6 Acute Renal Failure Nursing Care Plans

Excess Fluid Volume

In the case of prerenal acute kidney injury (AKI), fluid resuscitation is the gold standard, but if this resuscitation continues beyond the correction of hypovolemia, then it is associated with increased morbidity, mortality, and length of hospital stay as well as increased risk of AKI. Several observational studies have demonstrated a correlation between fluid overload and mortality in critically ill clients with acute respiratory distress syndrome, acute lung injury, sepsis, and AKI (Patil & Salunke, 2020).

Nursing Diagnosis

• Excess Fluid Volume

May be related 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

• The client will display appropriate urinary output with specific gravity/laboratory studies near normal; stable weight, vital signs within the client’s normal range; and absence of edema.

Nursing Assessment and Rationales

1. Assess the level of consciousness. Investigate changes in mentation and the presence of restlessness.
This may reflect fluid shifts, accumulation of toxins, acidosis, electrolyte imbalances, or developing hypoxia. Older adults with vague mental status change are commonly found to have prerenal or normotensive ischemic AKI. Insensible fluid losses can result in severe hypovolemia in clients with restricted fluid access and should be suspected in older adult clients and in comatose or sedated clients (Workeneh & Batuman, 2022).

2. Assess skin, face, and dependent areas for edema. Evaluate the degree of edema (on a scale of +1–+4).
Edema occurs primarily in dependent tissues of the body, (hands, feet, lumbosacral area). The client 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.

3. 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 clients with poor cardiac function. Although clients with heart failure may have low blood pressure, volume expansion is present, and effective renal perfusion is poor, which can result in AKI (Workeneh & Batuman, 2022).

4. Auscultate lung and heart sounds.
Fluid overload may lead to pulmonary edema and heart failure evidenced by the development of adventitious breath sounds, and extra heart sounds. The most important part of physical examination is the assessment of cardiovascular status and volume status. The cardiovascular examination may reveal murmurs, pericardial friction rub, and increased jugulovenous distention, rales, and S3 gallops (Workeneh & Batuman, 2022).

5. Accurately record intake and output (I&O) noting to include “hidden” fluids such as IV antibiotic additives, liquid medications, frozen treats, and ice chips. Religiously measure gastrointestinal losses and estimate insensible losses (sweating), including wound drainage, nasogastric outputs, and diarrhea.
The widely accepted Kidney Disease: Improving Global Outcome (KDIGO) definition of AKI is based on the change of serum creatinine and urine output of < 0.5 mL/kg/hour for six hours. Accurate monitoring of I&O is necessary for determining renal function and fluid replacement needs and reducing the risk of fluid overload. Oliguria generally favors AKI. Abrupt anuria suggests acute urinary obstruction, acute severe glomerulonephritis, or embolic renal artery occlusion. A gradually diminishing urine output may indicate a urethral stricture or bladder outlet obstruction (Workeneh & Batuman, 2022).

6. Monitor urine-specific gravity.
This 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. Aggressive fluid resuscitation is appropriate in prerenal AKI. However, overly aggressive volume resuscitation in a client with ATN who is unable to excrete the extra fluid can result in volume overload and respiratory embarrassment. To help with the differentiation of prerenal azotemia, analysis of urine may provide important clues (Sinert & Sugalski, 2019).

7. Weigh daily at the same time of day, on the same scale, with the same equipment and clothing.
Daily body weight is the best monitor of fluid status. A weight gain of more than 0.5 kg/day suggests fluid retention. Over-aggressive volume resuscitation can cause tissue congestion and hypoxia and is associated with worse survival in general ICU populations and in clients with AKI (Fülöp et al., 2010).

8. Monitor diagnostic studies.  

• 8.1. Blood urea nitrogen (BUN), and creatinine (cr)
  BUN assesses the 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 the ratio is higher than 10:1 or if therapy fails to indicate fluid overload or metabolic acidosis. The ratio of BUN to creatinine is an important finding. The ratio can exceed 20:1 in conditions in which enhanced reabsorption of urea is favored (Workeneh & Batuman, 2022).
  
• 8.2. Urine sodium
  In acute tubular necrosis, tubular functional integrity is lost and sodium resorption is impaired, resulting in increased sodium excretion. Urine electrolyte findings can also serve as valuable indicators of functioning renal tubules. The fractional excretion of sodium (FENa) is the commonly used indicator. Calculating FENa is useful in AKI only in the presence of oliguria (Workeneh & Batuman, 2022).
  
• 8.3. Serum sodium
  Hyponatremia may result from fluid overload (dilutional) or the kidney’s inability to conserve sodium. Hypernatremia indicates total body water deficit. Clients suffering from AKI were associated with impaired sodium and potassium homeostasis. Hyponatremia and hypernatremia are common electrolyte abnormalities among critically ill clients. A study suggested that abnormal sodium is an important risk factor for mortality independent of potassium levels among clients with heart failure (Gao et al., 2019).
  
• 8.4. Serum potassium
  Lack of renal excretion and/or selective retention of potassium to excrete excess hydrogen ions leads to hyperkalemia, requiring prompt intervention. Hyperkalemia is a common and important complication of AKI (Sinert & Sugalski, 2019).
  
• 8.5. Hemoglobin and hematocrit
  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. Postoperative anemia and a decrease in hemoglobin levels have been reported as predictive factors for AKI and in-hospital mortality in cardiac surgery. The results of the studies emphasize the importance of detecting and correcting anemia in clients with AKI (Lombardi et al., 2021).

9. Monitor Serial chest x-rays
Increased cardiac size, prominent pulmonary vascular markings, pleural effusion, and congestion indicate acute responses to fluid overload or chronic changes associated with renal and heart failure. Obtain chest radiographs on a routine basis to look for evidence of volume overload (Sinert & Sugalski, 2019).

