Sunday, July 8, 2012

Nursing Care Plan For Acute Renal Failure

Acute renal failure (ARF) or Acute Kidney Injury (AKI) is a rapid loss (breakdown or decrease) of renal function due to damage to the kidneys, resulting in retention of nitrogenous (urea and creatinine) and non-nitrogenous waste products that are normally excreted by the kidney.

Acute Renal Failure (ARF) is classified as :

  1. Pre Renal; occurs as a result of renal hypoperfusion which usually responds well to rehydration, or result from condition that diminish blood flow to the kidney.

  2. Intra Renal; result from damage to the kidneys, usually from acute tubular necrosis. In critically ill patients other insults such as infection, hypoxia, drugs etc, may convert a simple problem of poor perfusion into one of acute tubular necrosis where there is structural damage to the renal parenchyma. The patient may not die from renal failure although this may be present at the time of death. There is a high mortality in patients who develop ARF in the context of other severe illness.

  3. Post Renal (obstructive); result from bilateral obstruction of urine flow. The most common cause of obstructive uropathy in men is prostate.

Acute renal failure has four phases : onset, oliguric-anuric, diuretic and convalescent. The convalescent period can last up to 12 months.

The possible causes of acute renal failure are Acute glomerulonephritis, Acute tubular necrosis, Anaphylaxis, Benign prostatic hyperplasia, Blood transfusion reaction, Burns, Cardiopulmonary bypass, Collagen disease, Congenital deformity, Dehydration, Diabetes Mellitus, Heart failure, Cardiogenic shock, Endocarditis, Malignant hypertension, Hemorrhage, Infection (pyelonephritis and septicemia), Neprotoxins (antibiotics, X-ray dyes, pesticides and anesthetic) and Thrombi or emboli.

Nursing care plan (NCP) or nursing intervention for the patients who diagnosed as acute renal failure during admitted on the hospital should be complete, comprehensive monitor and quick action in order to improve of patient's condition.

A. Assessment Findings on Acute Renal Failure

During assessment, the nurses may find some sign and symptom of acute renal failure. There are many complain from patient related to his/her condition such as ; Anorexia, Nausea, Vomiting, Costovertebral plain, Headache, diarrhea or constipation, Irritability, Restlessness, Lethargy, Drowsiness, Stupor, Coma, Pallor, Ecchymosis, Stomatitis, Thick tenaciouse sputum, Urine output less than 400 ml/day for 1 to 2 weeks and then followed by diuresis (3 to 5 L/day) for 2 to 3 weeks, Weight gain.

B. Diagnostic Evaluation for Acute Renal Failure

  1. Arterial blood gas (ABG) analysis shows metabolic acidosis.

  2. Blood chemistry shows increased potassium, phosphorus, magnesium, blood urea nitrogen (BUN) creatinine, and uric acid levels. Also decreased of calcium, carbon dioxide, and sodium levels.

  3. Creatinine clearance is low

  4. Excretory urography shows decreased renal perfusion and function.

  5. Glomerular filtration rate (GFR) is 20 - 40 ml/minute (renal insufficiency), 10 - 20 ml/minute (renal failure), or less than 10 ml/minute (end-stage renal disease).

  6. Hematology shows decreased hemoglobin (Hb) level, hematocrit (HCT), and erythrocytes. Also increase of prothrombin time (PT) and partial thromboplastin time (PTT).

  7. Urine chemistry shows albuminuria, proteinuria, increase sodium levels {casts, red blood cells (RBCs), and white blood cells (WBCs)}, and urine specific gravity greater than 1.025 which continue fixed at less than 1.010.

C. Nursing Diagnose (Problems) in Acute Renal Failure

  • Ineffective tissue perfusion (renal)

  • Excess fluid volume

  • Risk for infection

  • Risk for deficient fluid volume.

D. Treatment of Acute Renal Failure
  • Continuous arteriovenous hemofiltration

  • Low protein, increased carbohydrate, moderate fat, and moderate calorie dietwith potassium, sodium and phosphorus intake regulated according to serum levels

  • Peritoneal dialysis or hemodialysis

  • Fluid intake restricted to the amount needed to replace fluid loss.

  • Transfusion therapy with packed RBCs administered over 1 to 3 hours as tolerated.

