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 LAGUARDIA COMMUNITY COLLEGE CITY UNIVERSITY OF NEW YORK PRACTICAL NURSING PROGRAM Acute Renal Failure by Marie Jimenez, SPN SCL 115: Maternity Nursing Fall 2007 Session I Clinical Professor: Prof. Wilkes Picture courtesy of © Mayo Foundation for Medical Education and Research
DIAGNOSIS
Acute Renal Failure
DEFINITION
One of the basic functions of the kidneys, in addition to regulating blood pressure and
producing red blood cells, is to rid wastes from the body. Acute renal failure (ARF) occurs when
the kidneys are unable to rid the body of toxic substances which results in the build up of fluids,
electrolytes, and metabolic waste products in the blood. The accumulation of fluids, waste and
electrolytes causes fluid retention and therefore, results in a decrease of urine production.
According to Sommers & Johnson, acute renal failure is “often reversible…[however], if it is
ignored or inappropriately treated it can lead to irreversible kidney damage and chronic renal
failure (Sommers & Johnson, 2002, p. 848).
ETIOLOGY/RISK FACTORS
The causes of acute renal failure can be due to poor kidney perfusion, nephrotoxicity, and
urinary obstruction. These causes are divided into three major categories which are: prerenal,
intrarenal (intrinsic), and postrenal.
Prerenal ARF – occurs when there is a decrease in blood flow to the kidneys. According
to Sommers & Johnson, “disorders that can lead to prerenal ARF include cardiovascular
disorders (such as dysrhythmias, cardiogenic shock, congestive heart failure, and myocardial
infarction), disorders that cause hypovolemia (such as burns, trauma, dehydration, hemorrhage),
misdistribution of blood (such as septic shock, anaphylactic shock), and renal artery
obstruction”(Sommers & Johnson, 2002, p. 848).
Intrarenal ARF – occurs when there is a destruction of the renal tubules due to an renal
injury or nephrotoxicity. According to Sommers & Johnson, “Nephrotoxicity injuries occur
when the renal tubules are exposed to a high concentration of a toxic chemical” (Sommers &
Johnson, 2002, p. 848). According to Schrier, examples of nephrotoxic drugs include
“antibiotics such as acyclovir, antineoplastics such as cisplatin, and anesthetics such as
enflurane”(Schrier, 2003, p. 402).
Postrenal ARF –occurs when there is a urinary obstruction from the renal tubules to the
urinary meatus. According to Somers & Johnson, “one of the most common causes of postrenal
ARF in hospitalized patients is an obstructed Foley catheter. Other conditions that can lead to
postrenal ARF include urethral inflammation or obstruction, bladder obstruction due to infection,
drugs, tumors, and/or trauma”(Somers & Johnson, 2002, p. 848).
INCIDENCES AMONG SEXES/ETHNICITY
According to Sommers & Johnson, the elderly are more prone to be diagnosed with acute
renal failure because some experts report that the concentrating ability of the kidneys decreases
with advancing age(Sommers & Johnson, 2007, p. 849).
According to Gilbert & Harmon, “acute renal failure rarely occurs during pregnancy,
but it can be triggered by various complications of pregnancy such as renal calculi, lupus, acute
glomerulonephritis, diabetic renal disease, polycystic renal disease, and after renal
transplant”(Gilbert & Harmon, 2003, p. 282).
PROGNOSIS
According to MedlinePlus, “while acute kidney failure is potentially life-threatening and
may require intensive treatment, the kidneys usually start working again within several weeks to
months after the underlying cause has been treated. In cases where this does not happen, chronic
renal failure or end-stage renal disease develops” (http://www.nlm.nih.gov/medlineplus/ency
article/000501.htm).
SIGNS AND SYMPTOMS
Non-Pregnant women
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Oliguira (decreased urine production, producing less than 500mL per day)
Anuria (absence of urine production)
Edema (generalized swelling or swelling of the extremities)
Fluid retention
Fatigue
Prolonged bleeding (clotting time of blood is reduced)
Bruising easily
Hand tremors (shaking)
Seizures (abnormal brain activity)
Mood changes
Decreased appetite
Nausea and vomiting lasting for days
SIGNS AND SYMPTOMS
Pregnant women
According to Jones & Rospond, “pregnancy can cause an increase in renal blood flow
and glomerular filtration rate (GFR). In addition, the growing uterus displaces the kidneys and
the uterers as well as increases pressure on the bladder, especially during the first and third
trimesters. Therefore, urinary frequency is a common consequence of pregnancy”(Jones &
Rospond, 2003, p. 309). The increase in urinary frequency is in contrast to the regular
symptoms seen in non-pregnant women diagnosed with acute renal failure in which oliguria
and anuria are present.
