ACUTE RENAL FAILURE

Patient’s Profile
Name: T.M Age: 46 Religion: RC Address: Quezon City Birthdate: 05/09/63 Civil status: married Occupation: none

Cc: LBM Medical Dx: Acute Renal Failure Attending Physician: Dr. A.R

Present Medical Hx
Three days prior to admission, patient had loose bowel movement of about five times associated with vomiting more tan ten times, and abdominal pain. No consultation done, no med’s taken two days prior. Pt still on above symptoms developed fever promptly consult then admitted

Past Medical Hx
• (-) HPN • (-)PTB • (+)DM

Family Medical Hx
• (+) HPN • (+)DM

Personal Social Hx
Since 20 yrs old, the patient was a alcohol drinker and a smoker

Body Part

Methodology of Assessment

Normal findings

Actual findings

I. Upper Extremities 1. hands & nails INSPECTION a. color b. temp c. texture d. turgor e. presence of lesions f. edema 2. Brachial pulse 3. forearm & upper ar, a. tenderness 4. ROM PALPATION INSPECTION INSPECTION INSPECTION No limitation Bed rest Pinkish Nor cold, nor warm Smooth No lesion No presence Good pulsation Cyanotic Cold to touch Rough No lesion With edema Weak pulse

Good skin turgur Poor skin turgur

II. Head 1. Hair & scalp a. quantity thickness and texture b. distribution c. lesions 2. Face a. facial expression b. symmetry

INSPECTION Good in quality, Soft & silky hair Well distributed No lesions INSPECTION Good facial expression Symmetry in proportion Natural pinkish Facial grimace Good in quality

Well distributed No lesions

Symmetry Normal

c. skin, color, edema, lession 3. Eye INSPECTION a. movement of eyeballs b. color of sclera & conjunctiva c. size of pupil

Normal eye movement White conjunctiva / pinkish round

Normal Normal Normal

III. Neck

INSPECTION PALPATION

1. asymmetry

Symmetry

Normal

a. active ROM

Symmetric none Bed rest tender

b. carotid pulsation

Good pulsation

Weak pulse

IV. Chest & INSPECTION Lungs 1. thoracic cage 2. respiration 3. level of consciousness 4. confirm, symmetrical expansion 5. note adventious sounds AUSCULTATION

Symmetrical Normal and relax Conscious

Normal Dyspnea Conscious

symmetrical

Normal

None

Crackles

6. lesions & INSPECTION edema 7. color & temp

No lesion & edema Warm

No lesions Cold to touch

V. Abdomen

INSPECTION

1. contour, gen symmetry

Symmetrical, flat and smooth

Normal

2. skin/umbilicus 3. bowel sound

INSPECTION

Smooth

Smooth

AUSCULTATION

Normo active

4. four quadrant

No tenderness

Normal

VI. Lower Extremities 1. lower extremities a. color

INSPECTION

Pinkish

cyanotic

b. temp

Not warm nor cold No lesion

Cold to touch

c. lesion

No lesion

d. edema

No edema

With edema

INTRODUCTION

Acute renal failure
Acute renal failure is the abrupt and severe inability of intra renal(kidney) or extra renal system to excrete the proper amount of waste product as urine leading to retention of waste products in blood.

Acute renal failure (ARF), also known as acute kidney failure is a rapid loss of renal function due to damage to the kidneys, resulting in retention of nitrogenous and non-nitrogenous waste products that are normally excreted by the kidney. Depending on the severity and duration of the renal dysfunction, this accumulation is accompanied by metabolic disturbances, such as metabolic acidosis and hyperkalaemia, changes in body fluid balance, and effects on many other organ systems.

