Running Head: ACUTE RENAL FAILURE

Nursing Management 1

Nursing Management of a Patient with Acute Renal Failure BSN 3Y1-6

Running Head: ACUTE RENAL FAILURE

Nursing Management 2

Nursing Management of a Patient with Acute Renal Failure V.C., a 32 year old, male and married and a resident of Valenzuela City with a medical history of methamphetamine use since he was 21 years old and alcoholic drinker was admitted at Fatima Medical Center on July 9, 2011. He was complaining of unable to urinate after claiming to take 50 pieces of Paracetamol and then diagnosed with Acute Renal Failure. According to Brunner and Suddarth (2010), Acute Renal Failure (ARF) is a rapid loss of renal function due to damage to the kidneys. Depending on the duration and severity of ARF, a wide range of potentially life-threatening metabolic complications can occur, including metabolic acidosis as well as fluid and electrolyte imbalances. Serious fluid and electrolyte imbalances can occur in patients with acute renal failure. The patients serum electrolyte levels and IV fluids should be carefully monitored. All oral intake and medications should be carefully screened so as to prevent any sources of potassium to be inadvertently administered or consumed. Daniels (2007) stated that acute renal failure is relatively asymptomatic and is most often detected by laboratory studies. Counts (2008) also stated that the urine output may be normal or may occur changes like oliguria (less than 500ml/day), nonoliguria (greater than 800ml/day), or anuria (less than 50ml/day). The patient complains of difficulty in urinating and has reported that he was only able to urinate 5ml or a teaspoon of urine.

Running Head: ACUTE RENAL FAILURE Pathophysiology

Nursing Management 3

There are many factors that cause acute renal failure and many times there is a specific underlying problem (Brunner and Suddarth, 2010). Some of these factors may be reversible if identified and treated promptly before kidney function is impaired. ARF begins with oliguria, anuria, or even normal urine output. Increased BUN and creatinine levels are also present in patients with acute renal failure. According to Daniels (2007) oliguria is the most common clinical manifestation, with anuria and normal urine output being less common in occurrence. The etiology of acute renal failure is varied. According to Brunner and Suddarth (2010), there are three major categories of renal failure which are the prerenal causes, intrarenal causes and postrenal causes. Kieran and Brady (2003) stated that prerenal causes of ARF are those that result in decrease blood flow to kidney. This may be as simple as dehydration from fluid loss or as complex as the vascular expansion of sepsis or the deficient pumping of cardiac failure. Intrarenal causes are intrinsic to the kidney. These include inflammation of the renal parenchyma, intrarenal vascular thrombosis or drug toxicity because these medications may interfere to the normal auto regulatory of kidney mechanism that may cause hypoperfusion or the decrease blood flow in the organ that may eventually lead to ischemia or direct kidney damage. Due to the damage to kidney it may lead to acute tubular necrosis then eventually lead to renal failure. V.C. has stated that before he experienced the symptoms he ingested 50 pieces of paracetamol. Postrenal failure is caused by obstruction of urine flow. More commonly the obstruction is caused by an enlarged prostate gland or calculus. There is simply no route caused for the urine to exit the system.

Running Head: ACUTE RENAL FAILURE

Nursing Management 4

According to Kieran and Brady (2003) acute renal failure is a potential precursor to chronic renal insufficiency or chronic renal failure. Factors influencing resolution or progression of failure episode are early diagnosis, adequacy of treatment, and the presence of preexisting kidney disease. Major complications of ARF include hyperkalemia, hyponatremia, hypocalcemia, hyperphosphatemia, and hyperuricemia.

