Acute Renal Failure Ppt

Renal FailureRenal Failure

Acute Renal FailureAcute Renal Failure

Is a condition in which the kidneys are Is a condition in which the kidneys are unable to remove accumulated unable to remove accumulated metabolites from the blood, leading to metabolites from the blood, leading to altered fluid, electrolyte, and acid-base altered fluid, electrolyte, and acid-base balance.balance.

Has an abrupt onset and with prompt Has an abrupt onset and with prompt intervention is often reversible.intervention is often reversible.

ACUTE RENAL FAILUREACUTE RENAL FAILURE

Acute renal failure (ARF) has four well-Acute renal failure (ARF) has four well-defined stages/phases: onset, oliguric or defined stages/phases: onset, oliguric or anuric, diuretic, and convalescent. anuric, diuretic, and convalescent. Treatment depends on stage and severity Treatment depends on stage and severity of renal compromise. of renal compromise.

Phases of ARF:Phases of ARF:Onset – initial phase of insult or injuryOnset – initial phase of insult or injuryOliguric – less than 400cc/24 hrOliguric – less than 400cc/24 hr

- for older (600 – 700 cc/24 hr)- for older (600 – 700 cc/24 hr)- lasts 8-14 days or 1-2 weeks- lasts 8-14 days or 1-2 weeks--↓K+, ↑Na, ↑Mg↓K+, ↑Na, ↑Mg

Diuretic – Lasts 10 daysDiuretic – Lasts 10 days- diuresis of 3-5L/day- diuresis of 3-5L/day- ↑BUN & Creatinine level- ↑BUN & Creatinine level- dangers: FVD, hyponatremia, - dangers: FVD, hyponatremia,

hypotension, shock hypotension, shock Recovery – lasts from 6-12 monthsRecovery – lasts from 6-12 months

- avoid nephrotoxic drugs- avoid nephrotoxic drugs

ARF can be divided into three major classifications, ARF can be divided into three major classifications, depending on site:depending on site:

Prerenal:Prerenal:

Prerenal failure is caused by interference with Prerenal failure is caused by interference with renal perfusion (e.g., blood volume depletion, renal perfusion (e.g., blood volume depletion, volume shifts [“third-space” sequestration of volume shifts [“third-space” sequestration of fluid], or excessive/too-rapid volume expansion), fluid], or excessive/too-rapid volume expansion), manifested by decreased glomerular filtration rate manifested by decreased glomerular filtration rate (GFR). Disorders that lead to prerenal failure (GFR). Disorders that lead to prerenal failure include cardiogenic shock, heart failure (HF), include cardiogenic shock, heart failure (HF), myocardial infarction (MI), burns, trauma, myocardial infarction (MI), burns, trauma, hemorrhage, septic or anaphylactic shock, and hemorrhage, septic or anaphylactic shock, and renal artery obstruction.renal artery obstruction.

RenalRenal ( (or intrarenalor intrarenal))::

Intrarenal causes for renal failure are associated Intrarenal causes for renal failure are associated with parenchymal changes caused by ischemia with parenchymal changes caused by ischemia or nephrotoxic substances. Acute tubular or nephrotoxic substances. Acute tubular necrosis (ATN) accounts for 90% of cases of necrosis (ATN) accounts for 90% of cases of acute oliguria. Destruction of tubular epithelial acute oliguria. Destruction of tubular epithelial cells results fromcells results from

(1) ischemia/hypoperfusion (similar to prerenal (1) ischemia/hypoperfusion (similar to prerenal hypoperfusion except that correction of the hypoperfusion except that correction of the causative factor may be followed by continued causative factor may be followed by continued oliguria for up to 30 days) and/or oliguria for up to 30 days) and/or

(2) direct damage from nephrotoxins.(2) direct damage from nephrotoxins.

