1) Acute renal failure (ARF) is an abrupt reduction in renal function that results in the inability to excrete wastes and maintain fluid and electrolyte balance. It can be caused by pre-renal issues like decreased blood flow, intrarenal issues like direct kidney damage, or post-renal issues like urinary tract obstruction. 2) ARF progresses through initiating, oliguric, diuretic, and recovery phases. It is characterized by decreased urine output, fluid overload, electrolyte imbalances, and rising BUN and creatinine. Treatment focuses on fluid management, electrolyte control, and sometimes dialysis. 3) Nursing care for ARF involves frequent monitoring for

1. ACUTE RENAL FAILURE
Presented By:
SUBHASHREE
MAHAPATRO
FACULTY OF KIIT

2. INTRODUCTION

3. Acute renal failure (ARF) is an
abrupt and sudden reduction in renal
function resulting in the inability to excrete
metabolic wastes and maintain proper fluid
& electrolyte balance.

4. Etiology
1)Pre- Renal causes
Volume depletion resulting from:
 Hemorrhage
 Renal losses
 Gastrointestinal losses
Impaired cardiac efficiency resulting
from:
 Myocardia infraction
 Heart failure
 Dysrhythmias
 Cardiogenic shock

5. CONT…
Vasodilation resulting from:
 Sepsis
 Anaphylaxis
 Antihypertensive medications or other
medications that cause vasodilation.

6. CONT…
2)Intrarenal causes
Prolonged renal ischemia resulting
from:
• Pigment nephropathy
• Myoglobinuria
• Hemoglobinreuria
Nephrotoxic agents such as:
• Aminoglycoside antibiotics
• Radiopaque contrast agents
• Heavy metals

7. CONT…
• Solvents and chemicals (ethylene glycol,
carbon tetrachloride, arsenic)
• NSAIDS
• ACE inhibitors
Infections processes such as:
• Acute pyelonephritis
• Acute glomerulonephritis

8. CONT…
3) Post renal causes
Calculi formation
Benign prostatic hyperplasia
Tumors
Strictures
Trauma (to back, pelvis or perineum)
Blood clots

9. Pathophysiology

10. impaired blood flow
hypo perfusion of the kidney
hypoxemia and ischemia
GFR decreases
electrolyte imbalance and increased
tubular reabsorption of sodium and
water
Prerenal ARF

11. actual parenchymal damage to the
glomeruli or kidney tubules
Acute tubular necrosis
GFR decreases
fluid electrolyte imbalances
Intrarenal ARF

12. obstruction distal to the kidney
Pressure rises in the kidney tubules
GFR decreases
fluid electrolyte imbalance
Postrenal ARF

13. Phases of Acute Renal Failure
Initiating phase
begins at the time of the insult and continues
until the signs and symptoms become apparent. It
can last hours to days.

14. CONT….
Oliguria phase
 In the oliguria phase, less than 400ml of urine is
produced in 24 hrs. Fifty percent of those with
acute kidney injury experience this, which
occurs from 24 hrs. to 7 days after the initial
phase. This stage can last up to 2 weeks to
several months.
 This phase accompanied by rise in serum
concentration of elements usually excreted by
kidney(urea, creatinine, organic acids, and the
intracellular actions-potassium & magnesium)

15. CONT..
 There can be a decrease in renal function with
increasing nitrogen retention even when the
patient is excreting more than 2 to 3lof urine
daily called nonoliguric or high output renal
failure.
Diuretic phase
 As the kidney begins to excrete waste products
again, 1 to 3l/day of urine is produced.
 Osmotic diuresis occurs from the elevated waste
products (urea), which the body is attempting to
eliminate.

16. CONT….
 The kidneys are not yet able to concentrate urine
and so dehydration and hypotension are a
concern.
 Monitor for hypovolemia, hyponatremia and
hypotension in this phase. Serum BUN and
creatinine levels are high until the end of this
phase.
 This phase may last 1 to 3 weeks.

17. CONT….
Recovery phase
 In this final phase, recovery begins as the
glomerular filtration rate rises.
 Waste products levels (BUN, creatinine)
decreases greatly within the first 2 weeks of
this phase. However recovery can take up to1
year. In this that doesn’t cover renal function,
chronic kidney disease occurs.

18. Clinical Manifestations
1)Urinary system –
decreased urine output, proteinuria,
casts, decreased specific gravity,
decreased osmolality, increased urinary
sodium
2)Cardiovascular system –
volume overload, heart failure,
hypotension(early), hypertension (after
development of fluid overload),
pericarditis, pericardial effusion,
dysrhythmias.

19. CONT…
3)Respiratory –
pulmonary edema, kussmaul
respirations, pleural effusion
4)Gastrointestinal –
nausea and vomiting, anorexia,
stomatitis, bleeding, diarrhea, constipation
5)Hematologic –
anemia (development within 48hr)
increased susceptibility to infection,
leukocytosis, defect in platelet functioning.

20. CONT…
6) Neurologic –
lethargy, seizures, asterixis,
memory impairment
7) Metabolic –
increased BUN, creatinine,
decreased sodium, increased potassium,
decreased PH, bicarbonate, calcium,
increased phosphate.

21. Diagnostic Evaluation
 A through history
Prerenal causes
Intrarenal causes
Postrenal causes
 Urinalysis – revels proteinuria,
hematuria, casts
 Rising serum creatinine and BUN
levels.
 A renal ultrasound
 CT scan, MRI scan
 Cultures of drainage

22. Management

23. Medical management
 Maintenance of fluid balance is based
on daily weight, serial measurement of
CVP, serum & urine concentration,
fluid losses, blood pressure & clinical
status of patient and daily intake-
output measurement.
 Fluid excess can be detected by the
clinical findings of dyspnea,
tachycardia and distended neck veins.
The patient’s lungs are auscultated for
moist crackles.

