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Acute Renal Failure

Dr. Belal Hijji, RN, PhD April 9 & 16, 2012

students will be able to: • Define renal failure and discuss its pathophysiological changes. • Discuss the nursing interventions designed to meet specific goals associated with ARF.Learning Outcomes At the end of this lecture. • Describe the categories of acute renal failure (ARF). • Recognise the clinical manifestations of ARF. • Describe the medical management of a patient with ARF. 2 . • Discuss the assessment and diagnostic findings associated with ARF.

electrolyte.Renal Failure • Renal failure results when the kidneys cannot remove the body’s metabolic wastes (urea) or perform their regulatory functions. The wastes accumulate in the body fluids. leading to a disruption in endocrine and metabolic functions as well as fluid. 3 . Renal failure is a systemic disease and is a final common pathway of many different kidney and urinary tract diseases. and acid–base disturbances.

ARF manifests with oliguria (less than 400 mL/day of urine). anuria (less than 50 mL/day of urine). 4 . The patient has high serum creatinine and BUN levels (azotemia) and retention of other metabolic waste products normally excreted by the kidneys. or normal urine volume.Acute Renal Failure • Pathophysiology: Acute renal failure (ARF) is a sudden and almost complete loss of kidney function over a period of hours to days.

5 . Conditions such as burns. nephrotoxic agents (nonsteroidal anti-inflammatory drugs (NSAIDs). may lead to acute tubular necrosis and cessation of renal function.Categories of Renal Failure • Prerenal conditions occur as a result of impaired blood flow that leads to hypoperfusion of the kidney and a drop in the GFR. The causes could be hemorrhage. sepsis or anaphylaxis. causing renal toxicity. crush injuries. • Intrarenal causes of ARF are the result of actual parenchymal damage to the glomeruli. myoglobin (a protein released from muscle when injury occurs) and hemoglobin are liberated. and infections. ischemia. With burns and crush injuries. myocardial infarction. or both. or cardiogenic shock. heart failure. angiotensin-converting enzyme (ACE) inhibitors).

strictures. tumors. Common causes include calculi (stones).Categories of Renal Failure (Continued…) • Postrenal causes of ARF are usually the result of an obstruction somewhere distal to the kidney. the GFR decreases. eventually. 6 . benign prostatic hyperplasia. and blood clots. Pressure rises in the kidney tubules.

with persistent nausea. Central nervous system signs and symptoms include drowsiness. headache. and the breath may have the odor of urine. vomiting and diarrhea. • The patient may appear critically ill and lethargic [‫]يميل للنوم‬. The skin and mucous membranes are dry from dehydration. Next slide summarizes some common clinical findings for all three categories of ARF.Clinical Manifestations • Almost every system of the body is affected when there is failure of the normal renal regulatory mechanisms. 7 . and seizures [‫]نوبات مرضية‬. muscle twitching [‫]ارتعاش‬.

or sudden anuria Urine sodium Decreased to <20 mEq/L Increased Increased to >40 mEq/L Varies.Comparing Types of Acute Renal Failure TYPES Characteristics Etiology BUN value Creatinine Urine output Prerenal Hypoperfusion Increased Increased Decreased Intrarenal Parenchymal damage Increased Increased Varies. 1.010 Varies Urine specific gravity 8 . often decreased to 20 mEq/L or less Low normal. often decreased Postrenal Obstruction Increased Increased Varies. may be decreased.