Postrenal:Postrenal:

Postrenal failure occurs as the result of an Postrenal failure occurs as the result of an obstruction in the urinary tract anywhere from the obstruction in the urinary tract anywhere from the tubules to the urethral meatus. Obstruction most tubules to the urethral meatus. Obstruction most commonly occurs with stones in the ureters, commonly occurs with stones in the ureters, bladder, or urethra; however, trauma, edema bladder, or urethra; however, trauma, edema associated with infection, prostate enlargement, associated with infection, prostate enlargement, and strictures also cause postrenal failure.and strictures also cause postrenal failure.

Note:Note: Iatrogenically induced ARF should be Iatrogenically induced ARF should be considered when failure develops during or considered when failure develops during or shortly after hospitalization. The most common shortly after hospitalization. The most common causative factor is administration of potentially causative factor is administration of potentially nephrotoxic agents.nephrotoxic agents.

CARE SETTINGCARE SETTING

Inpatient acute medical or surgical unitInpatient acute medical or surgical unit

RELATED CONCERNSRELATED CONCERNS

Metabolic acidosis (primary base bicarbonate Metabolic acidosis (primary base bicarbonate deficiency)deficiency)Fluid and electrolyte imbalancesFluid and electrolyte imbalancesPsychosocial aspects of carePsychosocial aspects of careRenal dialysisRenal dialysisRenal failure: chronicRenal failure: chronicSepsis/septicemiaSepsis/septicemiaTotal nutritional support: parenteral/enteral Total nutritional support: parenteral/enteral feedingfeedingUpper gastrointestinal/esophageal bleedingUpper gastrointestinal/esophageal bleeding

Patient Assessment DatabasePatient Assessment Database

ACTIVITY/RESTACTIVITY/REST

May report:May report: Fatigue, weakness, Fatigue, weakness, malaisemalaise

May exhibit:May exhibit: Muscle weakness, loss of Muscle weakness, loss of tonetone

CIRCULATIONCIRCULATION

May exhibit:May exhibit:Hypotension or hypertension (including malignant Hypotension or hypertension (including malignant hypertension, eclampsia/pregnancy-induced hypertension, eclampsia/pregnancy-induced hypertension)hypertension)Cardiac dysrhythmiasCardiac dysrhythmiasWeak/thready pulses, orthostatic hypotension Weak/thready pulses, orthostatic hypotension (hypovolemia)(hypovolemia)Jugular venous distension (JVD), full/bounding pulses Jugular venous distension (JVD), full/bounding pulses (hypervolemia); flat neck veins (diuretic phase)(hypervolemia); flat neck veins (diuretic phase)Generalized tissue edema (including periorbital area, Generalized tissue edema (including periorbital area, ankles, sacrum)ankles, sacrum)Pallor (anemia); bleeding tendenciesPallor (anemia); bleeding tendencies

ELIMINATIONELIMINATION

May report:May report:Change in usual urination pattern: Increased frequency, Change in usual urination pattern: Increased frequency, polyuria (early failure and early recovery), or decreased polyuria (early failure and early recovery), or decreased frequency/oliguria (later phase)frequency/oliguria (later phase)Dysuria, hesitancy, urgency, and retention Dysuria, hesitancy, urgency, and retention (inflammation/obstruction/infection)(inflammation/obstruction/infection)Abdominal bloating, diarrhea, or constipationAbdominal bloating, diarrhea, or constipationHistory of benign prostatic hyperplasia (BPH), or History of benign prostatic hyperplasia (BPH), or kidney/bladder stones/calculikidney/bladder stones/calculiMay exhibit:May exhibit:Change in urinary color, e.g., absence of color, deep Change in urinary color, e.g., absence of color, deep yellow, red, brown, cloudyyellow, red, brown, cloudyOliguria (may last 12–21 days and occurs in 70% of Oliguria (may last 12–21 days and occurs in 70% of patients); polyuria (2–6 L/day of urine, lacking patients); polyuria (2–6 L/day of urine, lacking concentration and regulation of waste products)concentration and regulation of waste products)

