College of Nursing: Civil Hospital
College of Nursing: Civil Hospital
College of Nursing: Civil Hospital
CIVIL HOSPITAL
AHMEDABAD
SUBJECT: NURSING
EDUCATION
TOPIC:ACUTE RENAL
FAILURE
SUBMITT
ED TO:
Ms. M. D. PATEL
LECTURER CLASS – I
SENIOR SCALE
COLLEGE OF NURSING
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SUBMITTED BY:
RONALD THAKOR
F.Y. M.Sc NURSING
COLLEGE OF NURSING
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RENAL FAILURE
Renal failure results when the kidneys cannot remove the body’s metabolic wastes or perform
their regulatory functions. The substances normally eliminated in the urine accumulate in the
body fluids as a result of impaired renal excretion, leading to a disruption in endocrine and
metabolic functions as well as fluid, electrolyte, and acid–base disturbances. Renal failure is a
systemic disease and is a final common pathway of many different kidney and urinary tract
diseases. Each year, the number of deaths from irreversible renal failure increases (U.S. Renal
Data System, 2001).
PRERENAL FAILURE
Sepsis
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vasodilation
INTRARENAL FAILURE
-Angiotensin-converting enzyme
inhibitors (ACE inhibitors)
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-Acute pyelonephritis -Acute glomerulonephritis
POSTRENAL FAILURE
ETIOLOGY
PRERENAL FAILURE
INTRARENAL FAILURE
Intrarenal failure (inside the kidney) occurs when there is damage to the
nephrons inside the kidney. The most common causes are ischemia,
reduced blood flow, and toxins. Other causes are from infectious
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processes leading to glomerulonephritis, trauma to the kidney, exposure
to nephrotoxins, allergic reactions to radiographic dyes, and severe
muscle injury, which releases substances that are harmful to the kidneys
(Table 37.4).
POSTRENAL FAILURE
Signs and symptoms are managed as they develop and supportive care is
given. Treatment may include restoring fluid and electrolyte balance,
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discontinuing nephrotoxic drugs that may have caused the problem,
bypassing urinary tract obstructions with catheters, or short-term
continuous renal replacement therapy to filter blood and restore
potassium and other electrolytes to normal. Some symptoms such as
anemia may not have time to develop in the patient with ARF as they do
in CRF. The care of the patient with acute renal failure is similar to care
of the patient with chronic renal failure, as explained in the next section.
PATHOPHYSIOLOGY
In acute renal failure, rapid damage to the kidney causes waste products
to accumulate in the bloodstream, resulting in the symptoms of renal
failure. The patient becomes oliguric, with urine output decreasing to less
than 20 mL/h. Treatment is directed toward correcting the cause,
supporting the patient with dialysis, and prevention of complications that
may lead to permanent damage. Many patients with acute renal failure
recover completely. Approximately 50% of patients with intrarenal ARF
die as a result of complications of infection, pneumonia, or septicemia.
ARF can progress through four stages, with an intrarenal cause taking a
longer recovery time frame since there is actual renal damage. Once an
event causes ARF in the initial phase, symptoms occur in hours to days.
OLIGURIC PHASE.
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from 24 hours to 7 days after the initial phase. This phase can last up to 2
weeks to several months. Prognosis for renal recovery is decreased the
longer this phase lasts.
DIURETIC PHASE
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During CRRT, a permeable hemofilter is attached to the vascular access.
Blood flows through the hemofilter and excess fluids and solutes move
into a collection bag. The remaining blood returns to the patient via the
venous access.
Clinical Manifestations
Almost every system of the body is affected when there is failure of the
normal renal regulatory mechanisms. The patient may appear critically ill
and lethargic, with persistent nausea, vomiting, and diarrhea. The skin
and mucous membranes are dry from dehydration, and the breath may
have the odor of urine (uremic fetor). Central nervous system signs and
symptoms include drowsiness, headache, muscle twitching, and seizures.
