Acute renal failure or acute kidney injury is characterized by determination of renal functions over a period of hours to few days, resulting in failure of the kidney to excrete nitrogenous waste product and to maintain fluid, electrolytes and acid-base homeostasis.

1. A C U T E R E N A L
FA I L U R E
MS.K.UDAYASREE
ASSISTANT PROFESSOR
MEDICAL SURGICAL NURSING DEPT

2. Abrupt decrease in renal function resulting in the
accumulation of nitrogenous compounds such as urea
and creatinine
ARF is a sudden decline in glomerular filtration rate
(GFR) often accompanied by a drop in urine output.
Decreased GFR results in accumulation of nitrogenous
wastes and alterations in fluid and electrolyte balance.
DEFINITION

3. • Acute renal failure or acute kidney injury is characterized by
determination of renal functions over a period of hours to few days,
resulting in failure of the kidney to excrete nitrogenous waste product
and to maintain fluid, electrolytes and acid-base homeostasis.
• - BRUNNER & SUDDHARTH’S (2021)
DEFINITION

4. INCIDENCE
• Male are greater than female
• Age – above 40
• The incidence rises to approx. 20% in critically ill
patients. Type Incidence
Prerenal 35%
Intrarenal 55%
Postrenal 10%

5. CLASSIFICATION
• Prerenal failure: circumstances or conditions that
decrease blood flow to the kidneys
• Post renal failure: conditions that obstruct urine
outflow from the kidney
• Intrarenal failure: conditions affecting internal
structures of the kidney; most often, acute tubular
necrosis (ATN) , which develops when a toxin or
ischemia damages the renal tubules.

7. PRE-RENAL ACUTE RENAL FAILURE
 HYPOVOLEMIA
 Dehydration
 Hemorrhage
 GI losses (Diarrhea, Vomiting)
 Excessive diuresis
 Hypoalbuminemia
 Burns
 DECREASED CO
 Cardiac dysrhythmias
 Cariogenic shock
 Heart failure, MI
 DECREASED RENAL FLOW
 B/L renal vein thrombosis
 Embolism
 Hepatorenal syndrome
 Renal artery thrombosis
 CHANGE IN PVR
 Anaphylaxis
 Neurogenic injury
 Septic shock
 Antihypertensive drugs, drug
overdose

8. INTRA-RENAL ACUTE RENAL FAILURE
NEPHROTOXIC INJURY
 Drugs : Aminoglycosides, antineoplastics, NSAIDS
 Contrast media
 Hemolytic blood transfusion reaction
 Severe crush injury
 Chemical exposure :lead, arsenic
INTERSTITIAL NEPHRITIS
 Allergies : Antibiotics, NSAIDs
 Infections
OTHERS
 A/C Glomerulonephritis, toxemia, SLE

9. POST-RENAL ACUTE RENAL FAILURE
• BPH
• Bladder cancer
• Calculi formation
• Neuromuscular disorders
• Prostate cancer
• Spinal cord disease
• Strictures
• Trauma (Back, pelvis, perineum)
• Urinary tract infections

10. PATHOPHYSIOLOGY

11. PHASES
There are four phases of ARF
• INITIATION : The initiation period begins with the initial
and ends when oliguria develops
• OLIGURIA : The oliguria period is accompanied by an increase
in the serum concentration of substances usually excreted by
kidneys
• DIURESIS : The diuresis period is marked by a gradual
in urine output, which signals that glomerular filtration has
started to recover (1-3 wks)
• RECOVERY : The recovery period signals the improvement of
renal function and may take 3 to 12 months

12. CLINICAL FEATURES
•Oliguric phase
• Urinary changes :
– <400 ml/day
– Occurs within 7 days of injury(depending on cause and tissue injury)
– Lasts for about 10-14 days
– Longer it lasts, poor prognosis
• Fluid volume :
– Treat with fluid replacement
– If oliguria/ anuria fluid retention results which can lead to fluid excess
– Results in increased JVP, bounding pulse, edema, hypertension
– It can lead to complications such as HF, pulmonary edema, pericardial and
pleural effusion