FOOD/FLUIDFOOD/FLUID

May report:May report:Weight gain (edema), weight loss Weight gain (edema), weight loss (dehydration)(dehydration)Nausea, anorexia, heartburn, vomitingNausea, anorexia, heartburn, vomitingMetallic tasteMetallic tasteUse of diureticsUse of diureticsMay exhibit:May exhibit:Changes in skin turgor/moistureChanges in skin turgor/moistureEdema (generalized, dependent)Edema (generalized, dependent)

NEUROSENSORYNEUROSENSORY

May reportMay report::Headache, blurred visionHeadache, blurred visionMuscle cramps/twitching; “restless leg” Muscle cramps/twitching; “restless leg” syndrome; numbness, tinglingsyndrome; numbness, tinglingMay exhibitMay exhibit::Altered mental state, e.g., decreased attention Altered mental state, e.g., decreased attention span, inability to concentrate, loss of memory, span, inability to concentrate, loss of memory, confusion, decreasing level of consciousness confusion, decreasing level of consciousness (LOC) (azotemia, electrolyte and acid-base (LOC) (azotemia, electrolyte and acid-base imbalance)imbalance)Twitching, muscle fasciculations, seizure activityTwitching, muscle fasciculations, seizure activity

PAIN/DISCOMFORTPAIN/DISCOMFORT

May reportMay report::

Flank pain, headacheFlank pain, headache

May exhibitMay exhibit::

Guarding/distraction behaviors, Guarding/distraction behaviors, restlessnessrestlessness

RESPIRATIONRESPIRATION


Shortness of breathShortness of breath


Tachypnea, dyspnea, increased rate/depth Tachypnea, dyspnea, increased rate/depth (Kussmaul’s respiration); ammonia breath(Kussmaul’s respiration); ammonia breath

Cough productive of pink-tinged sputum Cough productive of pink-tinged sputum (pulmonary edema)(pulmonary edema)

SAFETYSAFETY


Recent transfusion reactionRecent transfusion reaction


Fever (sepsis, dehydration)Fever (sepsis, dehydration)

Petechiae, ecchymotic areas on skinPetechiae, ecchymotic areas on skin

Pruritus, dry skinPruritus, dry skin

TEACHING/LEARNINGTEACHING/LEARNINGMay reportMay report::Family history of polycystic disease, hereditary nephritis, Family history of polycystic disease, hereditary nephritis, urinary calculus, malignancyurinary calculus, malignancyHistory of exposure to toxins, e.g., drugs, environmental History of exposure to toxins, e.g., drugs, environmental poisons; substance abusepoisons; substance abuseCurrent/recent use of nephrotoxic drugs, e.g., aminoglycoside Current/recent use of nephrotoxic drugs, e.g., aminoglycoside antibiotics, amphotericin B; anesthetics; vasodilators; antibiotics, amphotericin B; anesthetics; vasodilators; nonsteroidal anti-inflammatory drugs (NSAIDs)nonsteroidal anti-inflammatory drugs (NSAIDs)Recent diagnostic testing with radiographic contrast mediaRecent diagnostic testing with radiographic contrast mediaConcurrent conditions: Tumors in the urinary tract, Gram-Concurrent conditions: Tumors in the urinary tract, Gram-negative sepsis; trauma/crush injuries, hemorrhage, negative sepsis; trauma/crush injuries, hemorrhage, disseminated intravascular coagulation (DIC), burns, disseminated intravascular coagulation (DIC), burns, electrocution injury; autoimmune disorders (e.g., scleroderma, electrocution injury; autoimmune disorders (e.g., scleroderma, vasculitis), vascular occlusion/surgery, diabetes mellitus (DM), vasculitis), vascular occlusion/surgery, diabetes mellitus (DM), cardiac/liver failurecardiac/liver failure

Discharge PlanDischarge Plan

Projected mean length of inpatient Projected mean length of inpatient stay: 5.9 daysstay: 5.9 days

Considerations:Considerations:

