The client with RENAL ALTERATION:

ACUTE RENAL FAILURE

INTRODUCTION
WHAT IS ACUTE RENAL FAILURE?

the sudden loss of our kidneys' ability to perform their main function of eliminating excess fluid and salts (electrolytes) as well as waste material from our blood. develops rapidly over a few hours or a few days.

can be fatal and requires intensive treatment

REVERSIBLE!

PHASES OF ACUTE RENAL FAILURE

1. Oliguric-anuric phase

urine volume less than 400 ml per 24 hours. increased in serum creatinine, urea, uric acid, organic acids, potassium, and magnesium lasts 3 to 5 days in infants and children 10 to 14 days in adolescents and adults.

PHASES OF ACUTE RENAL FAILURE

2. Diuretic phase begins when urine output exceeds 500 ml per 24 hours

end when BUN and creatinine levels stop rising.

PHASES OF ACUTE RENAL FAILURE

3. RECOVERY PHASE

Asymptomatic last several months to 1 year

CAUSES OF ARF
3 categories: 1. PRERENAL - A sudden, serious drop in blood flow to the kidneys. 2. INTRARENAL - Direct damage t the kidneys by inflammation, toxins, drugs, infection or reduced blood supply. 3. POSTRENAL - A sudden blockage that stops urine from flowing out of the kidneys.

SIGNS AND SYMPTOMS:

Decreased urine output, although occasionally urine output remains normal Fluid retention, causing swelling in your legs, ankles or feet Drowsiness Shortness of breath Fatigue Confusion Nausea Seizures or coma in severe cases Chest pain or pressure

TESTS AND DIAGNOSIS:

Urine output measurements Urine test Blood test may reveal rapidly rising levels of urea and creatinine Imaging test ultrasound and computerized tomography (CT)

TESTS AND DIAGNOSIS:

Urine output measurements Urine test Blood test may reveal rapidly rising levels of urea and creatinine Imaging test ultrasound and computerized tomography (CT)

COMPLICATIONS
1.Permanent kidney damage 2.DEATH

SUMMARY OF THE CASE

Totoy Bato,65, has had a history of heart trouble for several years. He is admitted because he has urinated very little for two days, gets dizzy when getting up from ying down, and cannot get his shoes on because his feet are fat. He states that he does not know what is happening to him. Results of laboratory test are as follows: BUN, 90mg/dL; creatinine, 4mg/dL; urine sodium 15mEq/dL and urine specific gravity 1.030.

ACUTE RENAL FAILURE

TERMS AND LEARNING ISSUES

TERMS

HYPOTHESIS

INFERENCE
Blood urea nitrogen (BUN) measures the amount of urea nitrogen, a waste product of protein metabolism, in the blood. Urea is formed by the liver and carried by the blood to the kidneys for excretion. Creatinine is a breakdown product of creatine phosphate in muscle, and is usually produced at a fairly constant rate by the body (depending on muscle mass).
Reference: http://en.wikipedia.org/wiki/Creatini ne http://www.rnceus.com/renal/renalb un.html

CONCLUSION

BUN, BUN CREATININE Blood Urea

Partially accepted.

Nitrogen
Waste products excreted by the kidneys.

TERMS URINE SODIUM

HYPOTHESIS

INFERENCE

CONCLUSION

Presence of measurement sodium in

Accepted

the urine .
Measureme nt of amount of sodium

of the level of sodium in the urine.

Reference: http://en.wikipedia.org/wi ki/Urine_sodium

excreted in
the urine.

TERMS

HYPOTHESIS

INFERENCE

CONCLUSION

URINE To measure SPECIFIC urine GRAVITY concentrat ion

Urine specific Accepted gravity is a laboratory test that measures the concentration of all chemical particles in the urine.
Reference: http://www.nlm.nih.gov/medli neplus/ency/article/003587.ht m

LEARNING ISSUE 1. What is the relationshi p of (+) history of heart trouble in the renal alteration of the client?

