ACUTE RENAL FAILURE

Is an abrupt or rapid decline in renal filtration function. This form most often occurs because of a sudden body insult, such as dehydration.

CAUSES:
accidents complications from surgeries in which the kidneys are deprived of normal blood flow for extended periods of time Prolonged anesthesia Hemorrhage Shock Severe diarrhea Sudden traumatic injury

NURSING DIAGNOSES

NURSING DIAGNOSIS 1

Excess Fluid Volume related to decreased glomerular filtration rate and sodium retention

Client will achieve fluid and electrolyte balance

GOAL

NURSING INTERVENTIONS
Independent:
Monitor intake and output. RATIONALE: Low urine output less than 400mL/24H may be first indicator of acute failure, especially in a high-risk client. Accurate I & O is necessary for determining fluid replacement needs and reducing risk of fluid overload.

NURSING INTERVENTIONS
Independent:
Monitor urine specific gravity. RATIONALE: Measure the kidneys ability to concentrate urine. In intrarenal failure, spec gravity is usually equal to or less than 1.010, indicating loss of ability to concentrate urine. Weigh daily at same time of day, on same scale with same equipment and clothing. RATIONALE: Daily body weight is best monitor of fluid status. A weight gain of more than 0.5 kg/day suggests fluid retention.

NURSING INTERVENTIONS
Independent:
Assess skin, face, and dependent areas for edema. Evaluate degree of edema. RATIONALE: Edema occurs primarily in dependent tissues of the body, such as hands, feet, and lumbosacral area. Periorbital edema may be a presenting sign of fluid shift because these fragile tissues are easily distended by even minimal fluid accumulation.

NURSING INTERVENTIONS
Independent:
Monitor HR, BP, and CVP. RATIONALE: tachycardia and HPN can occur because of failure of the kidneys to excrete urine, excessive fluid resuscitation during efforts to treat hypovolemia or hypotension, and changes in the renin-angiotensin system, which helps regulate long-term BP and blood volume. Auscultate heart and lung sounds. RATIONALE: Fluid overload may lead to pulmonary edema and HF, as evidenced by development of adventitious breath sounds and extra heart sounds.

NURSING INTERVENTIONS
Independent:
Plan oral fluid replacement with client, w/in multiple restrictions. Intersperse desired beverages throughout 24H. Vary offerings, such as hot, cold, and frozen. RATIONALE: Helps avoid periods without fluids, minimizes boredom of limited choices, and reduces sense of deprivation and thirst. Monitor for signs and symptoms of hypovolemia or hypervolemia RATIONALE: regulating capacity of kidneys is inadequate.

NURSING INTERVENTIONS
Independent:
Insert and maintain indwelling catheter, as indicated. RATIONALE: Catheterization excludes lower tract obstruction and provides means of accurate monitoring or urine output during acute phase; however, indwelling catheter may be contraindicated because of increased risk of infection.

NURSING INTERVENTIONS
Dependent:
Administer sodium bicarbonate or glucose and insulin, as ordered. RATIONALE: to shift potassium into the cells. Administer cation exchange resin (sodium polystyrene sulfonate [Kayexalate]) orally or rectally, as ordered. RATIONALE: to provide more prolonged correction of elevated potassium.

EVALUATION
After 3 days of effective nursing interventions, goal was met as evidenced by stable blood pressure, no edema or shortness of breath, intact skin integrity, achieved fluid and electrolyte balance.

NURSING DIAGNOSIS 2

Risk for infection related to alterations in the immune system and host defenses The patient will remain free from signs or symptoms of infection

GOAL

NURSING INTERVENTIONS
Monitor for all signs of infection. RATIONALE: Be aware that renal failure patients do not always demonstrate fever and leukocytosis. Remove bladder catheter as soon as possible; monitor for UTI. Use intensive pulmonary hygiene high incidence of lung edema and infection. Carry out meticulous wound care.

NURSING INTERVENTIONS
If antibiotics are administered, care must be taken to adjust the dosage for renal impairment. administration of a low protein diet RATIONALE: to delay inevitable renal replacement therapy or to lengthen the interval between sessions is physiologically unsound

EVALUATION
Client has no signs and symptoms of infection

DISCHARGE PLANNING

ACTIVITY
Normal to feel very tired much of the time with acute kidney failure. Your symptoms may get even worse if you get overtired. Rest or nap when you feel it is needed. Match your activity to the amount of energy you have. Pace your activities and make your work simple in order to save your energy. Break tasks down into smaller tasks. Going to bed early and getting up late may also help.