Incidence
• 5% - 7% of hospital admission • 30% of ICU admission

ARF: Signs and Symptoms
• • • • • • • Hyperkalemia (cause arrhythmias) Nausea/Vomiting Malaise Pericardial effusion Pulmonary edema bleeding Encephalopathy

Causes of ARF in 3 Categories

Phases of Ischemic ARF

begins with renal insult hypothetical period of time S/S: Urine 400ml or less/24 hrs, Increasing BUN

Phases of Ischemic ARF

Period of ongoing renal failure and lasts 7-14 days S/S: Urine Output is Lowest

Phases of Ischemic ARF

Gradual return of renal function S/S: Can be complicated my marked diuretic phase

Diagnostic Evaluation
1. Urinalysis shows proteinuria, hematuria, casts. Urine chemistry distinguishes various forms of ARF(prerenal, postrenal, intrarenal). 3. Serum creatinine and BUN levels are elevated; arterial blood gas (ABG) levels, serum electrolytes may be abnormal.

3. Renal untrasonography estimates renal size and rules out treatable obstructive uropathy.

• A Swan-Ganz catheter may be used, to measure pulmonary artery occlusion pressure to provide a guide to left atrial pressure (and thus left heart function) as a target for inotropic support.

ANATOMY & PHYSIOLOGY

Urinary System

• The body takes nutrients from food and converts them to energy. After the body has taken the food that it needs, waste products are left behind in the bowel and in the blood. • The urinary system keeps the chemicals and water in balance by removing a type of waste, called urea, from the blood. Urea is produced when foods containing protein, such as meat, poultry, and certain vegetables, are broken down in the body. Urea is carried in the bloodstream to the kidneys.

How does the urinary system work?

Two kidneys
• a pair of purplish-brown organs located below the ribs toward the middle of the back. Their function is to remove liquid waste from the blood in the form of urine; keep a stable balance of salts and other substances in the blood; and produce erythropoietin, a hormone that aids the formation of red blood cells.

• The kidneys remove urea from the blood through tiny filtering units called nephrons. Each nephron consists of a ball formed of small blood capillaries, called a glomerulus, and a small tube called a renal tubule. Urea, together with water and other waste substances, forms the urine as it passes through the nephrons and down the renal tubules of the kidney.

Two ureters
• narrow tubes that carry urine from the kidneys to the bladder. Muscles in the ureter walls continually tighten and relax forcing urine downward, away from the kidneys. If urine backs up, or is allowed to stand still, a kidney infection can develop. About every 10 to 15 seconds, small amounts of urine are emptied into the bladder from the ureters.

Bladder
• a triangle-shaped, hollow organ located in the lower abdomen. It is held in place by ligaments that are attached to other organs and the pelvic bones. The bladder's walls relax and expand to store urine, and contract and flatten to empty urine through the urethra. The typical healthy adult bladder can store up to two cups of urine for two to five hours.

Two sphincter muscles
• circular muscles that help keep urine from leaking by closing tightly like a rubber band around the opening of the bladder.

Nerves in the bladder
• alert a person when it is time to urinate, or empty the bladder.

Urethra
• the tube that allows urine to pass outside the body. The brain signals the bladder muscles to tighten, which squeezes urine out of the bladder. At the same time, the brain signals the sphincter muscles to relax to let urine exit the bladder through the urethra. When all the signals occur in the correct order, normal urination occurs.

PATHOPHYSIOLOGY

Types Pre-renal

etiology

What happens
Reduced or deprived perfusion of kidney-renal ischemia-functional disorder or depression of GFR or both
The necrotic debris,cellular blebs block the filteration barrier + macula densa is also activated due to chloride load hence causes prerenal vasodilatation. So we have now prerenal dilation and blockage of capillary bed so it results in decrease in filterateoliguria and retention of creatinine and nitrogenous waste products in blood.

