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ACUTE RENAL FAILURE

Patient’s Profile
Name: T.M
Age: 46
Religion: RC
Address: Quezon City
Birthdate: 05/09/63
Civil status: married
Occupation: none
Cc: LBM
Medical Dx: Acute Renal Failure
Attending Physician: Dr. A.R
Present Medical Hx
Three days prior to admission,
patient had loose bowel
movement of about five times
associated with vomiting more tan
ten times, and abdominal pain.
No consultation done, no med’s
taken two days prior. Pt still on
above symptoms developed fever
promptly consult then admitted
Past Medical Hx
• (-) HPN
• (-)PTB
• (+)DM
Family Medical Hx
• (+) HPN
• (+)DM
Personal Social Hx
Since 20 yrs old, the patient was a
alcohol drinker and a smoker
Body Part Methodology Normal Actual
of Assessment findings findings

I. Upper
Extremities
1. hands & nails INSPECTION
a. color Pinkish Cyanotic
b. temp Nor cold, nor Cold to touch
c. texture warm
Smooth Rough
d. turgor Good skin turgur Poor skin turgur
e. presence of No lesion No lesion
lesions
f. edema No presence With edema
2. Brachial PALPATION Good pulsation Weak pulse
pulse
3. forearm & INSPECTION
upper ar,
a. tenderness INSPECTION
4. ROM INSPECTION No limitation Bed rest
II. Head
1. Hair & scalp INSPECTION
a. quantity Good in quality, Good in quality
thickness and Soft & silky hair
texture
b. distribution Well distributed Well distributed
c. lesions No lesions No lesions
2. Face INSPECTION
a. facial Good facial Facial grimace
expression expression

b. symmetry Symmetry in Symmetry


proportion
c. skin, color, Natural pinkish Normal
edema, lession
3. Eye INSPECTION
a. movement of Normal eye Normal
eyeballs movement
b. color of sclera White conjunctiva Normal
& conjunctiva / pinkish
c. size of pupil round Normal
III. Neck INSPECTION
PALPATION

1. asymmetry Symmetry Normal

a. active ROM Symmetric none Bed rest


tender

b. carotid Good pulsation Weak pulse


pulsation
IV. Chest & INSPECTION
Lungs
1. thoracic cage Symmetrical Normal

2. respiration Normal and Dyspnea


relax
3. level of Conscious Conscious
consciousness

4. confirm, symmetrical Normal


symmetrical
expansion

5. note AUSCULTATION None Crackles


adventious
sounds

6. lesions & INSPECTION No lesion & No lesions


edema edema
7. color & temp Warm Cold to touch
V. Abdomen INSPECTION

1. contour, gen Symmetrical, Normal


symmetry flat and smooth

2. INSPECTION Smooth Smooth


skin/umbilicus

3. bowel sound AUSCULTATION Normo active

4. four No tenderness Normal


quadrant
VI. Lower INSPECTION
Extremities

1. lower
extremities

a. color Pinkish cyanotic

b. temp Not warm nor Cold to touch


cold

c. lesion No lesion No lesion

d. edema No edema With edema


INTRODUCTION
Acute renal failure
Acute renal failure is
the abrupt and severe
inability of intra
renal(kidney) or extra
renal system to excrete
the proper amount of
waste product as urine
leading to retention of
waste products in
blood.
Acute renal failure (ARF), also known as
acute kidney failure is a rapid loss of
renal function due to damage to the kidneys,
resulting in retention of nitrogenous and
non-nitrogenous waste products that are
normally excreted by the kidney. Depending
on the severity and duration of the renal
dysfunction, this accumulation is
accompanied by metabolic disturbances,
such as metabolic acidosis and
hyperkalaemia, changes in body
fluid balance, and effects on many other
organ systems.
Incidence
• 5% - 7% of hospital admission
• 30% of ICU admission
ARF: Signs and Symptoms
• Hyperkalemia (cause arrhythmias)
• Nausea/Vomiting
• Malaise
• Pericardial effusion
• Pulmonary edema
• bleeding
• Encephalopathy
Causes of ARF in 3
Categories
Phases of Ischemic ARF

begins with renal insult


hypothetical period of time
S/S: Urine 400ml or less/24 hrs,
Increasing BUN
Phases of Ischemic ARF

Period of ongoing renal failure


and lasts 7-14 days
S/S: Urine Output is Lowest
Phases of Ischemic ARF

Gradual return of renal function


S/S: Can be complicated my marked
diuretic phase
Diagnostic Evaluation
1. Urinalysis shows proteinuria, hematuria,
casts. Urine chemistry distinguishes
various forms of ARF(prerenal, postrenal,
intrarenal).