13. • Metabolic acidosis:
– Impaired excretion of hydrogen ions and metabolic waste
products
– Decreased production of bicarbonate ions
– May develop Kussmaul respiration
• Sodium balance:
– Sodium may be below normal levels
• Potassium excess:
– Hyperkalemia
– Bleeding, blood transfusion & metabolic acidosis worsens
hyperkalemia

14.  Waste product accumulation :
o BUN, creatinine - elevated
Neurologic disorders :
oNeuro changes can occur as the nitrogenous waste products
accumulate in the brain & other nervous tissue
oManifestations : Fatigue, difficulty concentrating, seizures,
stupor & coma
Hematologic disorders :
oImpaired erythropoietin production
oPlatelet abnormalities
oDecreased WBC
oCalcium deficit and phosphate excess

15. DIURETIC PHASE :
• Begins with gradual increase in output and it reach to 5L /day
• High urine volume caused by osmotic diuresis from the high
urea concentration in the glomerular filtrate & inability to
concentrate urine
• Hypovolemia, hypokalemia, hypotension & dehydration can
occur from massive fluid losses
• May last 1-3 weeks
• Near the end, acid-base, electrolyte, BUN, creatinine values
stabilize

16. RECOVERY PHASE :
• Begins when the GFR increases
• BUN & creatinine comes to decrease
• 1-2wks but may last for 12 months
• Some individuals do not recover & progress to ESRD

17. DIAGNOSIS
• History
• Physical examination
 Urine output
• Urine analysis
 Urine specific gravity : <1.020
 Osmolality: Less than 350 mosm/kg
 Twenty–four–hour urine tests
 Presence of dirty brown casts, crystals
• Blood tests
 BUN, S.creatinine, S. electrolytes, Hb, RBC
• Arterial blood gases (ABGs) - Metabolic acidosis

18. DIAGNOSIS
 Kidney, ureter, bladder (KUB) X-ray :
 Demonstrates size of kidneys/ureters/bladder,
presence of cysts, tumors, stones
 Retrograde pyelogram:
 Outlines abnormalities of renal pelvis and ureters
 Renal arteriogram:
 Voiding cystoureterogram:
Shows bladder size, reflux into ureters,
retention
 Renal ultrasound

19. DIAGNOSIS
 Nonnuclear computed tomography (CT) scan: Cross-sectional
view of kidney and urinary tract detects presence/extent of
disease
 Magnetic resonance imaging (MRI): Provides information about
soft tissue damage
 Excretory urography (intravenous urogram
or pyelogram): Radiopaque contrast
concentrates in urine and facilitates
visualization of KUB.

20. DIAGNOSIS
• Endourology: Direct visualization may be done of urethra,
bladder, ureters, and kidney to diagnose problems, biopsy, and
remove small lesions and/or calculi
• Electrocardiogram (ECG): May be abnormal, reflecting
electrolyte and acid-base imbalances
• Renal biopsy : A sample of the kidney tissue (biopsy) is
sometimes required in cases in which the cause of the kidney
disease is unclear

21. MEDICAL MANAGEMENT
Goal:
• Treat the underlying disease
• To Improve renal functioning
Medical Management:
• Strictly monitor I/O, weight
• Monitor serum electrolytes
• Adjust medication dosages according to GFR
• Avoid highly nephrotoxic drugs
• Determine adequate CO to ensure kidney perfusion

22. MEDICAL MANAGEMENT
• Maximize perfusion
Intravenous fluids
Plasma expanders (i.e., albumin)
Blood transfusion
Pressor agents (i.e., dopamine / dobutamine)
Unloading agents (i.e., nipride/ nitroglycerine) in
cases of congestive heart failure

23. • Stop fluid loss
Assess and control bleeding sites
Replace GI fluid losses and treat bacterial infections with appropriate
antibiotics
Broad-spectrum antibiotics for sepsis
Excisison of eschar and grafting in burn injuries
• Eliminate renal toxins
Diuresis with saline plus IV loop diuretic may prevent ARF due to
contrast.
Alkalinization of the urine with acetazolimide or sodium bicarbonate
may help prevent intratubular precipitation of uric acid (acetazolamide
150 – 500 mg IV)
Withdraw nephrotoxic drugs (i.e., ACE inhibitors, NSAIDS,