Other signs and symptoms, according to Gilbert & Harmon include “irritability, twitching
around the mouth, numbness, muscle spasms, hypotension, dysrhythmias, and diarrhea due to
calcium deficit when calcium levels are lower that 5.5 mEq/L”(Gilbert & Harmon, 2003, p.
288).
ACUTE RENAL FAILURE
Effects on the fetus
The effects of acute renal failure in pregnancy affects the fetus since there is a build up of
nitrogenous waste in pregnant women with ARF, it can lead to an accumulation of toxic
substances that may harm the fetus. In addition, according to Gilbert & Harmon, “because of the
loss of water from the plasma volume, circulation to the uterus can be diminished. The fetus can
suffer nutritionally from the resultant deficiency. [Furthermore], intrauterine growth retardation
is common in the fetus of a woman with renal disease.”(Gilbert & Harmon, 2003, p. 289)
Therefore, providing proper nutrition and nutritional guidelines to the pregnant woman with
ARF is important to prevent any nutritional deficiencies to the growing fetus.
PREVENTION
In preventing acute renal failure, according to Medline Plus, “treating disorders such as
high blood pressure can help prevent acute kidney failure. Unfortunately, prevention is not
always possible” (http://www.nlm.nih.gov/medlineplus/ency/article/000501.htm). However,
according to Merahn, “prerenal and intrinsic renal failure may be prevented or their severity can
be reduced by early recognition and appropriate management of risk factors”(Merahn, 2003, p.
665). Therefore, it is important to recognize the signs and symptoms of acute renal failure to
prevent further complications.
COMPLICATIONS
One of the major complications of acute renal failure is that it can develop into chronic
renal failure. Other complications include hemorrhaging, according to Merahn, “particularly if a
patient has a prolonged bleeding time. This may be due to accumulation of nitrogenous waste
products in the blood or a deficiency in coagulation of the blood” (Merahn, 2003, p.664). In
addition, Medline notes further complications of acute renal failure such as “loss of blood in the
intestines, end-stage renal disease, damage to the heart or nervous system, and
hypertension”(http://www.Nnlm.nih.gov/medlineplus/ency/article/000501.htm).
DISCHARGE/CLIENT TEACHING
According to Sommers & Johnson, the following are discharge and client teaching protocols for
persons diagnosed with ARF (Sommers & Johnson, 2002, p. 852):
• All patients with ARF will need an understanding of renal function, signs and symptoms of
renal failure, and how to monitor their own renal function
• Patients who have recovered viable renal function still need to be monitored by a
nephrologist for at least a year
• Teach the patient that he or she may be more susceptible to infection than previously
• Advise daily weight checks
• Emphasize rest to prevent overexertion
• Teach the patient or significant other about all medications, including dosage, potential side
effects, and drug interactions
• Explain all dietary and fluid restrictions
REFERENCES
Gilbert, S., E. & Harmon, S., J. (2003) Manual of High Risk Pregnancy & Delivery. (3rd ed).
St. Louis: Mosby, 282, 288, 289
Jones, M., R. & Rospond, M., R.(2003) Patient Assessment in Pharmacy Practice. Lippincott
Williams & Wilkins, 309.
MedlinePlus Medical Encyclopedia.(2006) Acute Kidney Failure. Retrieved October 14,
2007 from http://www.nlm.nih.gov/medlineplus/ency/article/000501.htm
Merahn, S. (2003) PDxMD: Renal & Genitourinary Disorders. Philadephia: Elsevier Science,
665, 664.
Schrier, W., R. (2003) Renal and Electrolyte Disorders. (6th ed). Philadelphia: Lippincott
Williams & Wilkins, 402.
Sommers, S., M. & Johnson, A., S. (2002) Diseases and Disorders: A Nursing Therapeutic
Manual. (2nd ed). Philadelphia: F.A. Davis Company, 848-849, 852.
