6 Acute Renal Failure Nursing Care Plans

February 27, 2014

Acute renal failure (ARF), also known as acute kidney failure or acute kidney injury, is the abrupt loss of kidney function. The glomerular filtration rate (GFR) falls over a period of hours to a few days and is accompanied by concomitant rise in serum creatinine and urea nitrogen. If left untreated, acute renal failure may complicate to chronic renal failure.

The annual incidence of acute renal failure is 100 cases for every million people in the United States. It is diagnosed in 1% of hospital admissions.

Nursing Care Plans

Nursing goal of treating patients with acute renal failure is to correct or eliminate any reversible causes of kidney failure. Provide support by taking accurate measurements of intake and output, including all body fluids, monitor vital signs and maintain proper electrolyte balance.

Here are six (6) nursing care plans (NCP) and nursing diagnosis for patients with acute renal failure:

Excess Fluid Volume

Excess Fluid Volume: Increased isotonic fluid retention

Nursing Diagnosis

Excess fluid volume

May be relate to

Compromised regulatory mechanism (renal failure)

Possibly evidenced by

Intake greater than output, oliguria; changes in urine specific gravity
Venous distension; blood pressure (BP)/central venous pressure (CVP) changes
Generalized tissue edema, weight gain
Changes in mental status, restlessness
Decreased Hb/hematocrit (Hct), altered electrolytes; pulmonary congestion on x-ray

Desired Outcomes

Display appropriate urinary output with specific gravity/laboratory studies near normal; stable weight, vital signs within patient’s normal range; and absence of edema.

Nursing Interventions	Rationale
Accurately record intake and output (I&O) noting to include “hidden” fluids such as IV antibiotic additives, liquid medications, frozen treats, ice chips. Religiously measure gastrointestinal losses and estimate insensible losses (sweating), including wound drainage, nasogastric outputs, and diarrhea.	Decrease in output (to less than 400 ml per 24 hours) may indicate acute failure, especially in high-risk patients. Accurate monitoring of I&O is necessary for determining renal function and fluid replacement needs and reducing risk of fluid overload. Do note that hypervolemia usually occurs in anuric phase of ARF and may mask the symptoms.
Monitor urine specific gravity.	Measures the kidney’s ability to concentrate urine. In intrarenal failure, specific gravity is usually equal to or less than 1.010, indicating loss of ability to concentrate the urine.
Weigh daily at same time of day, on same scale, with same equipment and clothing.	Daily body weight is best monitor of fluid status. A weight gain of more than 0.5 kg/day suggests fluid retention.
Assess skin, face, dependent areas for edema. Evaluate degree of edema (on scale of +1–+4).	Edema occurs primarily in dependent tissues of the body, (hands, feet, lumbosacral area). Patient can gain up to 10 lb (4.5 kg) of fluid before pitting edema is detected. Periorbital edema may be a presenting sign of this fluid shift because these fragile tissues are easily distended by even minimal fluid accumulation.
Monitor heart rate (HR), BP, and JVD/CVP.	Tachycardia and hypertension can occur because of: (1) failure of the kidneys to excrete urine, (2) excess fluid resuscitation during efforts to treat hypovolemia and/or hypotension or convert oliguric phase of renal failure, (3) changes in the renin-angiotensin system. Invasive monitoring may be needed for assessing intravascular volume, especially in patients with poor cardiac function.
Auscultate lung and heart sounds.	Fluid overload may lead to pulmonary edema and HF evidenced by development of adventitious breath sounds, extra heart sounds.
Assess level of consciousness. Investigate changes in mentation, presence of restlessness.	May reflect fluid shifts, accumulation of toxins, acidosis, electrolyte imbalances, or developing hypoxia.
Scatter desired beverages throughout the 24-hour period and give various offering (hot, cold, frozen).	Helps avoid periods without fluids, minimizes boredom of limited choices, and reduces sense of deprivation and thirst.
Correct any reversible cause of ARF: replace blood loss, maximize cardiac output, discontinue nephrotoxic drug, relieve obstruction via surgery.	Kidneys may be able to return to normal functioning, preventing or limiting residual effects.
Use appropriate safety measures (raising side rails and restraints.	Patient with CNS involvement may be dizzy and/or confused.
Monitor diagnostic studies:
Blood urea nitrogen (BUN), creatinine (cr)	BUN assess management of renal dysfunction. Both values may increase but creatinine is a better indicator of renal function because it is not affected by hydration, diet, and tissue catabolism. Dialysis is usually indicated if ratio is higher than 10:1 or if therapy fails to indicate fluid overload or metabolic acidosis.
Urine sodium and Cr.	In ATN, tubular functional integrity is lost and sodium resorption is impaired, resulting in increased sodium excretion. Urine creatinine is usually decreased as serum creatinine elevates.
Serum sodium.	Hyponatremia may result from fluid overload (dilutional) or kidney’s inability to conserve sodium. Hypernatremia indicates total body water deficit.
Serum potassium.	Lack of renal excretion and/or selective retention of potassium to excrete excess hydrogen ions leads to hyperkalemia, requiring prompt intervention.
Hb/Hct.	Decreased values may indicate hemodilution (hypervolemia) however, during prolonged failure, anemia frequently develops as a result of RBC loss. Other possible causes (active or occult hemorrhage) should also be evaluated.
Serial chest x-rays.	Increased cardiac size, prominent pulmonary vascular markings, pleural effusion, congestion indicate acute responses to fluid overload or chronic changes associated with renal and heart failure.
Administer and/or restrict fluids as indicated.	Fluid management is usually calculated to replace output from all sources plus estimated insensible losses (metabolism, diaphoresis). Prerenal failure (azotemia) is treated with volume replacement and/or vasopressors. The oliguric patient with adequate circulating volume or fluid overload who is unresponsive to fluid restriction and diuretics requires dialysis. Note: During oliguric phase, “push/pull” therapy (push IV fluids and diurese with diuretics) may be tried to stimulate kidney function.
Administer medication as indicated:
Diuretics: furosemide (Lasix), bumetanide (Bumex), torsemide (Demadex), mannitol (Osmitrol).	Given early in oliguric phase of ARF in an effort to convert to non-oliguric phase, flush the tubular lumen of debris, reduce hyperkalemia, and promote adequate urine volume.
Antihypertensives: clonidine (Catapres), methyldopa (Aldomet), prazosin (Minipress).	May be given to treat hypertension by counteracting effects of decreased renal blood flow and/or circulating volume overload.
Calcium channel blockers.	Given early in nephrotoxic ATN to reduce influx of calcium into kidney cells, thereby helping to maintain cell integrity and improve GFR.
Prostaglandins.	Vasodilatory effect may improve circulating volume and reestablish renal blood flow to aid in clearing nephrotoxic agents from nephrons.
Insert indwelling catheter, as indicated.	Catheterization excludes lower tract obstruction and provides means of accurate monitoring of urine output during acute phase; however, indwelling catheterization may be contraindicated because of increased risk of infection.
Prepare for dialysis as indicated: hemodialysis, peritoneal dialysis, or continuous renal replacement therapy (CRRT).	Done to correct volume overload, electrolyte and acid-base imbalances, and to remove toxins. The type of dialysis chosen for ARF depends on the degree of hemodynamic compromise and patient’s ability to withstand the procedure.
During peritoneal dialysis, position the patient carefully: elevate the head of the bed.	Doing so would reduce the pressure on the diaphragm and can aid in respiration.
Watch out for complications such as peritonitis, atelectasis, hypokalemia, pneumonia and/or shock.	These complications are common for patients undergoing peritoneal dialysis.