HYPOTHESIS
When the patient

INFERENCE

CONCLUSION

Renal vasoconstriction, has renal failure, which is the narrowing of the blood vessels there is water resulting from retention in the contraction of the body that results muscular wall, is an early symptom of to fluid overload. congestive heart This results to an failure. Progressively, severe hypertension increase in the can do incredible workload of the damage to the kidneys

REJECTED

heart that leads to heart trouble.

Reference: Renal Failure & Heart Disease | eHow.com http://www.ehow.com/abo ut_5108490_renal-failure-heartdisease.html#ixzz1OsiO8qIa

LEARNING ISSUE
2. Why does the patient experience dizziness when getting up from lying position?

HYPOTHESIS
Maybe this is due to orthostatic hypotension. The patient maybe suddenly gets up from a lying position that causes sudden decrease in his blood pressure and also because of his age.

INFERENCE
Orthostatic hypotension also called postural hypotension is a form of low blood pressure that happens when you stand up from sitting or lying down. Orthostatic hypotension can make you feel dizzy or lightheaded, and maybe even faint. Orthostatic hypotension can happen to anyone but is more common in older adults.
Reference: http://www.mayoclinic.com/health/ort hostatic-hypotension/DS00997

CONCLUSION

ACCEPTED

LEARNING ISSUE
3. What is the
possible diagnosis for the patients case?

HYPOTHESIS
Based on the patients case, it can be urinary retention or acute renal failure.

INFERENCE

CONCLUSION

LEARNING ISSUE
4. Why does the
patient experience swelling / edema of the feet?

HYPOTHESIS
Because there is fluid overload and urinary retention.

INFERENCE
Swollen foot indicates heart failure, kidney failure. In these conditions, there is too much fluid in the body. Reference: http://www.nlm.nih.gov/ medlineplus/ency/article /003104.htm

CONCLUSION

ACCEPTED

LEARNING ISSUE
5. What are the
risk factors contributing to the possible diagnosis (acute renal failure)?

HYPOTHESIS
Age, history of heart trouble, lifestyle and genetics.

INFERENCE
Being hospitalized, especially for a serious condition that requires intensive care, Advanced age, Blockages in the blood vessels in your arms or legs (peripheral artery disease),Diabetes, High blood pressure, Heart failure, Kidney diseases, Liver disease. Reference: http://www.mayoclinic.co m/health/kidneyfailure/DS00280/DSECT ION=risk-factors

CONCLUSION

ACCEPTED

LEARNING ISSUE
6. What are the
signs and symptoms of the possible diagnosis (acute renal failure)?

HYPOTHESIS
Urinary retention, edema, dry skin, hypertension, dizziness.

INFERENCE
Decreased urine output, although occasionally urine output remains normal Fluid retention, causing swelling in your legs, ankles or feet Drowsiness Shortness of breath Fatigue Confusion Nausea Seizures or coma in severe case Chest pain or pressure Reference: http://www.mayoclinic.co m/health/kidneyfailure/DS00280/DSECT ION=symptoms

CONCLUSION

ACCEPTED

LEARNING ISSUE
7. What are the
normal values of BUN, creatinine, urine sodium, and specific gravity of the urine?

HYPOTHESIS
BUN = 60-80mg/dL CREATININE= 0.1 1.0 mg/dlL URINE SPECIFIC GRAVITY = 0.001 0.010 URINE SODIUM = 8 10 mEq/L

INFERENCE
BUN = 8.00 23.00 CREATININE = 0.51 0.95 URINE SPECIFIC GRAVITY = 1.002 1.030 URINE SODIUM = 15 250 mEq/L REFERENCE: (PPDs Nursing Drug Guide 2nd edition) Medical Surgical Nursing by J.B. Lippincott Company

CONCLUSION

REJECTED

LEARNING ISSUE
8. What are the
purpose or indications of BUN, creatinine, urine sodium and specific gravity in the possible diagnosis (acute renal failure)?

HYPOTHESIS
To asses if the result are within the normal and can be useful in diagnosing the patients condition.

INFERENCE
Kidney function tests are common lab tests used to evaluate how well the kidneys are working. These include: BUN, creatinine blood, creatinine clearance, creatinine urine. Reference: http://www.nlm.nih.gov/ medlineplus/ency/article /003435.htm

CONCLUSION

ACCEPTED

ACUTE RENAL FAILURE

ANATOMY AND PHYSIOLOGY

The kidneys are bean-shaped organs, each about the size of a fist. They are located near the middle of the back, just below the rib cage, one on each side of the spine. The kidneys are sophisticated reprocessing machines.