E. There are Many of Drug Therapy Options
  • Alkalinizing agent ; sodium bicarbonate

  • Antacid ; aluminum hydroxide (AlternaGEL)

  • Antibiotic ; cefazolin (Ancef)

  • Anticonvulsant ; phenytoin (Dilantin)

  • Antiemetic ; prochlorperazine (Compazine)

  • Antipyretic ; acetaminophen (Tylenol)

  • Beta-adrenergic blocker ; dopamine (Intropin) initially to improve renal perfusion

  • Cation exchange resin ; sodium polystyrene sulfonate (Kayexalate)

  • Diuretic ; furosemide (Lasix) , metolazone (Zaroxolyn)

F. Planing and Goal of Nursing Care Plane
  1. The client will have normal fluid and electrolyte levels

  2. The client will experience no preventable complication

  3. The client will understand the means by which His/Her family members will implement health teaching after discharge.

G. Nursing Intervention for Acute Renal Failure

To the nursing intervention, the nurses should be have good knowledge to decide which phase of his/her patient related to the acute renal failure. Base on that information, bellow are some nursing intervention they can do to the patient with acute renal failure :

* Oliguric-anuric phase ; In this phase, the client's urine output falls bellow 400 ml/day. With resultant electrolyte imbalance, metabolic acidosis, and retention of nitrogenouse wastes from non functioning nephrons. This pahse may last up to 14 days. The Nurses should be follow these steps :
  1. Maintain the client on complete bed rest, organize care to provide long rest periods. Activity increase the rate of metabolism, which increase production of nitrogenouse waste product.

  2. Implement intervention to prevent infection and the complications of immobility. Because She/He is on bed rest, the client becomes susceptible to the hazards of immobility. Infection is a serious risk and the leading cause of death in client with acute renal failure.

  3. Observe the client for metabolic acidosis to identify complication of renal failure.Observe the fluid and electrolyte balance hourly.

  4. Insert an indwelling urinary catheter and measure output and specific gravity hourly. These action allow the nurse to monitor the kidneys, which have the major role in regulating fluid and electolyte balance. High potassium levels can occur.

  5. Provide only enough fluid intake to replace urine output to avoid an edema caused by excessive fluid intake.

  6. Monitor the client's diet to provide high carbohydrates, adequate fats, and low protein. If client receives high calories from fat and carbohydrate metabolism, the body doesn't break down protein for energy. Protein is thus available for growth and repair.

  7. Reduce the client's potassium intake to help prevent elevated potassium levels. Protein catabolism causes potassium release from cells into the serum.

  8. Observe for the arrhytmias and cardiac arrest to identify complications of high serum potassium.

  9. Provide frequent oral hygiene to avoid tissue irritation and sometime ulcer formation caused by urea and other acid waste products excreted through the skin and mucous membranes.

  10. Provide the client with hard candy and chewing gum to stimulate saliva flow and decrease thirst.

  11. Maintain skin care with cool water to relive pruritus and remove uremic frost (white crystal formed on skin from excretion of urea).

  12. Administer stool softeners to prevent colon irritation from high levels urea and organic acids.

  13. Provide emotional reassurance to the client and family members to help decrease anxiety levels caused by the fact that the client has an acute illness with unknown prognosis.

  14. Explain treatments and progress to the client to help reduce anxiety.

  15. Provide hemodialysis or peritoneal dialysis as ordered.

* Early diuretic phase ; During early diuretic phase, which last about 10 days, the client excretes a large volume (over 3,0000 ml/day) of very dilute urine. The glomeruli are beginning to function effectively, but tubules aren't, and the client still experiences electrolyte imbalance, retention of nitrogenous waste product and metabolism acidosis. The nurse should be do intervention such as ;
  1. Assess fluid and electrolyte balance to identify continued fluid and electrolyte imbalance when the renal tubules aren't functioning.

  2. Assess the emotional status of the client and family members to provide support because the prognosis is still uncertain.

  3. Continue interventions used during the oliguric phase.

* Late Diuretic phase ; In the late diuretic phase, the client is still excreting more fluid than normal. Urine specific gravity is increasing because the tubules are beginning to function effectively. Fluid, electrolyte and acid-base balances are returning to normal. In this condition, The nurse should do the following steps ;
  1. Continuing implementations of the early diuretic phase. Allow the client to engage in nonstrenuous activity for brief periods and increase the activity level gradually. Don't let him/her become fatigued which may increase the rate of metabolism and overwork the kidneys.

  2. Teach the client to prevent infection and to avoid the factors that caused renal failure to help prevent a recurrence.

H. Evaluation of Nursing Intervention
  • The client regains fluid and electrolyte balance.

  • The client understands the rationale behind activity restriction.


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