Protein catabolism results in the release of cellular potassium into the body fluids. Hyperkalemia may lead to dysrhythmias and cardiac arrest. the patient cannot excrete potassium normally.Assessment and Diagnostic Findings • Changes in urine: Please refer to the previous slide to see the urine changes based on the type of ARF. Serum creatinine levels are useful in monitoring kidney function and disease progression. • Increased BUN and creatinine levels: Rise in the BUN depends on the degree of catabolism (breakdown of protein). and protein intake. • Hyperkalemia: With a declining GFR. renal perfusion. 9 . causing severe hyperkalemia.

blood pressure. serum and urine concentrations. are calculated and are used as the basis for fluid replacement. The parenteral and oral intake and the output. fluid losses. or possibly performing dialysis. serial measurements of central venous pressure. The objectives of treatment of ARF are to restore normal chemical balance and prevent complications. – Maintenance of fluid balance is based on daily body weight. avoiding fluid excesses. including insensible loss. • The medical management includes maintaining fluid balance. and the clinical status of the patient. 10 .Medical Management • The kidney has a remarkable ability to recover from insult.

and pulmonary edema. pericarditis. furosemide. distended neck veins. tachycardia. extreme caution must be used to prevent fluid overload (Characterised by dyspnea. Generalized edema is assessed by examining the presacral and pretibial areas several times daily. 11 . – Adequate blood flow to the kidneys in patients with prerenal causes of ARF may be restored by intravenous fluids or blood product transfusions.Medical Management (Continued…) – Because excessive administration of parenteral fluids may cause pulmonary edema. severe metabolic acidosis. such as hyperkalemia. – Dialysis may be initiated to prevent serious complications of ARF. Mannitol. or ethacrynic acid may be prescribed to initiate a diuresis and prevent or minimise subsequent renal failure. and crackles) .

Pharmacologic Therapy [Hyperkalemia] • Hyperkalemia is a life-threatening condition. tented. diarrhea. or peaked T waves) (next slide) – Signs and symptoms (muscle weakness. abdominal cramps) Schematic representation of normal ECG 12 . the patient is monitored for: – Serum potassium levels – Electrocardiogram (ECG) changes (tall. Therefore.

Peaked T waves 13 .

• Administration of a retention enema requires a rectal catheter with a balloon to facilitate retention for 30 to 45 minutes. • Immediate dialysis. Afterward. 14 . a cleansing enema is administered to remove the Kayexalate resin as a precaution against fecal impaction. • Intravenous glucose and insulin or calcium gluconate may be used as emergency measures to treat hyperkalemia.Pharmacologic Therapy (Continued…) • Hyperkalemia may be reduced by administering cation-exchange resins (sodium polystyrene sulfonate [Kayexalate]) orally or by retention enema. Kayexalate exchanges a sodium ion for a potassium ion in the colon (major site for potassuim exchange). Sorbitol is often administered in combination with Kayexalate to induce a diarrhea-type effect.

breath sounds. – reports to physician indicators of deteriorating fluid and electrolyte status. distention of the jugular veins. – monitors fluid status by paying careful attention to fluid intake. – monitors the patient closely for signs and symptoms of hyperkalemia (Slide 12). and intake and output record. The nurse: – monitors the patient’s serum electrolyte levels and physical indicators of fluid and electrolyte imbalances. – carefully screens parenteral fluids. apparent edema.Nursing Management of ARF • Monitoring fluid and electrolyte balance. urine output. – maintains accurate daily weight. and prepares for emergency treatment. 15 . and increasing difficulty in breathing. and all medications to ensure that hidden sources of potassium are not inadvertently administered or consumed. all oral intake.

Nursing Management of ARF (Continued…) • Reducing metabolic rate. 16 . The nurse: – should reduce the patient’s metabolic rate to reduce catabolism and the subsequent release of potassium and accumulation of waste products (urea and creatinine). – may keep the patient on bed rest to reduce exertion and the metabolic rate during the most acute stage of ARF. – should prevent or promptly treat fever and infection to decrease the metabolic rate and catabolism.

when possible. cough. 17 . • Preventing infection. inserting an indwelling urinary catheter as it is a high risk for urinary tract infection (UTI). The nurse: – strictly observes aseptic technique when caring for the patient to minimise the risk of infection and increased metabolism. The nurse: – assist the patient to turn. and take deep breaths frequently to prevent atelectasis and respiratory tract infection. – avoids.Nursing Management of ARF (Continued…) • Promoting pulmonary function.