Acute renal failure (ARF) has four well-defined stages: onset, oliguric or anuric, diuretic, and convalescent. Treatment depends on stage and severity of renal compromise.
Acute renal failure (ARF) can be divided into three major classifications, depending on site:
- Prerenal: Prerenal failure is caused by interference with renal perfusion (e.g., blood volume depletion, volume shifts [“third-space” sequestration of fluid], or excessive/too-rapid volume expansion), manifested by decreased glomerular filtration rate (GFR). Disorders that lead to prerenal failure include cardiogenic shock, heart failure (HF), myocardial infarction (MI), burns, trauma, hemorrhage, septic or anaphylactic shock, and renal artery obstruction.
- Renal (or intrarenal): Intrarenal causes for renal failure are associated with parenchymal changes caused by ischemia or nephrotoxic substances. Acute tubular necrosis (ATN) accounts for 90% of cases of acute oliguria. Destruction of tubular epithelial cells results from (1) ischemia/hypoperfusion (similar to prerenal hypoperfusion except that correction of the causative factor may be followed by continued oliguria for up to 30 days) and/or (2) direct damage from nephrotoxins.
- Postrenal: Postrenal failure occurs as the result of an obstruction in the urinary tract anywhere from the tubules to the urethral meatus. Obstruction most commonly occurs with stones in the ureters, bladder, or urethra; however, trauma, edema associated with infection, prostate enlargement, and strictures also cause postrenal failure.
Note: Iatrogenically induced ARF should be considered when failure develops during or shortly after hospitalization. The most common causative factor is administration of potentially nephrotoxic agents.
Nursing Care Plan for Acute Renal Failure
Nursing Care Plan for Acute Renal Failure: Nursing Priorities & Discharge Goals
NURSING PRIORITIES
- Reestablish/maintain fluid and electrolyte balance.
- Prevent complications.
- Provide emotional support for patient/significant other (SO).
- Provide information about disease process/prognosis and treatment needs.
DISCHARGE GOALS
- Homeostasis achieved.
- Complications prevented/minimized.
- Dealing realistically with current situation.
- Disease process/prognosis and therapeutic regimen understood.
- Plan in place to meet needs after discharge.
Nursing Care Plan for Acute Renal Failure: Nursing Diagnosis
Nursing Diagnosis of Acute Renal Failure:
- Fluid Volume excess related to Compromised regulatory mechanism (renal failure)
Nursing Care Plan for Acute Renal Failure: Nursing Intervention & Rationale
Fluid/Electrolyte Management (NIC)
Nursing Intervention of Acute Renal Failure: Independent
- Record accurate intake and output (I&O). Include “hidden” fluids such as IV antibiotic additives, liquid medications, ice chips, frozen treats. Measure gastrointestinal (GI) losses and estimate insensible losses, e.g., diaphoresis. Rationale: Low output (less than 400 mL/24 hr) may be first indicator of acute failure, especially in a high-risk patient. Accurate I&O is necessary for determining renal function and fluid replacement needs and reducing risk of fluid overload. Note:Hypervolemia occurs in the anuric phase of ARF.
- Monitor urine specific gravity. Rationale: Measures the kidney’s ability to concentrate urine. In intrarenal failure, specific gravity is usually equal to/less than 1.010, indicating loss of ability to concentrate the 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.
- Assess skin, face, dependent areas for edema. Evaluate degree of edema (on scale of +1–+4). Rationale: Edema occurs primarily in dependent tissues of the body, e.g., hands, feet, lumbosacral area. Patient can gain up to 10 lb (4.5 kg) of fluid before pitting edema is detected. Periorbital edema may be a presenting sign of this fluid shift because these fragile tissues are easily distended by even minimal fluid accumulation.
- Monitor heart rate (HR), BP, and JVD/CVP. Rationale: Tachycardia and hypertension can occur because of (1) failure of the kidneys to excrete urine, (2) excessive fluid resuscitation during efforts to treat hypovolemia/hypotension or convert oliguric phase of renal failure, and/or (3) changes in the renin-angiotensin system. Note: Invasive monitoring may be needed for assessing intravascular volume, especially in patients with poor cardiac function.
- Auscultate lung and heart sounds. Rationale: Fluid overload may lead to pulmonary edema and HF evidenced by development of adventitious breath sounds, extra heart sounds. (Refer to ND: Cardiac Output, risk for decreased, following.)
- Assess level of consciousness; investigate changes in mentation, presence of restlessness. Rationale: May reflect fluid shifts, accumulation of toxins, acidosis, electrolyte imbalances, or developing hypoxia.