3. Serum creatinine and BUN levels are


elevated; arterial blood gas (ABG) levels,
serum electrolytes may be abnormal.
3. Renal untrasonography estimates renal
size and rules out treatable obstructive
uropathy.
• A Swan-Ganz catheter may be used, to
measure pulmonary artery occlusion
pressure to provide a guide to left atrial
pressure (and thus left heart function) as a
target for inotropic support.
ANATOMY &
PHYSIOLOGY
Urinary System
How does the urinary
system work?
• The body takes nutrients from food and
converts them to energy. After the body has
taken the food that it needs, waste products are
left behind in the bowel and in the blood.
• The urinary system keeps the chemicals and
water in balance by removing a type of waste,
called urea, from the blood. Urea is produced
when foods containing protein, such as meat,
poultry, and certain vegetables, are broken
down in the body. Urea is carried in the
bloodstream to the kidneys.
Two kidneys
• a pair of purplish-brown organs located below
the ribs toward the middle of the back. Their
function is to remove liquid waste from the
blood in the form of urine; keep a stable
balance of salts and other substances in the
blood; and produce erythropoietin, a hormone
that aids the formation of red blood cells.
• The kidneys remove urea from the blood
through tiny filtering units called nephrons.
Each nephron consists of a ball formed of small
blood capillaries, called a glomerulus, and a
small tube called a renal tubule. Urea, together
with water and other waste substances, forms
the urine as it passes through the nephrons
and down the renal tubules of the kidney.
Two ureters
• narrow tubes that carry urine from the kidneys
to the bladder. Muscles in the ureter walls
continually tighten and relax forcing urine
downward, away from the kidneys. If urine
backs up, or is allowed to stand still, a kidney
infection can develop. About every 10 to 15
seconds, small amounts of urine are emptied
into the bladder from the ureters.
Bladder
• a triangle-shaped, hollow organ located in the
lower abdomen. It is held in place by ligaments
that are attached to other organs and the pelvic
bones. The bladder's walls relax and expand to
store urine, and contract and flatten to empty
urine through the urethra. The typical healthy
adult bladder can store up to two cups of urine
for two to five hours.
Two sphincter muscles
• circular muscles that help keep urine from
leaking by closing tightly like a rubber band
around the opening of the bladder.
Nerves in the bladder
• alert a person when it is time to urinate, or
empty the bladder.
Urethra
• the tube that allows urine to pass outside the
body. The brain signals the bladder muscles to
tighten, which squeezes urine out of the
bladder. At the same time, the brain signals the
sphincter muscles to relax to let urine exit the
bladder through the urethra. When all the
signals occur in the correct order, normal
urination occurs.
PATHOPHYSIOLOGY
Types etiology What happens Clinical findings
a) volume Reduced or deprived There is decrease in
Pre-renal depletion perfusion of kidney-renal GFR so causes
{ structurally intact b) Hypotension ischemia-functional oliguria, azotemia,
nephrons } (systemic disorder or depression of possible fluid
hypovolumia) GFR or both retention and oedema

• Acute The necrotic debris,cellular blebs Blocking of filteration


tubular block the filteration barrier + barrier ( capillary-
necrosis due macula densa is also activated microvasculature)
Renal to ischemia due to chloride load hence
causes prerenal vasodilatation.
here also causes
{with structural and nephrotoxin oliguria and if oliguria
So we have now prerenal dilation
functional damage } • diseases of nitrogenous
and blockage of capillary bed so
glomeruli it results in decrease in filterate- compounds and
oliguria and retention of creatinine is obviously
creatinine and nitrogenous waste increased in blood.
products in blood.

