-Urinary output decreases to less than 400 mL/24 hr for about 50% of patients
-Urinalysis may show casts, RBCs, WBCs, a specific gravity fixed at 1.010 and urine osmolality at about 300mOsm/kg. This is the same specific gravity and osmolality as for plasma reflecting tubular damage with loss of concentrating ability by the kidney.
-Proteinuria may be present if the renal failure is R/T glomerular membrane dysfunction.
*Urine sediment may be normal in both prerenal and postrenal ARF.
*Hematuria, pyuria, and crystals may be seen in postrenal conditions.
-Renal ultrasound*Often the firs test done
*Useful for possible renal disease and obstruction or the urinary collection system
Assesses for renal blood flow, tubular function and integrity of the collecting system
-CT/MRI*Identify lesions and masses as well as obstructions and vascular abnormalities
-Renal biopsy*Useful in the diagnosis of intrarenal causes of ARF
Common Indications for Dialysis in ARF
1. Volume overload resulting in compromised cardiac and/or pulmonary status
2. Elevated K level with ECG changes
3. Metabolic acidosis (serum bicarb <15 mEq/L)
4. BUN level >120 mg/dL
5. Significant changes in mental status
6. Pericarditis, pericardial effusion or cardiac tamponade
ARF - Nursing Assesment
-VS / I&O
-Mental status / LOC
-Review lab values
ARF - Overall Goals
-Recover without any loss of function
-Not experience any complications
-Maintain normal fluid and electrolyte balance
-Have decreased anxiety
-Comply with and understand the need for careful follow-up care
Nursing Diagnosis - ARF
-Excess fluid volume R/T renal failure and fluid retention
-Risk for infection R/T invasive lines, uremic toxins, and altered immune responses secondary to kidney failure. (infection leading cause of death in ARF)
-Imbalanced nutrition less than body requirements R/T altered metabolic state and dietary restrictions
-Disturbed thought process R/T effects of erema toxins on CNS
-FatigueR/T anemia, metablic acidosis, and uremic toxins
-Anxiety R/T disease process, theraputic interventions and uncertainty of prognosis
-Risk for injury R/T altered mental status
-Risk for dysrythmiasR/T electrolyte imbalnces
-Risk for metabolic acidosis R/T inability to excrete H+, impaired HCO3- reabsorption and decreased synthesis of ammonia.
Manifestations of ARF - Urinary
-Decreased urinary output
-Decreased specific gravity
-Increased urinary sodium
Manifestations of ARF - Cardiovascular
-Hypertension (after development of fluid overload)
Manifestations of ARF - Respiratory
Manifestations of ARF - GI
Manifestations of ARF - Hematologic
-Anemia (development w/in 48 hr)
-Increased susceptibility to infection
-Defect in platelet functioning
Manifestations of ARF - Neurologic
Manifestations of ARF - Metabolic
Clinical Manifestations for Hyperkalemia
Treatment for Hyperkalemia
-Regular Insulin IV Administration
-Sodium Bicarbonate-Calcium Gluconate-Dialysis
-Sodium Polystryrene Sulfonate (Kayexelate)
Treatment for Hyperkalemia - Insulin
Regular Insulin IV Administration
K moves into cells when insulin is given. Glucose is given concurently to prevent hypoglycemia. When effects of insulin diminish, K shifts back out of cells.
Treatment for Hyperkalemia - Sodium Bicarbonate
Therapy can correct acidosis and causes shift of K into cells
Treatment for Hyperkalemia - Calcium Gluconate
Therapy is given IV and generally used in advanced cardiac toxicity. Calcium raises the threshold for excitation, resulting in dysrhythmias.
Treatment for Hyperkalemia - Dialysis
DialysisHemodialysis can bring K levels to normal within 30 min to 2 hours
Treatment for Hyperkalemia - Sodium Polystryrene Sulfonate (Kayexelate)
Sodium Polystryrene Sulfonate (Kayexelate)Cation-exhange resin is administered by mouth or retention enema. When resin is in the bowel, K is exchanged for sodium. Therapy removes 1 mEq of K per gram of drug. It is mixed in water with sorbitol to produce osmotic diarrhea, allowing for evacuation of K-rich stool from the body.
Treatment for Hyperkalemia - Dietary Restriction
Dietary RestrictionDaily potassium intake is limited to 40 mEq.
-Nephron function decreases with age
-Impaired function of other organ systems
-Diuretics should be used with extreme caution
-Mortality rate is higher
Health Promotion - ARF Prevention
-Identify and monitor high risk populations
-Controlling exposure to nephroxic drugs and industrial chemicals
-Prevent prolonged periods of hypotension or hypovolemia. Must have prompt replacement of significant fluid loss.
-Monitor I&O/weights (1kg is = 1000mL of fluid)
-Prompt treatment of UTI
-NSAIDs used sparingly in renal insufficiency
-ACE inhibitors used springly: can decrease perfusionand decrease K levels
Nutrition Therapy for ARF
-Diet should be high in calories (about 30-35kcal/kg of body weight daily)
-Most of energy should come from carbohydrates and fats. 30-40% of total calories should come from fat.
-Protein intake can vary depening on pt condition but generally is 0.6 g/kg/day to control nitrogenous waste production and limit starvation ketosis
-K and Na are regulated in accordance with plasma levels.