Running Head: ACUTE RENAL FAILURE History

Nursing Management 5

The patients condition started 23 days prior to admission when the patient claimed to took more than 50 pieces of paracetamol together with the use of methamphetamine or shabu. After the said incidence, the patient experienced dizziness, headache, drowsiness and more than 20 episodes of vomiting. No consultation was done. 20 days prior to admission the patient experienced bloody urine and prompted consult at Calalang Hospital. He was advised for admission but he refused. He was given unrecalled medication which he only took 4 days after improving on the said symptoms. Fourteen days before admission, the patient experience bloody urine associated w/ flank pain. No further consultation done or medication taken. Four days prior to admission, still with bloody urine, he again consulted at Calalang Hospital and was subsequently admitted but went on HAMA after 2 days. One day before admission, he claimed that he had only a teaspoon of urine output in color black. Hence he consulted again at Calalang Hospital. Few hours prior to admission, still with no urine output, now w/ DOB, he was advised to be transferred to tertiary hospital. He was admitted at Fatima University Medical Center last July 9, 2011. The patient was diagnosed with hypertension last May, 2011 and took losartan and Micardis but not compliant to these drugs. He has no allergy in foods or drugs. He does not smoke but the patient is an alcoholic beverage drinker. He is a user of methamphetamine since he was 21 years old and an occasional marijuana user. He has a family history of hypertension, diabetes mellitus, pulmonary tuberculosis, and his mother was diagnosed with colon cancer.

Running Head: ACUTE RENAL FAILURE Nursing Physical Assessment

Nursing Management 6

The patient is conscious and coherent during the assessment. He was brought to the emergency room per stretcher-borne and was observed being obese and in distress. The patients temperature was 37.2 , pulse rate was 105 beats per minute, respiratory

rate was 32 cycles per minute, and blood pressure was 150/100 mmHg. Upon assessing, the patient was observed with anecteric sclerae and pink palpebral conjunctiva. He has symmetrical chest expansion with negative retraction and positive stridor. He also has tachycardia with regular rhythm and negative murmur sound. His abdomen was distended with normoactive bowel sound, soft, and non tender.

Running Head: ACUTE RENAL FAILURE Related Treatments

Nursing Management 7

The patient has no known allergies to any medication. The patient is treated with an Intravenous solution of 5% Dextrose in Water and the IV site is in left basilic vein. 5% Dextrose in Water is used to provide calories for some metabolic needs. As Ignatavicius (2006) has noted, insertion sites must be chosen carefully after consideration of skin integrity and vein condition. She also stated that IV therapy involves the entire vascular systems or multiple systems. The physician ordered a high carbohydrate and low protein, salt and potassium diet. According to Daniels (2007), dietary management in ARF is required to prevent exacerbation of azotemia and maintaining mineral and electrolyte balance. The nutritional care for ARF involve adequate caloric intake to prevent protein catabolism and starvation ketoacidosis; protein intake restriction, except in highly catabolic patients of 0.8 to 1g/kg/day, and phosphate restriction, as appropriate. The patients medications were furosemide 200mg TIV to increase the amount of urine produced and excreted by removing excessive water (edema). Low blood pressure, dehydration and electrolyte depletion are the side effects of the drug. Burinex 4mg a loop diuretic to treat renal disease. It inhibits the reabsorption of sodium and chloride and increases renal excretion of water, sodium, chloride, magnesium, hydrogen and calcium. Headache, dizziness and muscle cramps are the most common side effects. Amlodipine (Norvasc) 5mg long-acting calcium channel blocker used as an anti-hypertensive. It causes systemic vasodilation resulting to decreased blood pressure. Its side effects are headache, dizziness, peripheral edema and fatigue. Tramadol 50 mg/cap used in treating moderate to severe pain. Caltrate Plus 1tab/day help to

Running Head: ACUTE RENAL FAILURE

Nursing Management 8

build and maintain bone health. It also helps body to absorb calcium. Aminovital 1cap/day a nutrients supplement to recharge bodys energy. Norgesic forte 1tab/day used for acute or chronic painful muscular conditions and classified as a muscle relaxant. The patient has no known allergies in all the meds that was given. The patient has also undergone KUB prostate ultrasound and hemodialysis. No other treatment is done to the patient.