Clinical findings
There is decrease in GFR so causes oliguria, azotemia, possible fluid retention and oedema Blocking of filteration barrier ( capillarymicrovasculature) here also causes oliguria and if oliguria nitrogenous compounds and creatinine is obviously increased in blood. There is decrease in GFR so causes oliguria, azotemia,possible fluid retention and oedema

a) volume depletion { structurally intact b) Hypotension nephrons } (systemic hypovolumia)
• Acute tubular necrosis due to ischemia nephrotoxin

Renal
{with structural and functional damage }

diseases of glomeruli

Post-renal
(Obstruction of urine flow in anywhere along urinary tract)

a) b)

Obstructio Urine outflow is n of lumen obstructed so further Compressi filtration is declined. include stone disease; stricture; and on of intraluminal, extraluminal, or lumen
intramural tumors. Prostatic compression

LABORATORY

Hematology
RESULTS
RBC COUNT HGB HCT MCV MCH MCHC PLATELET COUNT WBC COUNT NEUTROPHILS LYMPHOCYTES EOSINOPHILS MONOCYTES BASOPHILS 3.36 106 0.30 89.6 31.5 35.5 313 17.6 0.788 0.087 0.040 0.089 0.001 4.70-6.10 140.0-180.0 0.40-0.54 85.0-96.0 27-31 32.0-36.0 150-450 5.0-10.0 0.500-0.700 0.200-0.700 0.000-0.090 0.020-0.090 0.000-0.020

Urinalysis
PHYSICAL EXAM CHEMICAL EXAM MICROSCOPIC EXAM

COLOR- YELLOW TRANSPARENCYTURBID REACTION-5.0

ALBUMIN-100 mg/dl PUS CELL-10-15 SUGAR- (-) RBC

KETONE

SPECIFIC GRAVITY- BILIRUBIN 1025 UROBILINOGEN

EPITHELIAL CELLFEW BACTERIAMODERATE

Serology
PROCEDURE TROPONIN-I RESULT POSITIVE

KUB-(UTZ)
IMPRESSION: • Non-obstructing nephrolithiasis, right, • Nephrolithiasis, left producing moderate pelvocalyectasia • Normal urinary bladder

CREATININE UREA SODIUM POTASSIUM CHLORIDE

RESULT 100.16 umol/L 2.91 umol/L 133.6 2.99 NA

53.0-97.0 2.14-7.214 3.5-5.3 mmol/L 3.5-5.3 98-107

MEDICATION

Indication > Schilling test 1) Kalium Durule flushing (KCl) dose.

Drug

Action > Replaces potassium & mininum potassium level.

Contraindication > Drug-drug: ACE inhibitors, digoxin, potassiumsparring

Nursing Responsibilities > Use cautiously in patients with cardiac disease or renal impairment.

> To prevent > 10mEq / T.I.D. hypokalemia

diuretics: May cause hyperkalemia. Use > Give oral potassium with supplements extreme caution. with extreme caution because different forms deliver varying amounts of potassium. Never switch products without prescriber's order.

> Hypokalemia

> Severe hypokalemia

> Acute MI

> Potassium preparations aren't interchangeable; verify preparation before use. > Make sure powders are completely dissolved before giving.

2.Ranitidine 50mg

> Duodenal and gastric ulcer > Gastroesophageal reflux dse. > heartburn

> Compatibility inhibits

> Contraindicated in > Use cautiously in patient with patients hepatic hypersensitive to drug action of histamine on and those dysfunction. > Assess patient with abdominal the H2 at receptors with acute porphyria. pain. Note for the presence of blood in emesis, stool, or gastric aspirate

ZANTAC

> erosive esophagitis sites of parietal cells, > Renal impairment > maintenance therapy for decreasing gastric > Pregnancy duodenal or gastric ulcer acid secretion. > Lactation

> Ranitidine may be added to total parenteral nutrition solution. > Instruct patient on proper use of OTC preparation as indicated > Remind patient to take once a day prescription drug at bed time for best result > Instruct patient to take without regard to meals besause absorption isn't affected by food. > Urge patient to aviod cigarette smoking because this may increase gastric acid secretion and worsen disease

4.Cefriaxone 500mg

>Skin and skin structure infections >Uncomplicated gonococcal

>Contrindicated in >A third generation patients cephalosporin that inhibits cee-wall synthesis promoting osmotic instability usually bactericidal. >pregnant woman >Lactation hypersensitive to drugs.

