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What clinical problems are associated with renal failure?
-Fluid volume excess -Electrolyte imbalances -Acid-Base disturbances -Accumulation of wastes -Hormonal deficiencies (chronic)
What characteristics define Acute Renal Filure? (ARF)
-Rapid decline in renal function -Often reversible, if treated promptly -Indidence:occures within hours to days in both hospitalized and community settings.
What causes of renal failure are prerenal?
-conditions associated with hypoperfusion of the kidneys -Severe dehydration, hemorrhage, MI, shock, vasodilation (sepsis)
Prerenal ARF facts
occurs in 60 - 70% of cases. and is the result of impaired blood flow that leads to hypoperfusion of the kidney and a decrease in GFR. Common clinical causes are volume depletion states.
What causes of renal failure are intrarenal?
-Damage to glomeruli (nephrons) or kidney tubules -burns and crash injuries (myoglobin released), infections, nephrotoxic substances (IVP dyes, antibiotics, chemicals, heavy metals, transfusion reactions, meds (NSAIDS, ACE Inhibitors)
What causes of renal failure are postrenal?
-Obstruction to outflow of urine
-Kidney Stones
-BPH (enlarged Prostate), tumors, stricures, blood clots
What are risk factors for developing ARF?
-Major trauma or surgery
-Hemorrhage
-Severe heart failure
-Severe liver disease
-Lower urinary tract obstruction
-Dehydration(major risk factor in children)
-Advanced age
-Chronic Renal Insufficiency
What are the four stages of ARF?
1) Initiation Stage
2) Oliguria Phase (may last 10-20 days)
3) Diuresis Phase
4) Recovery phas
What is the Initiation Phase?
Period from initiating event or injury to onset of oliguria
What is the Oliguria Phase?
-Diminished urine output < 400 ml/ 24 hours
-Elevated Se BUN, Cr, K+, Mg, Phosphate
-Decreased Se Ca
-Uncompensated metabolic acidosis
-S.G. low and often fixed
What is the non-oliguric form of ARF?
ARF in which there is adequete urine volume but wastes are not adequately cleared.
-This occures with patients that have been exposed to nephrotoxic antibiotics, burns, anesthesia
What is the Diuresis phase of ARF?
-Urine output decreases gradually
-Output of up to 10 L urine/24 hours may be seen
-lab values gradually improve
-GFR improving
-Uremic symptoms may still be present
What occures during the recvery phase of ARF?
-Renal Function improves over several months (3-12 mnths)
-Labs return to normal
-May have 1-3% reduction in pt GRF baseline
What labs and diagnostics are used to diagnose ARF?
-Serum BUN and creatinine levels
-Electrolytes
-Serum Ca
-ABGs
-Urinalysis
-Serum Phoshorus
-CBC
-KUB, Renal US, CT scan, Renal biopsy
In what stage is ARF most apparant?
oliguric stage
During ARF what are the Urinary Clinical manifestations?
Varying degrees of Oliguria and anuria
What neuro S&S do you see if ARF?
confusion, agitation, lethargy, decreased DTRs, muscle twitching, seizures or coma
What are the respiratory S&S of ARF?
SOB, crackles, pulmonary edema- if fluid overloaded.
What are the cardiovascular S&S of ARF?
-hypotension if prerenal or HTN
-JVD if fluid overloaded
-Tall peaked or "tented" T waves on EKG with hyperkalemia
-Pericarditis (pericardial friction rub on auscultation)
What GI S&S will be seen with ARF?
Anorexia, Nausea, Vomiting, ABD cramping
What skin and MM S&S would you see with ARF?
Dry, Uremic Breath (fetor-Urine Breath)
What is the key to medical managment of ARF?
PREVENTION
What is the GOAL of medical managment of ARF?
-Identify
-Treat
-Eliminate
-Restore
Overall managment of ARF?
Maintain fluid balance, avoid fluid axcess, or possibly dialysis
What is the medical managment of prerenal ARF?
(Goal-Increase renal perfusion)
-IV fluids-fluid challenges with/without diuretics
-low "renal" dose dopamine-dilates renal arteries
What is the medical managment of intrarenal ARF?
(Goal-eliminate nephrotoxins)
-Adjusted doses of ATB, digoxin, ACE inhibitors, mag
What is the medical managment of postrenal ARF?
relieve obstruction
What is the pharmacological tx of fluid overload dt ARF?
trial of diuretics
What is the pharmacological tx of Hyperkalemia dt ARF? (Hyperkalemia is potentially LIFE THREATENING)
-Ion exchange resins (e.g. Kayexalate)
-glucose and regular insulin IV (temporary
-IV calcium gluconate (temporary)
What is the pharmacological tx of Elevated Phosphorus dt ARF?
Phosphate binding agents (aluminum hydroxide)
What nutritional considerations are there during ARF?
-nutritional imbalances
-impaired metabolic processes and demands are present
What nutritional medical managment should there be during the Oliguric stage?
RESTRICT -Protein (1g/kg daily)
-restrict K+ (40-60 mEQ/daily) Phosphorus (restrict: bananas, Citrus, fruits, coffee)
-Na+ (2g/daily)
-encourage High carbohydrate diet, spares protein for for energy
-Oral fluids-previous days UO + 500cc
What nutritional medical managment should there be during the diuretic stage? What nutritional medical managment should there be during the Oliguric stage?
-High Calorie Diet
-Increase protein, K+, Na+ depending on lab results
What nursing assessment for ARF?
-VS-hourly to q4H
-Monitor Fluid Volume STRICT I&O and Daily Weight
-Monitor edema, breath sounds, CVP, PWCP
-Monitor labs-report abnormals
Other nursing considerations for ARF
-Administer IV and meds per order
-Encourage bed rest or reduced activities during acute phase (activity will increase as recovery begins as tolerated)
-Provide good skin care, repositioning q2h, massaging bony areas, good hygene
-Supportive/education explain treatment plan/procedures/meds/ect address psychological needs
Nursing managment to prevent infection during ARF
-Aspetic technique for invasive procedures
-Avoid foley-if able
-Encourage to cough, deep breath q2h, incentive spirometry use
Nursing managment to provide good safety measures during ARF
-Call light within reach at all times
-HOB elevated as tolerated
-Assist with ambulation
Acute Tubular Necrosis (ATN)
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