May require alteration/assistance with May require alteration/assistance with medications, treatments, supplies; medications, treatments, supplies; transportation, homemaker/maintenance transportation, homemaker/maintenance taskstasks

DIAGNOSTIC STUDIES DIAGNOSTIC STUDIES

UrineUrineVolume:Volume: Usually less than 100 mL/24 hr (anuric phase) or 400 mL/24 hr (oliguric Usually less than 100 mL/24 hr (anuric phase) or 400 mL/24 hr (oliguric phase), which occurs within 24–48 hr after renal insult. Nonoliguric (more phase), which occurs within 24–48 hr after renal insult. Nonoliguric (more than 400 mL/24 hr) renal failure also occurs when renal damage is than 400 mL/24 hr) renal failure also occurs when renal damage is associated with nephrotoxic agents (e.g., contrast media or antibiotics).associated with nephrotoxic agents (e.g., contrast media or antibiotics).Color:Color: Dirty, brown sediment indicates presence of RBCs, hemoglobin, myoglobin, Dirty, brown sediment indicates presence of RBCs, hemoglobin, myoglobin, porphyrins.porphyrins.Specific gravity:Specific gravity: Less than 1.020 reflects kidney disease, e.g., glomerulonephritis, Less than 1.020 reflects kidney disease, e.g., glomerulonephritis, pyelonephritis with loss of ability to concentrate; fixed at 1.010 reflects pyelonephritis with loss of ability to concentrate; fixed at 1.010 reflects severe renal damage.severe renal damage.pH:pH: Greater than 7 found in urinary tract infections (UTIs), renal tubular necrosis, Greater than 7 found in urinary tract infections (UTIs), renal tubular necrosis, and chronic renal failure (CRF).and chronic renal failure (CRF).Osmolality:Osmolality: Less than 350 mOsm/kg is indicative of tubular damage, and urine/serum Less than 350 mOsm/kg is indicative of tubular damage, and urine/serum ratio is often 1:1.ratio is often 1:1.

UrineUrineCreatinineCreatinine ( (CrCr) ) clearance:clearance: Renal function may be significantly decreased before blood urea nitrogen Renal function may be significantly decreased before blood urea nitrogen (BUN) and serum Cr show significant elevation.(BUN) and serum Cr show significant elevation.Sodium:Sodium: Usually increased if ATN is cause for ARF, more than 40 mEq/L if kidney is Usually increased if ATN is cause for ARF, more than 40 mEq/L if kidney is not able to resorb sodium, although it may be decreased in other causes of not able to resorb sodium, although it may be decreased in other causes of prerenal failure.prerenal failure.Fractional sodiumFractional sodium ( (FeNaFeNa)):: Ratio of sodium excreted to total sodium filtered by the kidneys reveals Ratio of sodium excreted to total sodium filtered by the kidneys reveals inability of tubules to reabsorb sodium. Readings of less than 1% indicate inability of tubules to reabsorb sodium. Readings of less than 1% indicate prerenal problems, higher than 1% reflects intrarenal disorders.prerenal problems, higher than 1% reflects intrarenal disorders.Bicarbonate:Bicarbonate: Elevated if metabolic acidosis is present.Elevated if metabolic acidosis is present.Red blood cellsRed blood cells ( (RBCsRBCs)):: May be present because of infection, stones, trauma, tumor, or altered May be present because of infection, stones, trauma, tumor, or altered glomerular filtration (GF).glomerular filtration (GF).

UrineUrine

Protein:Protein: High-grade proteinuria (3–4+) strongly indicates High-grade proteinuria (3–4+) strongly indicates glomerular damage when RBCs and casts are glomerular damage when RBCs and casts are also present. Low-grade proteinuria (1–2+) and also present. Low-grade proteinuria (1–2+) and white blood cells (WBCs) may be indicative of white blood cells (WBCs) may be indicative of infection or interstitial nephritis. In ATN, infection or interstitial nephritis. In ATN, proteinuria is usually minimal.proteinuria is usually minimal.Casts:Casts: Usually signal renal disease or infection. Usually signal renal disease or infection. Cellular casts with brownish pigments and Cellular casts with brownish pigments and numerous renal tubular epithelial cells are numerous renal tubular epithelial cells are diagnostic of ATN. Red casts suggest acute diagnostic of ATN. Red casts suggest acute glomerular nephritis.glomerular nephritis.