10. Monitor echocardiography results as indicated.
Echocardiography is an essential tool for guiding resuscitation in critically ill clients. Resuscitation often requires the infusion of intravenous fluids in an effort to reverse organ dysfunction. Echocardiography is an evidence-based approach and is ideally suited to address fluid overload (Effat et al., 2021).

Nursing Interventions and Rationale

1. Scatter desired beverages throughout the 24-hour period and give various offerings (hot, cold, frozen).
This helps avoid periods without fluids, minimizes boredom of limited choices, and reduces the sense of deprivation and thirst. Drinking black coffee, instead of coffee with high potassium and high phosphorus milk, or high-calorie sugar drinks is best. A cup of unsweetened green tea is full of compounds called “polyphenols”, which function as antioxidants. Carbonated, or sparkling, water hydrates, as well as water, does (Shusterman, 2021).

2. Maintain volume homeostasis and correct biochemical abnormalities.
Kidneys may be able to return to normal functioning, preventing or limiting residual effects. Measures include correction of fluid overload, correction of severe acidosis, and correction of hematologic abnormalities such as transfusions and administration of medications (Workeneh & Batuman, 2022).

3. Use appropriate safety measures (raising side rails and restraints.
Clients with CNS involvement may be dizzy and/or confused. The kidney and the brain are frequently injured during critical illness. Acute kidney injury, which affects up to half of the critically ill clients, is strongly associated with short and long-term morbidity and mortality. Similarly, acute brain dysfunction, which manifests as delirium or coma in the ICU, is common during critical illness and associated with adverse short and long-term outcomes (Siew et al., 2017).

4. 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 expansion and/or vasopressors. The oliguric client with adequate circulating volume or fluid overload who is unresponsive to fluid restriction and diuretics requires dialysis. During the oliguric phase, “push/pull” therapy (push IV fluids and diuresis with diuretics) may be tried to stimulate kidney function. However, a rapid fluid infusion can result in life-threatening fluid overload in clients with AKI (Sinert & Sugalski, 2019).

5. Assist the client in performing the passive leg-raising maneuver (PLR) or virtual fluid challenge as indicated.
PLR is a test that predicts whether cardiac output will increase with volume expansion. By transferring a volume of around 300 mL of venous blood from the lower body toward the right heart, PLR mimics a fluid challenge (Effat et al., 2021).

6. Promote sodium and fluid restriction as indicated.
Restriction of salt and fluid becomes crucial in the management of oliguric kidney failure, wherein the kidneys do not adequately excrete either toxins or fluids (Workeneh & Batuman, 2022). Oliguric clients should also have a fluid restriction of 400 ml plus the previous day’s urine output unless there are signs of volume depletion (Bindroo et al., 2022).

7. Insert indwelling catheter, as indicated.
Catheterization excludes lower tract obstruction and provides means of accurate monitoring of urine output during the acute phase; however, indwelling catheterization may be contraindicated because of the increased risk of infection. Placement of a urinary catheter in AKI not only allows diagnosis and treatment of urethral and bladder outlet urinary obstruction but also allows for accurate measurement of urine output (Sinert & Sugalski, 2019).

8. Administer medication as indicated. 

• 8.1. Diuretics such as furosemide, bumetanide, torsemide, and mannitol
  These are given early in the oliguric phase of ARF in an effort to convert to a non-oliguric phase, flush the tubular lumen of debris, reduce hyperkalemia, and promote adequate urine volume. Furosemide can be used to correct volume overload when the kidneys are still responsive; this often requires high intravenous doses. Furosemide plays no role in converting an oliguric AKI to a non-oliguric AKI or in increasing urine output when a client is not hypervolemic (Workeneh & Batuman, 2022).
  
• 8.2. Vasodilators such as fenoldopam
  Fenoldopam is a selective dopamine-receptor agonist that acts as a rapid-acting vasodilator. It is six times more potent than dopamine in producing renal vasodilation. It increases renal blood flow to the cortex and medullary regions in the kidney, increases diuresis, and has minimal adrenergic effects. Fenoldopam is indicated for the treatment of severe hypertension, including for clients with renal compromise (Workeneh & Batuman, 2022).
  
• 8.3. Calcium channel blockers
  These are given early in nephrotoxic acute tubular necrosis (ATN) to reduce the influx of calcium into kidney cells, thereby helping to maintain cell integrity and improve GFR. Calcium channel blockers have been shown in animal models to be protective in AKI if given before renal insult. Their only benefit in humans is preventing AKI in renal transplant clients receiving cyclosporine (Sinert & Sugalski, 2019).

9. Prepare for dialysis as indicated: hemodialysis, peritoneal dialysis, or continuous renal replacement therapy (CRRT).
Dialysis is 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 the client’s ability to withstand the procedure. However, dialysis, especially hemodialysis, may delay the recovery of clients with AKI. Most authorities prefer using biocompatible membrane dialyzers for hemodialysis. Peritoneal dialysis is not frequently used in AKI. Nevertheless, it can technically be used in acute cases and probably is tolerated better hemodynamically than conventional hemodialysis (Workeneh & Batuman, 2022). 

10. Assist in renal replacement therapy.
The principal methods of renal replacement therapy (RRT) are intermittent hemodialysis, continuous venovenous hemodiafiltration, and peritoneal dialysis. Continuous RRT techniques are more expensive, associated with increased bleeding risk, and not universally available. However, in addition to avoiding hypotension, they are believed to achieve better control of uremia and clearance of solute from the extravascular compartment (Sinert & Sugalski, 2019).