24. Cont…
 Immediate goal is to retain fluid volume
deficit through use of blood products and
crystalloids i.e. Normal Saline, Packed
RBC.
 The development of generalized edema is
asses by examining the presacral and
pretibial areas several times daily.
Mannitol, furosemide (Lasix) or
ethacrynic acid may be prescribed to
initiate diuresis.

25. Cont….
 ARF caused by
hypovolemia secondary to
hypoproteinemia, an
infusion of albumin may be
prescribed.
 Dialysis may be initiated to
prevent complications of
ARF, such as
hyperkalemia, metabolic
acidosis, pericarditis &
pulmonary edema.

26. Pharmacologic therapy
 elevated potassium levels may be reduced
by administering cation – exchange resins
(sodium polystyrene sulfonate) orally or by
retention enema.
 Sorbitol may be administered in
combination with kayexalate to induce a
diarrhea – type effect

27. Cont…
 If the patient is hemodynamically unstable
(low blood pressure, changes in mental
status, dysrhythmia), iv dextrose 50%,
insulin & calcium replacement may be
administered to shift potassium back into
the cells.
 Diuretic agents are often used to control
fluid overload. Adult dose: 20-80 mg PO/IV
once.
 Vasodilators- Dopamine, in small doses
causes selective dilatation of the renal
vasculature, enhancing renal perfusion.
Adult dose: 2-5 mcg/kg/min.

28. Cont…
 Alkalinizer-Sodium Bicarbonate, Increases
plasma bicarbonate, which buffers
Hydrogen ion concentration; reverses
acidosis. Adult Dose: Initial dose IV bolus
1 mEq/kg, then infuse 2-5 mEq/kg over 4-8
hr depending on CO2, pH.
 Many medications are eliminated through
kidneys, dosages must be reduced when a
patient has ARF, like ACE inhibitors,
antibiotic (especially aminoglycosides),
digoxin

29. Nutritional therapy
 Replacement of dietary proteins is
individualized to provide the maximum
benefit and minimize uremic symptoms.
 Caloric requirements are met with high
carbohydrate meals, because
carbohydrates have a protein – sparing
effect.

30. Cont….
 Foods & fluids containing potassium or
phosphorous (e.g. bananas, citrus fruits &
juices, coffee) are restricted.
 Following the diuretic phase, the patient is
placed on a high-protein, high caloric diet
& is encouraged to resume activities
gradually.

31. Nursing Management

32. Assessment
The nurse monitors for complications,
participates in emergency treatment of
fluid and electrolyte imbalances.
Assess the patient’s progress and
response to treatment, and provides
physical and emotional support.
Assess understanding of cause of renal
failure. Its consequences & its treatment.
Assess nutritional status.

33. Nursing Diagnosis- 1
Excess fluid volume related to
compromised regulatory mechanism as
evidence by intake greater than output
and increased blood pressure.
Goal
Maintain fluid volume and absence of
edema.

34. Intervention
 Assess skin, face, and dependent
areas for edema. Evaluate degree of
edema.
 Accurately record intake and output.
 Monitor urine specific gravity.
 Weight daily at same time of day, on
same scale, with same equipment and
clothing.
 Monitor vital signs and auscultate lung
and heart sounds.

35. Nursing Diagnosis- 2
Risk for decreased cardiac output as
evidence by fluid overload, electrolyte
imbalance.
Goal
Maintain cardiac output.

36. Intervention
 Monitor vital signs and observe ECG.
 Assess skin color of skin, mucous
membranes, and nail beds and
capillary refill.
 Auscultate heart sounds.
 Maintain bed rest or encourage
adequate rest and provide assistance
with care and desired activities.

37. Nursing Diagnosis- 3
Imbalanced nutrition less than body
requirements related to dietary
restrictions to reduce nitrogenous
waste products as evidence by physical
examination.
Goal
Maintain weight as indicated by
individual situation, free from edema.

38. Intervention
 Assess and document dietary intake.
 Provide frequent, small feedings.
 Give patient a list of permitted foods or
fluids and encourage involvement in menu
choices.
 Offer frequent mouth care. Give gums,
hard candy, and breath mints between
meals.
 Weight daily and record it.
 Provide high calorie, low to moderate
protein diet. Include complex
carbohydrate and fat sources to meet
caloric needs.

39. Nursing Diagnosis- 4
Risk for infection related to invasive
procedures (e.g., urinary
catheterization) or changes in dietary
intake.
Goal
Experience no sign/symptoms of
infection.

40. Intervention
 Assess skin integrity.
 Promote good hand washing by patient
and staff.
 Use aseptic technique when caring and
manipulating IV and invasive lines.
 Provide routine catheter care and
promote meticulous perineal care.
 Encourage deep breathing, coughing,
frequent position changes.

41. Prevention
 Identify patients with preexisting renal
disease.
 Initiate adequate hydration before, during
and after any procedure requiring NPO
status.
 Avoid exposure to nephrotoxins
 Monitor chronic analgesics use
 Prevent and treat shock with blood and
fluid replacement

42. Cont…
 Monitor urinary output and CVP hourly in
critically ill patients
 Schedule diagnostic studies requiring
dehydration
 Pay special attention to draining wounds,
burns and so forth
 Avoid infection
 Take every precaution to make sure that
the right person receives the right blood to
avoid complication.

43. Complication

44. Recent studies
.

48. BIBLIOGRAPHY