Orthostatic hypotension and tachycardia

HR.

suggest hypovolemia.
In diuretic or postobstructive phase of renal
failure, urine output can exceed 3 L/day.

Note signs and symptoms of dehydration:


dry mucous membranes, thirst, dulled
sensorium, peripheral vasoconstriction.

Extracellular fluid volume depletion activates


the thirst center, and sodium depletion
causes persistent thirst, unrelieved by
drinking water. Continued fluid losses
including inadequate replacement may lead
to hypovolemic state.

Control environmental temperature; limit bed

May reduce diaphoresis, which contributes

linens as indicated.

to overall fluid losses.


In nonoliguric ARF or in diuretic phase of
ARF, large urine losses may result in sodium

Monitor laboratory studies

wasting while elevated urinary sodium acts


osmotically to increase fluid losses.
Restriction of sodium may be indicated to
break the cycle.

6. Knowledge Deficit

May be related to

Lack of exposure/recall

Information misinterpretation

Unfamiliarity with information resources

Possibly evidenced by

Questions/request for information, statement of misconception

Inaccurate follow-through of instructions/development of preventable

Complications

Desired Outcomes

Verbalize understanding of condition/disease process, prognosis, and potential


complications.

Identify relationship of signs/symptoms to the disease process and correlate


symptoms with causative factors.

Verbalize understanding of therapeutic needs.

Initiate necessary lifestyle changes and participate in treatment regimen.


Nursing Interventions

Rationale

Review disease process, prognosis, and

Provides knowledge base from which patient

precipitating factors if known.

can make informed choices.

Explain level of renal function after acute


episode is over.

Patient may experience residual defects in


kidney function, which may or may not be
permanent.
Although these options would have been

Discuss renal dialysis or transplantation if


these are likely options for the future.

previously presented by the physician,


patient may now be at a point when options
need to be considered and may desire
additional input.

Review dietary plan and restrictions. Include


fact sheet listing food restrictions.

Adequate nutrition is necessary to promote


tissue healing; adherence to restrictions may
prevent complications.

Encourage patient to observe characteristics

Changes may reflect alterations in renal

of urine and amount, frequency of output.

function and need for dialysis.

Establish regular schedule for weighing.

Useful tool for monitoring fluid and dietary

Nursing Interventions

Rationale
needs.

Provide emotional support to the patient and

To reassure them of the all the procedures

family.

that patient may undergo.

Review fluid restriction. Remind patient to

Depending on the cause and stage of ARF,

spread fluids over entire day and to include

patient may need to either restrict or

all fluids (ice) in daily fluid counts.

increase intake of fluids.

Discuss activity restriction and gradual


resumption of desired activity. Encourage
use of energy-saving, relaxation, and
diversional techniques.

Discuss reality of continued presence of


fatigue.
Determine ADLs and personal
responsibilities. Identify available resources
and support systems.

Patient with severe ARF may need to restrict


activity and/or may feel weak for an
extended period during lengthy recovery
phase, requiring measures to conserve
energy and reduce boredom.
Decreased metabolic energy production,
presence of anemia, and states of
discomfort commonly result in fatigue.
Helps patient manage lifestyle changes and
meet personal needs.

Recommend scheduling activities with

Prevents excessive fatigue and conserves

adequate rest periods.

energy for healing, tissue regeneration.


Medications that are concentrated in and/or

Review use of medication. Encourage


patient to discuss all medications and herbal
supplements with physician.

excreted by the kidneys can cause toxic


cumulative reactions and/or permanent
damage to kidneys. Some supplements may
interact with prescribed medications and
may electrolytes.

Stress necessity of follow-up care,

Renal function may be slow to return

laboratory studies.

following acute failure (up to 12 mo), and

Nursing Interventions

Rationale
deficits may persist, requiring changes in
therapy to avoid recurrence.

Identify symptoms requiring medical


intervention: decreased urinary output,

Prompt evaluation and intervention may

sudden weight gain, presence of edema,

prevent serious complications or progression

lethargy, bleeding, signs of infection, altered

to chronic renal failure.

mentation.

Other Possible Nursing Care Plans

Fluid Volume, deficient (specify)dependent on cause, duration, and stage of


recovery.

Fatiguedecreased metabolic energy production/dietary restriction, anemia,


increased energy requirements, e.g., fever/inflammation, tissue regeneration.

Infection, risk fordepression of immunologic defenses (secondary to uremia),


changes in dietary intake/malnutrition, increased environmental exposure.

Therapeutic Regimen: ineffective managementcomplexity of therapeutic


regimen, economic difficulties, perceived benefit.