> Tell patient to report adverse reaction promptly

> Instruct patient to report discomfort at IV insertion site. > Teach patient and family receiving home care how to prepare and give drugs.

R0CEPHIN

vulvo vaginitis >Bone and joint infection

>Respiratory tract infection

drugs. > Alert: Do not confuse drug with other

>Intra abdominal infection

cephalosporin that sounds like. > Tell patient to notify prescriber about loose

,

>Septicemia >Bacteremia >Meningitis >Acute bacterial otitis media

stool or diarrhea.

5.Metoclopromid >To prevent or e reduce nausea andvvomiting from Hydrochloride IV emetogenic MALAXONCLOP cancer RA chemotherapy.

> Contraindicated in >Tell patient to aviod activities >Stimulates motility patients that require alertness of upper GI tract hypersensitive to increases drugs and in for 2 hours after doses. lower esophageal those sphincter pheochro,ocytoma or tone, and block >Urge patient to report dopamine seizure disorders. persistent or serious >To prevent or receptors at the Also contraindicated reduce trigger zone. in those for adverse effect promptly. postoperative whom stimulation of nausea and GI motility might be dangerous >Adice patient to aviod alcohol vomiting (ex. Those ingestion during >To facilitate smallwith hemorrhage, bowel obstruction or therapy. intubation, to aid in >When oral solution is used perforation. radiologic dilute in pudding, applesauce juice or water just examinations. before using. >Gastroesophageal reflux dse. >Safety and effectiveness of drug haven't been established for therapy lasting longer than 12 wks.

>Emesis during pregnancy. > Monitor bowel sounds.

NURSING CARE PLAN

ASSESSM DIAGNOSI INFERENC SUBJECTIVE: Renal E failure ENT Fluid S “Namamanas Volume ako at ang Decrease hina ng excess r/t blood flow to katawan ko” Compromis kidneys as verbalized ed by the patient. OBJECTIVE: regulatory Decrease •Venous mechanism perfusion in distension (renal kidney •Generalized failure) edema
•Patient reports of Fatigue, weakness, and malaise •V/S taken as follows; T: 35˚ CP: 50 R: 13 BP: 130/90

PLANNING INTERVENTI EVALUATI Independent; After 8 Goal met, ON ON •Record accurate hours of patient intake and output nursing has (I&O). intervention, •Weigh daily at displayed the patient same time of day, appropriat on same scale, will display with same e urinary appropriate equipment and output clothing urinary with output with •Assess skin, specific face, dependent specific gravity/lab Decrease areas for edema gravity/labor •Plan oral fluid oratory urinary replacement with studies atory output studies near patient, within near multiple Water normal; normal; restrictions retention stable stable Dependent; weight, vital •Administer/restri weight, Fluid volumes signs within ct fluids as vital signs indicated. excess patient’s within •Administer medication as normal patient’s range; and indicatedDiuretics normal , e.g., furosemide absence of (Lasix), mannitol range; and

DISCHARGE PLAN

MEDICATION
• • • • • Ranitidine 50 mg Metochlopromide Ceftriaxone 500mg Kalium durule, 1 tab daily Paracetamol 500mg

EXERCISE
• May exhibit what the body is tolerated

TREATMENT
• Take the medication exactly as prescribed on regular days

HEALTH TEACHINGS
• encourage only enough fluid intake to replace urine output to avoid an edema caused by excessive fluid intake. • encourage the client to reduced potassium intake to help prevent elevated potassium levels • Tell patient to avoid over fatigue

OUT-PATIENT
• Advise to avoid ‘miracle cures’ drugs that are not prescribed by the physician and other forms of quackery • Advise to have a follow up checkup • Advice to report to the physician or clinic regularly for evaluation

DIET
• Low salt, low fat with green leafy vegetables • Encourage to eat nutritious and vitamins rich food

SPIRITUALLY
• Encourage to pray always, and ask for guidance to our almighty GOD.

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