24. • Relieve obstruction
Foley catheter
Ureteral stents
Ureteroscopic stone removal
Lithotripsy
• Percutaneous nephrostomy
• Renal replacement therapy
Hemodialysis
Continuous arteriovenous hemoinfiltration (CAHF)
Peritoneal dialysis

25. • Therapies for elevated potassium levels
 Regular insulin IV : K+ moves into cells, given with glucose to
prevent hypoglycemia
 Sodium bicarbonate : correct acidosis & cause a shift of K+
into cells
 Calcium gluconate IV : Used in hyperkalemia ECG changes
 Hemodialysis
 Sodium polystyrene sulfonate: cation-exchange resin (mouth
or enema), it removes 1mEq/drug, it is mixed with sorbitol to
produce osmotic diarrhea, allowing for evacuation of
potassium-rich stool from body

26. NUTRITIONAL THERAPY
• Potassium intake is limited to 40mEq/day
• Low-protein, high-calorie diet : Caloric intake – 30-35kcal/kg &
0.8 – 1g of protein/kg of body weight to prevent breakdown of
body protein
• Sodium is restricted (To prevent edema, hypertension, HF)
• Dietary fat intake is increased (To prevent ketosis & endogenous
fat breakdown)
• Fat emulsion IV infusion
• TPN
• Potassium or phosphorus diet are restricted

27. NURSING MANAGEMENT
The goals for a patient with ARF are:
–Restore fluid & electrolyte balance
–Promote pulmonary function
–Prevent infection
–Promote skin care
–Improve nutritional intake

28. NURSING MANAGEMENT
• MAINTAIN FLUID & ELECTROLYTE BALANCE
 Fluid restriction- 24hrs fluid loss + 600ml
 Monitor daily weight (0.2-0.5kg/day)
 Diuretic therapy (Eg: Lasix)
 Monitor electrolytes & ABG
 Electrolyte replacement
 Acidosis is treated with bicarbonate
 ECG monitoring
 Dark green veg’s, unrefined grains, seeds, nuts, antacids & osmotic
laxatives containing magnesium should be avoided

29. NURSING MANAGEMENT
• PROMOTE PULMONARY FUNCTION
 Assisted to turn, cough, and take deep breaths frequently
to prevent atelectasis and respiratory tract infection
 Teach deep breathing exercises
• PREVENT INFECTION
 Asepsis is essential with invasive lines and catheters to
minimize the risk of infection
 Maintain personal hygiene
 Urinary catheters are avoided

30. NURSING MANAGEMENT
PROVIDE SKIN CARE
 Bathing the patient with cool water
 Frequent turning
 keep the skin clean and well moisturized
 keep the fingernails trimmed to avoid excoriation and prevent skin
breakdown
IMPROVE NUTRITIONAL INTAKE
 Low-protein, high-calorie diet
 Sodium, potassium & phosphorus restricted diet

31. 1. Excess fluid volume related to compromised regulatory mechanism as evidenced by
electrolyte imbalance.
2. Decreased cardiac output related to fluid over load as evidenced by oedema.
3. Imbalanced nutrition less than body requirement related to anorexia as evidenced
by ulceration in oral mucosa.
4. Activity intolerance related to fatigue as evidenced by decreased metabolic energy.
5. Impaired skin integrity related to pruritus as evidenced by scratching of skin, redness
of skin.
NURSING DIAGNOSIS:

32. CONT.,
6. knowledge deficit related to lack of exposure and information
misinterpretation as evidenced by asking doubts
7. Ineffective therapeutic regimen related to complexity of therapeutic regimen,
economic difficulties as evidenced by patient verbalization.
8. Risk for infection related to invasive procedures and poor aseptic techniques.

