Aileen Anne G.

De Ocampo
BSN IV-1 Group 1

Acute renal failure
Sudden interruption of kidney function to regulate fluid and electrolyte balance and remove
toxic products from the body

PATHOPHYSIOLOGY
1. Pre-renal failure
Factors interfering with perfusion and resulting in diminished blood flow and glomerular filtrate,
ischemia, and oliguria; include CHF, cardiogenic shock, acute vasoconstriction, hemorrhage, burns,
septicemia, hypotension, anaphylaxis

2. Intra-renal failure
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. Post-renal failure
Mechanical obstruction anywhere from the tubules to the urethra; includes calculi, BPH, tumors,
strictures, blood clots, trauma, and anatomic malformation

Three phases of acute renal failure
1. Oliguric phase
Urine output less than 400 cc/24 hours
duration 12 weeks
Manifested by dilutional hyponatremia, hyperkalemia, hyperphosphatemia, hypocalcemia,
hypermagnesemia, and metabolic acidosis
Diagnostic tests: BUN and creatinine elevated

2. Diuretic phase
Diuresis may occur (output 35 liters/day) due to partially regenerated tubules inability to
concentrate urine
Duration: 23 weeks; manifested by hyponatremia, hypokalemia, and hypovolemia
Diagnostic tests: BUN and creatinine slightly elevated

3. Convalescence or recovery phase
Renal function stabilizes with gradual improvement over next 312 months

Laboratory findings:
Urinalysis: Urine osmo and sodium
BUN and creatinine levels increased
Hyperkalemia
Anemia
ABG: metabolic acidosis

Nursing interventions
1. Monitor and maintain fluid and electrolyte balance.
Measure l & O every hour. note excessive losses in diuretic phase
Administer IV fluids and electrolyte supplements as ordered.
Weigh daily and report gains.
Monitor lab values; assess/treat fluid and electrolyte and acid-base imbalances as needed

2. Monitor alteration in fluid volume.
Monitor vital signs, PAP, PCWP, CVP as needed.
Weigh client daily.
Maintain strict I & O records.

3. Assess every hour for hypervolemia
Maintain adequate ventilation.
Restrict FLUID intake
Administer diuretics and antihypertensives

4. Promote optimal nutritional status.
Administer TPN as ordered.
With enteral feedings, check for residual and notify physician if residual volume increases.
Restrict protein intake to 1 g/kg/day
Restrict POTASSIUM intake
HIGH CARBOHYDRATE DIET, calcium supplements

5. Prevent complications from impaired mobility (pulmonary embolism, skin breakdown, and
atelectasis)

6. Prevent fever/infection.
Assess for signs of infection.
Use strict aseptic technique for wound and catheter care.

7. Support client/significant others and reduce/ relieve anxiety.
Explain pathophysiology and relationship to symptoms.
Explain all procedures and answer all questions in easy-to-understand terms
Refer to counseling services as needed

8. Provide care for the client receiving dialysis

Chronic Renal Failure (END-STAGE RENAL DISEASE)
Gradual, Progressive irreversible destruction of the kidneys causing severe renal dysfunction.
The result is azotemia to UREMIA

Predisposing factors:
DM= worldwide leading cause
Recurrent infections
Exacerbations of nephritis
urinary tract obstruction
hypertension

PATHOPHYSIOLOGY
STAGE 1= reduced renal reserve, 40-75% loss of nephron function
STAGE 2= renal insufficiency, 75-90% loss of nephron function
STAGE 3= end-stage renal disease, more than 90% loss. DIALYSIS IS THE TREATMENT!

Assessment findings
1. Nausea, vomiting; diarrhea or constipation; decreased urinary output
2. Dyspnea
3. Stomatitis
4. Hypertension (later), lethargy, convulsions, memory impairment, pericardial friction rub

Diagnostic tests:
a. 24 hour creatinine clearance urinalysis
b. Protein, sodium, BUN, Crea and WBC elevated
c. Specific gravity, platelets, and calcium decreased
d. CBC= anemia

Medical management
Diet restrictions
Multivitamins
Hematinics and erythropoietin
Aluminum hydroxide gels
Anti-hypertensive
Anti-seizures
DIALYSIS

Nursing interventions
1. Prevent neurological complications.
Assess every hour for signs of uremia (fatigue, loss of appetite, decreased urine output, apathy,
confusion, elevated blood pressure, edema of face and feet, itchy skin, restlessness, seizures).

2. Promote optimal GI function.
Assess/provide care for stomatitis
Monitor nausea, vomiting, anorexia
Administer antiemetics as ordered.
Assess for signs of Gl bleeding

3. Monitor/prevent alteration in fluid and electrolyte balance

4. Assess for hyperphosphatemia (paresthesias, muscle cramps, seizures, abnormal reflexes), and
administer aluminum hydroxide gels (Amphojel) as ordered

5. Promote maintenance of skin integrity.
Assess/provide care for pruritus.
Assess for uremic frost (urea crystallization on the skin) and bathe in plain water

6. Monitor for bleeding complications, prevent injury to client.
Monitor Hgb, hct, platelets, RBC.
Hematest all secretions.
Administer hematinics as ordered.
Avoid lM injections

7. Promote/maintain maximal cardiovascular function.
Monitor blood pressure and report significant changes.
Auscultate for pericardial friction rub.
Perform circulation checks routinely.

8. Provide care for client receiving dialysis.

Important Drugs

Aluminum hydroxide
(Amphogel)
Binds with PHOSPHATE to decrease
phosphorus
Kayexalate Binds with POTASSIUM to manage
hyperkalemia
Diuretics To decrease edema
Erythropoietin (Epogen) To increase RBC
Anti-Hypertensives To manage Hypertension