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 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. (3 rd 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. (6 th ed). Philadelphia: Lippincott Williams & Wilkins, 402. Sommers, S., M. & Johnson, A., S. (2002) Diseases and Disorders: A Nursing Therapeutic Manual. (2 nd ed). Philadelphia: F.A. Davis Company, 848-849, 852.
DIAGNOSTIC TESTS Diagnostic Test Purpose of test Normal values Abnormal values Rationale of Ab values Nursing Implications Blood Urea Nitrogen (BUN) Serum creatinine 24 hour urine creatinine Urine Sodium 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 Non-pregnant 10-16mg/dL Pregnant 8.7 ± 1.5 mg/dl Non-pregnant 0.67 1.2 mg/dl Pregnant 0.6 1.28 mg/dl Females : 85 125 ml/min Males: 95 135 ml/min 20 40 meq/l Elevated Elevated 50% decrease Prerenal < 20mEq/L Intranrenal < 20 meq/l Postrenal > 40mEq/L Kidneys cannot excrete wastes 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 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 Uric acid To help detect renal dysfunction Non-pregnant 4.2 ± 1.2 mg/dl Pregnant 3 ± 0.17 mg/dl Elevated Increased uric acid levels may indicate gout or impaired kidney function Instruct patient to fast for 8 hours before test
MEDICAL TREATMENT & NURSING IMPLICATIONS MEDICATION OR DRUG DOSAGE DESCRIPTION RATIONALE CLASS Diuretics Varies by drug Furosemide (Lasix); mannitol Convert oliguria ARF to non-oliguric Phosphate binders 15 30 ml with meals tid Aluminum hydroxide (Basalgel, Amphojel) Enhance GI excretion of phosphorus Generic name Trade name Classification Pregnancy Category Indications Action Therapeutic effects Side effects Route Nursing Implications 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 DIURETICS Generic name Furosemide Mannitol Trade name Lasix, Uritol, Myrosemide Osmitrol, Resectisol Classification Diuretics Diruetics Pregnancy Category C C Indications Edema due to CHF, hepatic, or renal Adjunct treatment of acute oliguric renal Action Therapeutic effects Side effects Route Nursing Implications 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 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 daily weight, intake and output ratios, amount of location of edema, lung sounds, skin turgor, and mucous membranes Notify physician or other healthcare provider if thirst, dry mouth, lethargy, weakness, hypotension, or oliguria occurs 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 Monitor vital signs, urine output before and hourly throughout administration Assess patient for signs and symptoms of dehydration, decreased skin turgor, fever, dry skin, thirst and dry mucous membranes Assess patient for anorexia, muscle weakness, numbness, tingling, paresthesia, confusion, and electrolyte