Acute Renal Failure
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Difference btwn acute and chronic renal failure
acute will resolve within 90 days
s/s are subtle at first and are characterized by a rise in BUN and serum creatinine
Labs that will tell you a person is in ARF
- BUN rises from 15 to 30
- Serum Creatinine rises from 1 to 2
- UO is < 30mL/hr
caused by a physiologic even that decreases circulation to the kidneys....compromised/decreased blood flow to the kidneys
Examples of problems that will cause Prerenal ARF
- decreased CO
- decreased peripheral vascular resistance...decreased volume =dilation
How do you correct Prerenal ARF?
- increase CO
- obtain normal intravascular volume
- increase BP
- increase vascular resistance
physiologic events that directly affect the kidney tissue structure and fxn
Describe 3 ways to get to Intrarenal ARF
- untreated prerenal ARF/ischemia
- exposure to nephrotoxic substances
Example of nephrotoxic substances
- anything with a "mycin"-vanco, genta,
- iodine contrast medium
What really happens with postrenal ARF?
the kidneys lose their ability to excrete nitrogen waste produced by protein metabolism
any obstruction in urine outflow from the collection ducts of the kidneys to the external urethral orifice
What is really going on with Postrenal ARF?
increased pressure in the kidneys, and they cant fxn.....
blockage makes urine back up in to the kidneys, increasing pressure causing a decrease in GFR
Examples of problems that can cause Postrenal ARF
- BPH-enlarged prostate
- Renal Calculi
- Strictures/Adhesion-multiple abdominal surgeries
How do you know a persons ARF is getting better?
- UO is increasing
- Labs are back to normal
- Edema is down
- No more crackles in the lungs
What do you give a person to increase their BP to increase renal perfusion, which will increase their UO?
Multiple antibiotics =
What do you give a person with ARF who has low volume?
Clinical manifestations of Prerenal ARF
- DECREASED GFR
- Oliguria <400mL/24 hours
- Fluid deficit
- Increased urine specific gravity
- Decreased Na
- Peripheral/Systemic edema
- Decreased CO
Collaborative Management of Prerenal ARF
- ID cause and re establish renal perfusion
- *Fenoldopam to increase blood flow to kidneys
- Albumin to expand intrav. volume
- Diuretics to encourage urine production
- Dopamine to increase BP
Intrarenal ARF has 2 types
Ischemic and Nephrotoxic
Clinical Manifestations of Intrarenal ARF
- Oliguria -<400mL in 24 hours or anuria
- S/S of volume overload
- Decreased LOC
- Electrolyte abnormalities
Collaborative management for Intrarenal ARF
- ID and treat cause
- Stop antibiotics?
Clinical Manifestations of Post Renal ARF
- Fluid excess
- Decreased GFR and excretion
*no actual impairment in kidney fxn??
Collaborative management of Post renal ARF
- ID and remove the obstruction
- Post obstruction diuresis will occur, so replace hourly urine output
- Monitor electrolytes and acid base balance
Describe Oliguric ARF
- no urine
- gradual accumulation of nitrogenous wastes
- lasts hours to days
Why metabolic acidosis with oliguric phase?
kidneys cant synthesize ammonia which is needed for H excretion, so unable to excrete acid metabolites
Why does the K increase during the oliguric phase?
they kidneys are unable to excrete 80-90% of the bodys K
What will show up in a patients EKG who has high K?
- tall peaked T waves
- wide QRS
Interventions for increases in K.....
- 5.5 and less=dietary changes
- 6 and above=dialysis
BUN at this level = a problem
During the diuretic phase what determines the amount of urine excreted?
it is related to how fluid volume overloaded the patient is...can be 4-5L/day
What is a big problem during the diuretic phase?
dumping lots of fluid volume, but the kidneys aren't healed, so they don't concentrate electrolytes.
What do I need to monitor a patient for in the diuretic phase?
- hyponatremia-CNS disturbances/seizures
What is normal UO?
1-2L/day...with the same for input
With a high K you can give....
diuretics to dump K
Describe the recovery phase...
- begins when the GFR is stable
- BUN and Creatinine levels are starting to stabilize, then they decrease to normal
*majority of improvements can occur in the first 2 weeks...but can continue for up to 12 months
Collaborative management of ARF
- PREVENTION-ID patients at risk
- Maintain fluid balance
- Decrease further damage
- Renal dosing of meds for clients with impaired renal fxn
Who is at risk to get ARF?
- Look at patient hx
- DM pt.
- Renal insufficiency
- patients on nephrotoxic meds
- patients with cardiovascular disease
- renal protectant
- increases renal perfusion
What is given to excrete K
phosphate binders....give with meals
How do we solve the problem of a person who needs to have a CT with contrast, but has renal issues?