Diagnostics:Diagnostics:

Radionuclide imaging:Radionuclide imaging: May reveal calicectasis, hydronephrosis, May reveal calicectasis, hydronephrosis, narrowing, and delayed filling or emptying as a narrowing, and delayed filling or emptying as a cause of ARF.cause of ARF.Kidney, ureter, bladder (KUB) x-ray:Kidney, ureter, bladder (KUB) x-ray: Demonstrates size of kidneys/ureters/bladder, Demonstrates size of kidneys/ureters/bladder, presence of cysts, tumors, ad kidney presence of cysts, tumors, ad kidney displacement or obstruction (stones).displacement or obstruction (stones).Retrograde pyelogram:Retrograde pyelogram: Outlines abnormalities of renal pelvis and Outlines abnormalities of renal pelvis and ureters.ureters.


Renal arteriogram:Renal arteriogram:

Assesses renal circulation and identifies Assesses renal circulation and identifies extravascularities, masses.extravascularities, masses.

Voiding cystoureterogram:Voiding cystoureterogram:

Shows bladder size, reflux into ureters, retention.Shows bladder size, reflux into ureters, retention.

Renal ultrasound:Renal ultrasound:

Determines kidney size and presence of masses, Determines kidney size and presence of masses, cysts, obstruction in upper urinary tract.cysts, obstruction in upper urinary tract.

Nonnuclear computed tomographyNonnuclear computed tomography ( (CTCT) ) scan:scan:

Cross-sectional view of kidney and urinary tract Cross-sectional view of kidney and urinary tract detects presence/extent of disease.detects presence/extent of disease.


Magnetic resonance imagingMagnetic resonance imaging ( (MRIMRI):): Provides Provides information about soft tissue damage.information about soft tissue damage.

Excretory urographyExcretory urography ( (intravenous urogram or intravenous urogram or pyelogrampyelogram):): Radiopaque contrast concentrates in Radiopaque contrast concentrates in urine and facilitates visualization of KUB.urine and facilitates visualization of KUB.

Endourology:Endourology: Direct visualization may be done of Direct visualization may be done of urethra, bladder, ureters, and kidney to diagnose urethra, bladder, ureters, and kidney to diagnose problems, biopsy, and remove small lesions and/or problems, biopsy, and remove small lesions and/or calculi.calculi.

ElectrocardiogramElectrocardiogram ( (ECGECG)):: May be abnormal, May be abnormal, reflecting electrolyte and acid-base imbalances.reflecting electrolyte and acid-base imbalances.

NURSING PRIORITIES:NURSING PRIORITIES:

1.1.Reestablish/maintain fluid and electrolyte Reestablish/maintain fluid and electrolyte balance.balance.

2.2.Prevent complications.Prevent complications.

3.3.Provide emotional support for Provide emotional support for patient/significant others (SO).patient/significant others (SO).

4.4.Provide information about disease Provide information about disease process/prognosis and treatment needs.process/prognosis and treatment needs.

DISCHARGE GOALSDISCHARGE GOALS

1.1.Homeostasis achieved.Homeostasis achieved.

2.2.Complications prevented/minimized.Complications prevented/minimized.

3.3.Dealing realistically with current situation.Dealing realistically with current situation.

4.4.Disease process/prognosis and Disease process/prognosis and therapeutic regimen understood.therapeutic regimen understood.

5.5.Plan in place to meet needs after Plan in place to meet needs after discharge.discharge.

……the end…the end…

Acute Renal Failure Ppt

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