 Every day, a persons kidneys process about 200 quarts of blood to sift out about 2 quarts of waste products and extra water. The wastes and extra water become urine, which flows to the bladder through tubes called ureters. The bladder stores urine until releasing it through urination.

 The kidneys remove wastes and water from the blood to form urine. Urine flows from the kidneys to the bladder through the ureters. Wastes in the blood come from the normal breakdown of active tissues, such as muscles, and from food. The body uses food for energy and self-repairs. After the body has taken what it needs from food, wastes are sent to the blood. If the kidneys did not remove them, these wastes would build up in the blood and damage the body.

 The actual removal of wastes occurs in tiny units inside the kidneys called nephrons. Each kidney has about a million nephrons. In the nephron, a glomeruluswhich is a tiny blood vessel, or capillaryintertwines with a tiny urine-collecting tube called a tubule.

The glomerulus acts as a filtering unit, or sieve, and keeps normal proteins and cells in the bloodstream, allowing extra fluid and wastes to pass through. A complicated chemical exchange takes place, as waste materials and water leave the blood and enter the urinary system.

ACUTE RENAL FAILURE

PATHOPHYSIOLOGY

Non-modifiable Risk factors >lifestyle

Modifiable Risk Factors

>Age >History of heart dse. >Intake of nephrotoxic drugs

Prolonged HPN
Increase Viscosity of blood

Sluggish blood flow

Decrease renal perfussion

Blood pressure regulation is impaired

Progressive deterioration of nephrons

RAAS is not activated

glumerulosclerosis

No release of renin

Increase BUN,Crea

Decrease GFR
Na,H2o,Urea retention

Urine output edema

HPN
Postural hypotension

Acute renal failure

ACUTE RENAL FAILURE

LABORATORY RESULTS

ANALYTE

RESULT

NORMAL RANGE

SIGNIFICANCE High. Indicates reduction in filtrate formation and

Nursing Consideration
1. Assess for urine ferrous, odor of breath, stomatitis and gastro

Blood 90 Urea Nitrog en

mg/dL 25 mg/dl

function of the tubular

epithelium and inability of the kidney to excrete metabolic waste products of protein through urine

intestinal bleeding.

2. Provide oral

cause increase in BUN and hygiene. Creatinine.

3. Promote skin care to prevent uremic frost and

Medical Surgical Nursing by J.B. Lippincott Company

pruritus.

ANALYTE

RESULT

NORMAL RANGE

SIGNIFICANCE High. Indicates reduction in filtrate formation and

Nursing Consideration 1. Assess for urine ferrous, odor of breath,

Creati 4 nine

0.4

mg/dL 1.2 mg/dl

function of the tubular

epithelium and inability of the kidney to excrete metabolic waste products of protein through urine

stomatitis and
gastro intestinal bleeding. 2. Provide oral

cause increase in BUN and hygiene. Creatinine. 3. Promote

Medical Surgical Nursing

by J.B. Lippincott Company

skin care to
prevent uremic frost and pruritus.

ANALYTE

RESULT

NORMAL RANGE

SIGNIFICANCE

Nursing Consideration
1. Accurate measurement and recording of intake and output.

Sodium 15

15

Within the normal range.

http://www.nlm.nih.gov/medlineplus/enc
y/article/003599.htm

mEq/L 250

mEq/L

2. Monitor for
weight gain and edema. 3. Encourage patient to remain within prescribed fluid restriction. 4. Provide hard candy and chewing

gum on ice cube as

thirst-quenchers.

ANALYTE

RESULT

NORMAL RANGE

SIGNIFICANCE

Nursing Consideration

Specific 1.030 Gravity

1.002

Within the normal range.

1.030

http://pathcuriel.
swmed.edu/path

demo/nrrt.htm#ur
ine

ACUTE RENAL FAILURE

NURSING CARE PLANS

Assessment

Diagnosis

Planning

Intervention

Rationale

Expected Outcome