The effect of ARF are widespread. The major consequences include the
following:
- Anemia
- Platelet dysfunction
- Uremic encephalopathy
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• Creatinine clearance is low
CHANGES IN URINE
NURSING MANAGEMENT
Nursing Diagnosis:
5. Anxiety
The nurse has an important role in caring for the patient with ARF. In
addition to directing attention to the patient’s primary disorder (which
may be a factor in the development of ARF), the nurse monitors for
complications, participates in emergency treatment of fluid and
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electrolyte imbalances, assesses progress and response to treatment, and
provides physical and emotional support. Additionally, the nurse keeps
family members informed about the patient’s condition, helps them
understand the treatments, and provides psychological support. Although
the development of ARF may be the most serious problem, the nurse
must continue to include in the plan of care those nursing measures
indicated for the primary disorder (eg, burns, shock, trauma, obstruction
of the urinary tract).
Because of the serious fluid and electrolyte imbalances that can occur
with ARF, the nurse monitors the patient’s serum electrolyte levels and
physical indicators of these complications during all phases of the
disorder. Hyperkalemia is the most immediate lifethreatening imbalance
seen in ARF. Parenteral fluids, all oral intake, and all medications are
screened carefully to ensure that hidden sources of potassium are not
inadvertently administered or consumed. Intravenous solutions must be
carefully selected according to the patient’s fluid and electrolyte status.
The patient’s cardiac function and musculoskeletal status are monitored
closely for signs of hyperkalemia. The nurse monitors fluid status by
paying careful attention to fluid intake (intravenous 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 difficulty in breathing. Accurate daily
weights, as well as intake and output records, are essential. Indicators of
deteriorating fluid and electrolyte status are reported immediately to the
physician, and preparation is made for emergency treatment.
Hyperkalemia is treated with glucose and insulin, calcium gluconate,
cation-exchange resins (Kayexalate), or dialysis. Fluid and other
electrolyte disturbances are often treated with hemodialysis, peritoneal
dialysis, or other continuous renal replacement therapies.
The nurse also directs attention to reducing the patient’s metabolic rate
during the acute stage of renal failure to reduce catabolism and the
subsequent release of potassium and accumulation of endogenous waste
products (urea and creatinine). Bed rest may be indicated to reduce
exertion and the metabolic rate during the most acute stage of the
disorder. Fever and infection, both of which increase the metabolic rate
and catabolism, are prevented or treated promptly.
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Attention is given to pulmonary function, and the patient is assisted to
turn, cough, and take deep breaths frequently to prevent atelectasis and
respiratory tract infection. Drowsiness and lethargy may prevent the
patient from moving and turning without encouragement and assistance.
PREVENTING INFECTION
Asepsis is essential with invasive lines and catheters to minimize the risk
of infection and increased metabolism. An indwelling urinary catheter is
avoided whenever possible because of the high risk for UTI associated
with its use.
PROVIDING SUPPORT
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may not have adequate renal reserve Patients with neoplastic disorders or
disorders of metabolism (ie, gout) and those receiving chemotherapy
2. Prevent and treat shock promptly with blood and fluid replacement.
3. Monitor central venous and arterial pressures and hourly urine output
of critically ill patients to detect the onset of renal failure as early as
possible.
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REFERENCES:
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acute renal failure: a prospective double blind, placebo-
controlled
10. Martin SJ, Danziger LH: Continuous infusion of loop diuretics in the
critically ill: A review of literature: Critical Care Medicine 1994; 22:
1323-1329.
11. Denton MD, Chertow GM, Brady HR : “Renal dose’’ dopamine for
the treatment of acute renal failure: Scientific rationale, experimental
studies and clinical trials. Kidney Int 1996; 50: 4-14.
12. Burton CJ, Tomson CR; Can the use of low-dose dopamine for the
treatment of acute renal failure be justified? Postgrad Med J 1999; 75:
269-274.
13. Marik PE Low dose dopamine: a systematic review Int. Care Med
2002 28: 877-883.
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