33. EXCESS FLUID VOLUME RELATED TO COMPROMISED
REGULATORY MECHANISM
INTERVENTIONS RATIONALE
• Accurately record intake and
output (I&O)
• Weigh daily at same time of day,
with same equipment(0.2-
0.5kg/day)
• Auscultate lung and heart sounds
• Monitor serum electrolytes,
• Monitor BUN, creatinine
• Restrict fluid intake(24hr
loss+600ml)
• Decrease in output may indicate
acute failure
• Daily body weight is best monitor
of fluid status
• Fluid overload may lead to
pulmonary edema and HF
• Fluid overload leads to electrolyte
imbalances
• Lack of renal excretion leads to
accumulation of waste products
• To prevent further fluid
accumulation
• To promote diuresis

34. IMBALANCED NUTRITION LESS THAN BODY
REQUIREMENT RELATED TO ANOREXIA
INTERVENTIONS RATIONALE
• Assess the nutritional status
including BMI
• Assess the likes and dislike of
patient
• Provide mouth wash frequently
• Provide high calorie and low
protein diet (30-35kcal/kg & 0.8 –
1g of protein/kg).
• Restrict sodium, potassium &
magnesium in the diet
• Dietary fat intake to be increased
• Restrict fluid intake
• To obtain baseline data
• To prove food accordingly.
• To increase appetite
• Lack of renal excretion leads to
accumulation of waste products
• To prevent fluid and electrolyte
imbalances
• To prevent ketosis & endogenous
fat breakdown
• To prevent further fluid
accumulation
• To maintain the optimal nutritional

35. IMPAIRED SKIN INTEGRITY RELATED TO PRURITUS
INTERVENTIONS RATIONALE
• Assess the skin integrity and sign
of pruritus.
• Monitor serum urea and creatinin
levels
• Bathing the patient with cool water
• Frequent turning – q2h
positioning.
• keep the skin clean and well
moisturized
• keep the fingernails trimmed
• To obtain baseline data
• To rule out the cause
• To prevent burning and for
soothing effect
• To prevent pressure ulcers
• To prevent skin breakdown and
trauma
• To avoid excoriation and prevent
skin breakdown

36. DEFICIENT KNOWLEDGE RELATED TO INFORMATION
MISINTERPRETATION
INTERVENTIONS RATIONALE
• Review disease process, prognosis,
and precipitating factors if known
• Discuss renal dialysis or
transplantation if these are likely
options for the future
• Review dietary plan and
restrictions. Include fact sheet
listing food restrictions
• Encourage patient to observe urine
output, weight
• Encourage for fluid restriction &
use ice for thirst
• Provides knowledge base from
which patient can make informed
choices
• Possible treatment
• Adequate nutrition is necessary to
promote tissue healing; adherence
to restrictions may prevent
complications
• To identify any alterations
• To prevent excess fluid
accumulation

37. RISK FOR INFECTION RELATED TO DEPRESSION OF
IMMUNOLOGIC DEFENSES
INTERVENTIONS RATIONALE
• Avoid invasive procedures and
manipulation of indwelling
catheters whenever possible
• Assess skin integrity
• Encourage deep breathing,
coughing, frequent position
changes
• Follow aseptic technique
• Limits introduction of bacteria
into body
• Excoriations from scratching
may become secondarily
infected
• Prevents atelectasis and
mobilizes secretions to reduce
risk of pulmonary infections
• To prevent infection

38. COMPLICATIONS
• Metabolic acidosis
• Fluid and electrolyte imbalances : Hyperkalemia, Hyperphosphatemia,
Hypocalcemia
• Anemia
• Bleeding
• Cardiopulmonary : Arrhythmia, pericarditis, pericardial effusion,
pulmonary edema
• Hyperuricemia
• Infection : Pneumonia, sepsis
• GI : Nausea, vomiting, malnutrition, GI bleeding
• CNS : Asterixis, mental changes, seizures
• Uremic syndrome

39. REFERENCES
• Brunner and suddarth’s, “Textbook of medical surgical nursing”, volume
2, 13th edition, wolter Kluwer publications.
• Lewis ‘s, “Medical surgical nursing assessment and management of
clinical problems”,7th edition, Elsevier publications.
• BT.Basavanthappa, “Medical surgical nursing”, 1st edition, Jaypee brother
medical publishers.
• Joyce M. Black, Jane Hokanson Hawks, “Medical surgical nursing clinical
management for positive outcomes”, volume-1, 7th edition, Elsevier
publications.
• Cambell - Walsh, “Text book of urology”, volume-2, 10th edition, Elsevier publications.
.

40. Thank You