Running Head: ACUTE RENAL FAILURE Laboratory Analysis

Nursing Management 9

Upon admission in the emergency room on July 9, 2011, the patient undergone CBG testing to measure his blood glucose level and the result was 111mg/dL. It is within normal range. On the same day he had SGPT, Creatinine, and BUN and serum electrolyte Test. His BUN is elevated as well as his creatinine level. His serum electrolytes were also low. The result of his CBC was also normal. Chest X-ray was done and the impression was slight cardiomegaly and pulmonary congestive changes. There was a second x-ray done to check the subclavian catheter insertion. The result shows that the jugular catheter is in place and the rest of the findings are the same. During the afternoon, his serum electrolyte was checked and his electrolytes were still below normal range. He also underwent urinalysis. The transparency of his urine is turbid. There is presence of protein and blood. On July 10, 2011, his creatinine test result shows that his creatinine level is still elevated.

Running Head: ACUTE RENAL FAILURE Nursing Care Plan

Nursing Management 10

V.C.s nursing diagnosis is impaired urinary elimination related to drug toxicity as manifested by dysuria and anuria secondary to acute renal failure. According to Daniels (2007) one of the concern of a patient with ARF is difficulty or unable to urinate. The urinary output of the patient is only 5 ml per day. The short term goal is to assess the daily intake and output especially the daily urinary output. Nursing interventions for the patient include promoting urinary elimination by performing perineal flushing and allowing the patient to hear running water from the faucet. Kozier (2004) noted that warm water helps relax muscles and hearing running water stimulates the voiding reflex. Foods that are high in potassium and protein should be avoided. Daniels (2007) stated that reducing intake of foods rich in these can reduce the need for the kidneys to filter the excess levels from the body. The patient has low urine output so fluid restriction is needed to prevent development of hypervolemia. Health teaching about the disease and the treatment plan is also necessary to ensure the patients understanding and compliance. Since the patient is unable to urinate, placing an indwelling catheter may be necessary. Administering diuretics as ordered is also needed to help in promoting urination. The patient may also undergo hemodialysis. According to Encyclopedia of Surgery (2001) hemodialysis may be used in the treatment of patients suffering from poisoning or overdose in order to quickly remove drugs from the bloodstream. After a few days of being hospitalized the patient shows signs of improvements. His urinary output is now within normal range.

Running Head: ACUTE RENAL FAILURE Recommendation

Nursing Management 11

For the patient to fully recover, he should follow up with his physician regarding the hemodialysis and medications. He should also comply with the recommended diet so as to avoid any complications and worsening of his condition. Daniels (2007) pointed out that dietary management in ARF requires the nurse, dietician, and the health care provider to put forth a concerted effort. Pierce, Morris, & Clancy (2002) suggested that medications such as dopamine in low doses has been used to increase renal perfusion by stimulating dopamine receptors by infusing a dose intended to prevent stimulation of related alpha and beta receptors. The nurse should closely observe the respiratory, cardiovascular, and the urinary system of the patient so as to monitor any adverse effect of the drug. Daniels (2007) noted that the patient and family will have a totally new and frightening illness experience when they develop any level of renal failure. They may need ongoing education relative to the disease process, medications inclusive of over-the-counter medication use, and nutrition.

Running Head: ACUTE RENAL FAILURE References

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Smeltzer, S., Bare, B., Hinkle, J., & Cheever, K. (2010). Brunner & Suddarths Textbook of Medical-Surgical Nursing (12th ed). Philippines: Wolters Kluwer Health Lippincott Williams & Wilkins. Daniels, R., Nosek, L., & Nicoll, L. (2007). Contemporary Medical-Surgical Nursing. Philippines: Thomson Delmar Learning. Kozier, B., Erb, G., Berman, A., & Snyder, S. (2004). Fundamentals of Nursing (7th ed). Philippines: Pearson Education South Asia PTE LTD. Kidney Dialysis. Retrieved from http://www.surgeryencyclopedia.com/Fi-La/KidneyDialysis.html