NURSING CONSIDERATION AND HEALTH TEACHING

1. ACUTE RENAL INJURY
ALBERT BLESSON V
NURSING TUTOR /CLINICAL INSTRUCTOR

2. ACUTE RENAL FAILURE
• About 5% of all hospitalized patients develop ARF, the sudden interruption of renal function resulting from
obstruction, reduced circulation, or renal parenchymal disease.
• This condition is classified as prerenal, intrarenal, or postrenal and normally passes through three distinct
phases: oliguric, diuretic, and recovery.
• It may be reversible with medical treatment. If it progresses to end-stage renal disease (ESRD) and dialysis is
not initiated, uremia and death are probable.
• The three types of ARF each have separate causes
Prerenal failure results from conditions that diminish blood flow to the kidneys. Between 40% and 80% of
all cases of ARF are caused by prerenal azotemia.
Intrarenal failure (also called intrinsic or parenchymal renal failure) results from damage to the kidneys
themselves, usually from ATN.
Postrenal failure results from bilateral obstruction of urine outflow.

3. CAUSES OF ACUTE RENAL FAILURE
ARF can be classified as prerenal, intrarenal, or postrenal.
All conditions that lead to
• prerenal failure impair renal perfusion, resulting in decreased GFR and increased proximal
tubular reabsorption of sodium and water.
• Intrarenal failure results from damage to the kidneys themselves;
• postrenal failure results from obstruction of urine flow.
Listed here are the possible causes of each type of ARF.

6. SIGNS AND SYMPTOMS
• Recent history of fever
• Chills
• Headache
• GI problems, such as anorexia, nausea, vomiting, diarrhea, and constipation
• Irritability
• Drowsiness
• Confusion
• Seizures and coma (advanced stages)
• Oliguria (less than 500 mL/24 hr) or anuria (less than 100 mL/24 hr)
• Petechiae and ecchymoses
• Hematemesis
• Dry, pruritic skin
• Uremic frost (rare)
• Dry mucous membranes
• Uremic breath odor
• Muscle weakness (with hyperkalemia)
• Tachycardia
• Irregular heart rhythm Bibasilar crackles and peripheral edema (with heart failure)
• Abdominal pain (with pancreatitis or peritonitis)
• Edema in lower extremities or facial edema

7. STAGES OF ACUTE RENAL FAILURE
Before assessing a patient with renal failure, review the stages of the condition and the characteristics as described here

8. MECHANISMS OF ACUTE RENAL FAILURE

9. TREATMENT
• Maintaining fluid balance, blood volume, and blood pressure during and
after surgery
• Identification and treatment of reversible causes, such as nephrotoxic
drug therapy and volume depletion
• Diet high in calories and low in protein, sodium, and potassium, with
supplemental vitamins and restricted fluids
• Meticulous electrolyte monitoring to detect hyperkalemia
• Hypertonic glucose-and-insulin infusions and sodium bicarbonate (IV)
and sodium polystyrene sulfonate (Kayexalate) by mouth or enema to
remove potassium from the body (for hyperkalemia)
• Hemodialysis or peritoneal dialysis
• Early initiation of diuretic therapy
• Continuous renal replacement therapy (CRRT) (for hemodynamically
unstable patients or those refractory to hemodialysis or peritoneal

10. NURSING CARE PLANS
1. Excess Fluid Volume
2. Risk for Decreased Cardiac Output
3. Risk for Imbalanced Nutrition: Less Than Body Requirements
4. Risk for Infection
5. Risk for Deficient Fluid Volume
6. Deficient Knowledge

11. NURSING CONSIDERATIONS
• Measure and record intake and output of all fluids, including wound drainage, nasogastric tube output,
and diarrhea.
• Be sure to weigh the patient daily especially before and after dialysis.
• Evaluate all drugs the patient is taking to identify those that may affect or be affected by renal function.
• Assess hematocrit and hemoglobin levels and replace blood components as ordered.
• Monitor vital signs. Watch for and report signs of pericarditis (pleuritic chest pain, tachycardia, and
pericardial friction rub), inadequate renal perfusion (hypotension), and acidosis.
• Maintain proper electrolyte balance. Strictly monitor potassium levels. Watch for symptoms of
hyperkalemia and report them immediately. Avoid administering medications that contain potassium.
• Maintain nutritional status. Provide a diet high in calories and low in protein, sodium, and potassium,
with vitamin supplements

12. • Monitor the patient for signs and symptoms of developing acidosis, such as decreased level of consciousness, development
of cardiac arrhythmias, and changes in the rate and depth of respirations.
• Prevent complications of immobility by encouraging frequent coughing and deep breathing and by performing passive
range-of-motion exercises.
• Provide mouth care frequently to lubricate dry mucous membranes.
• Monitor GI bleeding by testing all stools for occult blood.
• Provide meticulous perineal care to reduce the risk of ascending UTI (in women) and to protect skin integrity.
• If the patient requires hemodialysis, check the vascular access site (arteriovenous fistula or graft, subclavian or femoral
catheter) every 2 hours for patency and signs of clotting. Do not use the arm with the graft or fistula for measuring blood
pressure, inserting IV lines, or drawing blood.

13. • During hemodialysis, monitor vital signs, clotting times, blood flow, vascular access site function, and arterial and
venous pressures.
• After hemodialysis, monitor vital signs, check the vascular access site, weigh the patient, and watch for signs of fluid
and electrolyte imbalances.
• Provide emotional support to the patient and his family.
• Collaborate with a health care provider to ascertain which medications should be given prior to hemodialysis and which
should be administered after hemodialysis is completed. Many medications are removed from the blood during
treatment.
TIP: Monitor the patient for neurologic changes after dialysis. Disequilibrium syndrome is caused by a rapid reduction in
urea, sodium, and other solutes from the blood, which can lead to cerebral edema and increased intracranial pressure
(ICP). Signs and symptoms include headache, nausea, restlessness, vomiting, confusion, twitching, and seizures.

14. TEACHING ABOUT ACUTE RENAL FAILURE
• Reassure the patient and his family by clearly explaining all diagnostic tests, treatments, and procedures.
• Tell the patient about his prescribed medications, and stress the importance of complying with the regimen.
• Stress the importance of following the prescribed diet and fluid allowance.
• Instruct the patient to weigh himself daily and report changes of 3 lb (1.4 kg) or more (in one day) immediately.
• Advise the patient against overexertion. If he becomes dyspneic or short of breath during normal activity, tell him to report
this finding to his physician.
• Teach the patient how to recognize edema, and tell him to report this finding to the physician

15. DOCUMENTATION GUIDELINES
The focus of documentation in a patient with ARF include:
•Vital signs.
•Muscle strength and reflexes.
•Results of laboratory tests and diagnostic studies.
•Degree of deficit and current sources of fluid intake.
•I&O and fluid balance.
•Plan of care.
•Teaching plan.
•Client’s responses to treatment, teaching, and actions performed.
•Attainment or progress towards the desired outcomes.
•Modifications to plan of care.
•Long term needs.

16. Thank you
REFERANCE
LippincottVISUAL NURSING
A Guide to Diseases, Skills, and
Treatments
Third Edition