Acute Renal Failure

  1. General information
    1. Sudden inability of the kidneys to regulate fluid and electrolyte balance and remove toxic products from the body
    2. Causes
      1. Prerenal: factors interfering with perfusion and resulting in decreased blood flow and glomerular filtrate, ischemia, and oliguria; include CHF, cardiogenic shock, acute vasoconstriction, hemorrhage, burns, septicemia, hypotension
      2. Intrarenal: conditions that cause damage to the nephrons; include acute tubular necrosis (ATN), endocarditis, diabetes mellitus, malignant hypertension, acute glomerulonephritis, tumors, blood transfusion reactions, hypercalcemia, nephrotoxins (certain antibiotics, x-ray dyes, pesticides, anesthetics)
      3. Postrenal: mechanical obstruction anywhere from the tubules to the urethra; include calculi, BPH, tumors, strictures, blood clots, trauma, anatomic malformation
  2. Assessment findings
    1. Oliguric phase (caused by reduction in glomerular filtration rate)
      1. urine output less than 400 ml/24 hours; duration 1-2 weeks
      2. manifested by hypernatremia, hyperkalemia, hyperphosphatemia, hypocalcemia, hypermagnesemia, and metabolic acidosis
      3. diagnostic tests: BUN and creatinine elevated
    2. Diuretic phase (slow, gradual increase in daily urine output)
      1. diuresis may occur (output 3-5 liters/day) due to partially regenerated tubule's inability to concentrate urine
      2. duration: 2-3 weeks; manifested by hyponatremia, hypokalemia, and hypovolemia
      3. diagnostic tests: BUN and creatinine elevated
    3. Recovery or convalescent phase: renal function stabilizes with gradual improvement over next 3-12 months
  3. Nursing interventions
    1. Monitor/maintain fluid and electrolyte balance.
      1. Obtain baseline data on usual appearance and amount of client's urine.
      2. Measure I&O every hour; note excessive losses.
      3. Administer IV fluids and electrolyte supplements as ordered.
      4. Weigh daily and report gains.
      5. Monitor lab values; assess/treat fluid and electrolyte and acid-base imbalances as needed (see Tables 4.5 and 4.6).
    2. Monitor alteration in fluid volume.
      1. Monitor vital signs, PAP, PCWP, CVP as needed.
      2. Weigh client daily.
      3. Maintain strict I&O records.
      4. Assess every hour for hypervolemia; provide nursing care as needed.
        1. maintain adequate ventilation.
        2. decrease fluid intake as ordered.
        3. administer diuretics, cardiac glycosides, and antihypertensives as ordered; monitor effects.
      5. Assess every hour for hypovolemia; replace fluids as ordered.
      6. Monitor ECG and auscultate heart as needed.
      7. Check urine, serum osmolality/ osmolarity, and urine specific gravity as ordered.
    3. Promote optimal nutritional status.
      1. Weigh daily.
      2. Maintain strict I&O.
      3. Administer TPN as ordered.
      4. With enteral feedings, check for residual and notify physician if residual volume increases.
      5. Restrict protein intake.
    4. Prevent complications from impaired mobility (pulmonary embolism, skin breakdown, contractures, atelectasis; see Table 4.21).
    5. Prevent fever/infection.
      1. Take rectal temperature and obtain orders for cooling blanket/antipyretics as needed.
      2. Assess for signs of infection.
      3. Use strict aseptic technique for wound and catheter care.
    6. Support client/significant others and reduce/relieve anxiety.
      1. Explain pathophysiology and relationship to symptoms.
      2. Explain all procedures and answer all questions in easy-to-understand terms.
      3. Refer to counseling services as needed.
    7. Provide care for the client receiving dialysis if used.
    8. Provide client teaching and discharge planning concerning
      1. Adherence to prescribed dietary regime
      2. Signs and symptoms of recurrent renal disease
      3. Importance of planned rest periods
      4. Use of prescribed drugs only
      5. Signs and symptoms of UTI or respiratory infection, need to report to physician immediately