- Give Fenoldopam
- give dye plus fluids
- then after the procedure give Fenoldopam again to protect the kidneys
- H/H decreased....anemia
- Platelets decreased adhesiveness....bleed easily
- WBC increased...with infection
- Serum pH low....acidic
- Serum bicarb <22...low
- Serum calcium low
- Serum phos high
- BUN increased...but not radically
- Creatinine increased...but not radically
Creatinine Clearance is decreased WITH low GFR
How do you get a creatinine clearance?
- it is a 24 hour urine collection
- dump first collection
- collect all urine for next 24 hours and store it in a ice bucket.
- some time during that period have serum creatinine drawn
What is a normal Creatinine Clearance
Creatinine Clearance will tell you the extent of renal failure...what are the numbers?
- mild 50-84
- moderate 10-49
- severe <10
If a persons creatinine clearance is at this level they will need renal replacement therapy....
What is a lab that is equal to and will tell you the same thing as creatinine clearance?
Key intervention for a person who has ARF
don't stop drinking water....may be a fluid max of 1500 cc, but don't stop drinking!
Diet for a person with ARF
- high calorie
- low protein, K and na
passage of patient blood through an artificial kidney in order to remove fluid and waste products, then restores the fluid and electrolytes
Who is contraindicated to have hemodialysis?
- those with:
- bleeding disorder
- severe cardiac disease
- frail elderly
What is used to do hemodialysis
- AV fistula or graft or
- Central line...Quinton, or Perma Cath
How much fluid is removed during hemodialysis? Possible complication?
- 1000-3000 cc of fluid
- BP can drop and MAP can be low
surgically created anastomosis btwn an artery and a vein.
*takes 6 weeks for this to be usable
surgically imposed graft btwn an artery and a vein
can use right away
dual lumen catheter capable of tolerating blood flow of 300cc/min
When will you use an AV line vs. a central line?
AV is used when you know the person is in ESRD...so have to wait 90 days after ARF.
Central lines are used more for temporary dialysis, or while you are waiting for the AV fistula to heal and be ready to use
Care for the patient with a fistula or graft
This is their life line....
- no BP on that side
- no blood draws from that extremity
- no injections on in that extremity
- no IV's in that extremity
- watch for s/s of infection
- watch for clotting
- watch for signs of bleeding after dialysis
Nursing care of the patient pre dialysis
- Complete PA
- weigh patient
- Hold the following meds:
Nursing care of the patient post dialysis
- Observe for fluid volume deficit
- check VS
- Take temperature
- Complete physical assessment
- WATCH FOR NEURO CHANGES
Complication that can occur post hemodialysis. What does it present like?
Disequilibrium Syndrome-it is from movement of Na in to the brain. Pt. goes from hemodiluted to increase levels of Na post hemodialysis causing an increase in ICP
- neuro changes
How does peritoneal dialysis work?
it uses the peritoneum as the semi permeable membrane. A diasylate is infused in to the peritoneal cavity thru and implanted catheter. Waste diffuses thru the membrane in to the dialysate, which is drained from the peritoneum thru the catheter
Peritoneal hemodialysis is best for....
- people with severe cardiac disease
- frail elderly
- patients who cant tolerate systemic anticoagulation
- patients who lack vascular access
Who cant have peritoneal dialysis?
- anybody who has had multiple abd surgeries, or has known adhesions
How does peritoneal dialysis work?
1-2 L of dialysate is infused by gravity in to the peritoneal space over 10-20 min, and then it drains by gravity. The outflow contains the dialysate in addition to nitrogenous waste, excess water and electrolytes
Intermittent peritoneal dialysis
takes place over a prescribed time and is interrupted for a prescribed time before it resumes again
usually lasts about 40hrs a week....10hrs a day, 4 days a week
Major complication of peritoneal dialysis? S/S?
- cloudy dialysate....should be clear, pale, yellow
- abdominal pain/cramps
- abdominal tenderness
Complications from peritoneal dialysis
- insufficient flow
- respiratory difficulty
People who also cant have peritoneal dialysis...and why?
cuz wont be able to take deep breaths with all of that dialysate in their abdomen
Nursing care for the person receiving peritoneal dialsysis
- Lunch sounds
- Accurate I&O
- *Strict aseptic technique
Biggest nursing dx for ARF
potential for injury r/t hyperkalemia
Ways to decrease serum K
- insulin/glucose admin IV
- sodium bicarb
- calcium gluconate IV
- Dietary restrictions
How much K should be consumed when you have too much?
limited to 2 g/day
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