ACTIVITY
Measure the amount of urine and stool you have each day.

Weigh yourself every day, at the same time of day, and in the same kind of clothes. Keep a daily record of your daily weights.
Take your temperature every day. Keep a record of the results. Learn to take your own blood pressure. Keep a record of your results. Ask your doctor when you should seek emergency medical attention. He or she will tell you which blood pressure reading is dangerous.

DIET
Eat a high-calorie, low-protein in diet. Eat low sodium (salt) and potassium. Potassium can be found in the fruits and vegetables Limit the amount of phosphorus in your diet. Foods that are high in phosphorus are dairy products, beans, peas, and nuts. Phosphorous is also found in liquids, such as cocoa, beer, and cola drinks. Limit the amount of caffeine you drink, such as coffee, tea, and some sodas.

DIET
Write down how much liquid you drink every day. Remember to count ice cubes and ice chips. Try to drink only when you are thirsty. Good liquids to drink are water and some juices. Sucking on hard candy or chewing gum may help keep your mouth moist without having to drink liquids. Lemon wedges may also help keep your mouth moist. Do not drink alcohol. Alcohol can damage your brain, heart, and liver. Almost every part of your body can be harmed by alcohol. Drinking alcohol can also make your kidney failure worse.

MEDICATIONS
Keep a written list of the medicines you take. Ask your caregiver for information about your medicine. Do not use any medicines, over-the-counter drugs, vitamins, herbs, or food supplements without first talking to caregivers. Always take your medicine as directed by caregivers. Call your caregiver if you think your medicines are not helping or if you feel you are having side effects. Do not quit taking your medicines until you discuss it with your caregiver. If you are taking medicine that makes you drowsy, do not drive or use heavy equipment.

HYGIENE
Avoid contact with people who have infections (colds, bronchitis, or skin conditions). If client had surgery for an arteriovenous fistula (AVF) or arteriovenous graft (AVG): Clean the skin over the fistula or graft every day with soap and water. Take the bandage off the fistula or graft 4 to 6 hours after dialysis.

HYGIENE
Check your fistula or graft every day for good blood flow by touching it with your fingertips. The buzzing sensation means that it is working. Check for bleeding, pain, redness, or swelling. These may be signs of infection or a clogged fistula or graft. To prevent damage to the fistula or graft, no one should take your blood pressure or draw blood from the arm with the fistula or graft. Do not wear tight clothes or jewelry or sleep on that arm.

CALL YOUR DOCTOR IF YOU HAVE..

Signs of bladder infection (urinating more often than usual; burning, pain, bleeding, or hesitancy when you urinate) Signs of infection around your catheter (redness, swelling, warmth, or drainage) Rapid weight loss or gain, such as 3 pounds or more in 24 hours or 6 pounds or more in 7 days Fever above 100.4F or chills Muscle aches

CALL YOUR DOCTOR IF YOU HAVE..

Night sweats Very little or no urine output Swelling of your hands, legs, or feet Back pain Abdominal pain Extreme tiredness

CURRENT TREND

Anti-Rejection Drug Cleared for Use in Kidney Transplant Patients

Jody A. Charnow June 16, 2011

The FDA has approved belatacept (Nulojix) for preventing acute rejection of transplanted kidneys in adults.The drug is approved for use with other immunosuppressant agents, specifically basiliximab, mycophenolate mofetil, and corticosteroids. Belatacept is a selective T-cell costimulation blocker administered through 30-minute intravenous infusions. Belatacept was evaluated in two open-label, randomized, phase 3 studies that enrolled more than 1,200 patients. The studies compared two dose regimens of belatacept with cyclosporine. The drug carries a boxed warning for an increased risk of developing post-transplant lymphoproliferative disorder (PTLD).

The risk of PTLD is higher for transplant recipients who have never been exposed to Epstein-Barr virus (EBV). Transplant recipients who have not been exposed to EBV have more difficulty mounting an effective immune response to the virus if they get infected following transplantation. The virus is present in about 80% of donated organs. Patients should be tested for EBV and should only receive belatacept if testing shows they already have been exposed to EBV. Common adverse reactions from belatacept observed in the clinical trials included anemia, constipation, kidney or bladder infection, and edema.