- Plan oral fluid replacement with patient, within multiple restrictions. Intersperse desired beverages throughout 24 hr. Vary offerings, e.g., hot, cold, frozen. Rationale: Helps avoid periods without fluids, minimizes boredom of limited choices, and reduces sense of deprivation and thirst.
Nursing Intervention of Acute Renal Failure: Collaborative
- Correct any reversible cause of ARF, e.g., replace blood loss, maximize cardiac output, discontinue nephrotoxic drug, relieve obstruction via surgery. Rationale: Kidneys may be able to return to normal functioning, preventing or limiting residual effects.
- Monitor laboratory/diagnostic studies, e.g.:
- BUN, Cr; Rationale: Assess progression and management of renal dysfunction/failure. Although both values may be increased, Cr is a better indicator of renal function because it is not affected by hydration, diet, and tissue catabolism. Note: Dialysis is indicated if ratio is higher than 10:1 or if therapy fails to correct fluid overload or metabolic acidosis.
- Urine sodium and Cr; Rationale: In ATN, tubular functional integrity is lost and sodium resorption is impaired, resulting in increased sodium excretion. Urine creatinine is usually decreased as serum creatinine elevates.
- Serum sodium; Rationale: Hyponatremia may result from fluid overload (dilutional) or kidney’s inability to conserve sodium. Hypernatremia indicates total body water deficit.
- Serum potassium; Rationale: Lack of renal excretion and/or selective retention of potassium to excrete excess hydrogen ions leads to hyperkalemia, requiring prompt intervention.
- Hb/Hct; Rationale: Decreased values may indicate hemodilution (hypervolemia); however, during prolonged failure, anemia frequently develops as a result of RBC loss/decreased production. Other possible causes (active or occult hemorrhage) should also be evaluated.
- Serial chest x-rays. Rationale: Increased cardiac size, prominent pulmonary vascular markings, pleural effusion, infiltrates/congestion indicate acute responses to fluid overload or chronic changes associated with renal and heart failure.
3. Administer/restrict fluids as indicated. Rationale: Fluid management is usually calculated to replace output from all sources plus estimated insensible losses (metabolism, diaphoresis). Prerenal failure (azotemia) is treated with volume replacement and/or vasopressors. The oliguric patient with adequate circulating volume or fluid overload who is unresponsive to fluid restriction and diuretics requires dialysis. Note: During oliguric phase, “push/pull” therapy (push IV fluids and diurese with diuretics) may be tried to stimulate kidney function.
4. Administer medication as indicated:
- Diuretics, e.g., furosemide (Lasix), bumetanide (Bumex), torsemide (Demadex), mannitol (Osmitrol); Rationale: Given early in oliguric phase of ARF in an effort to convert to nonoliguric phase, flush the tubular lumen of debris, reduce hyperkalemia, and promote adequate urine volume.
- Antihypertensives, e.g., clonidine (Catapres), methyldopa (Aldomet), prazosin (Minipress); Rationale: May be given to treat hypertension by counteracting effects of decreased renal blood flow and/or circulating volume overload.
- Calcium channel blockers; Rationale: Given early in nephrotoxic ATN to reduce influx of calcium into kidney cells, thereby helping to maintain cell integrity and improve GFR.
- Prostaglandins. Rationale: Vasodilatory effect may improve circulating volume and reestablish renal blood flow to aid in clearing nephrotoxic agents from nephrons.
5. Insert/maintain indwelling catheter, as indicated. Rationale: Catheterization excludes lower tract obstruction and provides means of accurate monitoring of urine output during acute phase; however, indwelling catheterization may be contraindicated because of increased risk of infection.
6. Prepare for dialysis as indicated, e.g., hemodialysis, peritoneal dialysis, or continuous renal replacement therapy (CRRT). Rationale: Done to correct volume overload, electrolyte and acid-base imbalances, and to remove toxins. The type of dialysis chosen for ARF depends on the degree of hemodynamic compromise and patient’s ability to withstand the procedure. (Refer to CP: Renal Dialysis).
Nursing Care Plan for Acute Renal Failure; Nursing Care Plan for Acute Renal Failure: Overview; Nursing Care Plan for Acute Renal Failure: Nursing Priorities & Discharge Goals; Nursing Care Plan for Acute Renal Failure: Nursing Diagnosis; Nursing Care Plan for Acute Renal Failure: Nursing Intervention & Rationale;
Nursing Care Plan for Acute Renal Failure