DIAGNOSTIC TESTS
Diagnostic Test
Blood Urea Nitrogen
(BUN)
Serum creatinine
24 hour urine
creatinine
Urine Sodium
Uric acid
Purpose of test
• reflects protein intake
and renal excretory
capacity
• to aid in assessment
of hydration because
abnormal values
contribute to reduced
renal blood flow or
renal disease
• to assess glomerular
filtration
• to screen for renal
damage
• To assess glomerular
filtration
• To check for
accuracy of 24 hr
urine collection based
on constant creatinine
levels
• to evaluate fluid and
electrolyte imbalance
• to evaluate renal and
adrenal disorders
• To help detect renal
dysfunction
Normal values
Abnormal values
Rationale of Ab values
Non-pregnant
10-16mg/dL
Pregnant
8.7 ± 1.5 mg/dL
Elevated
Kidneys cannot excrete
wastes
Non-pregnant
0.67 – 1.2 mg/dl
Elevated
Pregnant
0.6 – 1.28 mg/dl
Females : 85 – 125
mL/min
Males: 95 – 135
mL/min
20 – 40 mEq/L
50% decrease
Prerenal < 20mEq/L
Intranrenal < 20 mEq/L
Postrenal > 40mEq/L
Non-pregnant
4.2 ± 1.2 mg/dl
Elevated
Pregnant
3 ± 0.17 mg/dl
Kidneys cannot excrete
wastes
Acute damage to the
kidney limits the ability
to clear creatinine
Prerenal and sometimes
intrarenal ARF leads to
sodium retention
whereas postrenal ARF
leads to sodium loss in
urine
Increased uric acid
levels may indicate gout
or impaired kidney
function
Nursing Implications
• Tell patient that this
test is used to
evaluate kidney
function to reduce
anxiety
• Inform patient to
avoid a diet high in
meat
• Explain to patient
that the test is used
to evaluate kidney
function
• Instruct the patient
to not restrict food
and fluids
• Inform patient not
to restrict fluids,
but to not eat an
excessive amount
of meat before the
test
• Advise patient to
avoid strenuous
exercise during
urine collection
• Tell patient not to
contaminate the
specimen with
toilet tissue or stool
• Instruct patient on
proper collection
technique
• Instruct patient to
fast for 8 hours
before test
MEDICAL TREATMENT & NURSING IMPLICATIONS
MEDICATION OR DRUG
CLASS
Diuretics
Phosphate binders
Generic name
Trade name
Classification
Pregnancy Category
Indications
Action
Therapeutic effects
Side effects
Route
Nursing Implications
DOSAGE
DESCRIPTION
RATIONALE
Varies by drug
Furosemide (Lasix); mannitol
15 – 30 mL with meals tid
Aluminum hydroxide
(Basalgel, Amphojel)
Convert oliguria ARF to
non-oliguric
Enhance GI excretion of
phosphorus
PHOSPHATE BINDERS
Aluminum hydroxide
Amphojel, Basagel
Phosphate binders, hydrophosphatemics
UK
Lowering phosphate levels in patients with renal failure
Binds phosphate in GI tract. Neutralizes gastric acid and inactivates pepsin
Lowering of serum phosphate levels
Constipation
PO (Adults): 1.9 – 4.8 g (30-40 mL of regular suspension or 15-20 mL of concentrated
suspension) 3-4 times daily
• Assess location, duration, character, and precipitating factors of gastric pain
• Monitor serum phosphate and calcium levels periodically during chronic use of
aluminum hydroxide
• Inform patients of potential for constipation from aluminum hydroxide
MEDICAL TREATMENT & NURSING IMPLICATIONS
Generic name
Trade name
Classification
Pregnancy Category
Indications
Action
Therapeutic effects
Side effects
Route
Nursing Implications
DIURETICS
Furosemide
Lasix, Uritol, Myrosemide
Diuretics
C
Edema due to CHF, hepatic, or renal
disease. Hypertension
Inhibits reabsorption of sodium chloride
from the loop of Henle and distal renal
tubule. Increases renal excretion of H20,
Na, Cl, Mg, H, and Ca
Mannitol
Osmitrol, Resectisol
Diruetics
C
Adjunct treatment of acute oliguric renal
failure, edema
Increases the osmotic pressure of the
glomerular filtrate, thereby inhibiting
reabsorption of water and electrolytes.
Causes excretion of H20, Na, K, Cl, Ca, P,
Mg, Urea, and Uric Acid
Mobilization of excess fluid in oliguria
renal failure or edema
Nausea, vomiting, thirst, headache,
dehydration, urinary retention
IV (Adults) Edema, oliguric renal failure –
50 – 100 g as 5-25% solution; may precede
with a test dose of 0.2g/kg over 3-5
minutes
Diuresis and subsequent mobilization of
excess fluid. Decrease blood pressure.
Dizziness, dehydration, hypokalemia,
hypovolemia, constipation, nausea
PO (Adults) 20-80 mg/day as a single
dose, may repeat in 6-8 hr
IM, IV (Adults) 20-40 mg, may repeat in 2
hr and increase by 20 mg every 2 hr until
response is obtained
• Assess fluid status during therapy
• Monitor vital signs, urine output before
and hourly throughout administration
• Monitor daily weight, intake and output
ratios, amount of location of edema, lung • Assess patient for signs and symptoms
sounds, skin turgor, and mucous
of dehydration, decreased skin turgor,
membranes
fever, dry skin, thirst and dry mucous
membranes
• Notify physician or other healthcare
provider if thirst, dry mouth, lethargy,
• Assess patient for anorexia, muscle
weakness, hypotension, or oliguria
weakness, numbness, tingling,
occurs
paresthesia, confusion, and electrolyte