a) Obstructio Urine outflow is There is decrease in


Post-renal n of lumen obstructed so further GFR so causes
(Obstruction of oliguria,
urine flow in b) Compressi filtration is declined. azotemia,possible
anywhere along on of include stone disease; stricture; and fluid retention and
lumen intraluminal, extraluminal, or
urinary tract) oedema
intramural tumors. Prostatic
compression
LABORATORY
Hematology
RESULTS
RBC COUNT 3.36 4.70-6.10
HGB 106 140.0-180.0
HCT 0.30 0.40-0.54
MCV 89.6 85.0-96.0
MCH 31.5 27-31
MCHC 35.5 32.0-36.0
PLATELET COUNT 313 150-450
WBC COUNT 17.6 5.0-10.0
NEUTROPHILS 0.788 0.500-0.700
LYMPHOCYTES 0.087 0.200-0.700
EOSINOPHILS 0.040 0.000-0.090
MONOCYTES 0.089 0.020-0.090
BASOPHILS 0.001 0.000-0.020
Urinalysis
PHYSICAL EXAM CHEMICAL EXAM MICROSCOPIC
EXAM

COLOR- YELLOW ALBUMIN-100 mg/dl PUS CELL-10-15


TRANSPARENCY- SUGAR- (-) RBC
TURBID

REACTION-5.0 KETONE EPITHELIAL CELL-


FEW
SPECIFIC GRAVITY- BILIRUBIN BACTERIA-
1025 MODERATE

UROBILINOGEN
Serology

PROCEDURE RESULT
TROPONIN-I POSITIVE
KUB-(UTZ)
IMPRESSION:

• Non-obstructing nephrolithiasis, right,


• Nephrolithiasis, left producing moderate
pelvocalyectasia
• Normal urinary bladder
RESULT
CREATININE 100.16 53.0-97.0
umol/L
UREA 2.91 umol/L 2.14-7.214
SODIUM 133.6 3.5-5.3
mmol/L
POTASSIUM 2.99 3.5-5.3
CHLORIDE NA 98-107
MEDICATION
Drug Indication Action Contraindication Nursing Responsibilities
> Schilling test > Replaces > Drug-drug: ACE
1) Kalium Durule flushing potassium & inhibitors, > Use cautiously in patients with
mininum potassium digoxin, potassium- cardiac disease or renal
(KCl) dose. level. sparring impairment.

diuretics: May cause


> To prevent hyperkalemia. Use > Give oral potassium
> 10mEq / T.I.D. hypokalemia with supplements

extreme caution. with extreme caution because

> Hypokalemia different forms deliver varying


amounts of potassium. Never
switch
> Severe products without prescriber's
hypokalemia order.

> Acute MI > Potassium preparations aren't


interchangeable; verify
preparation

before use.

> Make sure powders are


completely

dissolved before giving.


> Duodenal and > Compatibility > Contraindicated in > Use cautiously in patient with
2.Ranitidine gastric ulcer inhibits patients hepatic
> Gastroesophageal hypersensitive to drug
50mg reflux dse. action of histamine on and those dysfunction.
> Assess patient with abdominal
> heartburn the H2 at receptors with acute porphyria. pain.
ZANTAC > erosive esophagitis sites of parietal cells, > Renal impairment Note for the presence of blood
> maintenance therapy
for decreasing gastric > Pregnancy in emesis, stool, or gastric aspirate
duodenal or gastric
ulcer acid secretion. > Lactation
> Ranitidine may be added to total
parenteral
nutrition solution.
> Instruct patient on proper use of
OTC
preparation as indicated

> Remind patient to take once a


day
prescription drug at bed time for
best result

> Instruct patient to take without


regard to
meals besause absorption isn't
affected by food.

> Urge patient to aviod cigarette


smoking because
this may increase gastric acid
secretion and worsen disease
>Skin and skin >Contrindicated in > Tell patient to report adverse
4.Cefriaxone structure >A third generation patients reaction promptly
cephalosporin that hypersensitive to
500mg infections inhibits drugs.
>Uncomplicated cee-wall synthesis > Instruct patient to report
gonococcal promoting discomfort at IV insertion
osmotic instability
R0CEPHIN vulvo vaginitis usually >pregnant woman site.

>Bone and joint > Teach patient and family


infection bactericidal. >Lactation receiving home care how

to prepare and give drugs.


>Respiratory tract
infection drugs.
> Alert: Do not confuse drug
with other
>Intra abdominal
infection cephalosporin that sounds like.
> Tell patient to notify prescriber
about loose

, >Septicemia stool or diarrhea.

>Bacteremia

>Meningitis
>Acute bacterial
otitis media
5.Metoclopromid >To prevent or > Contraindicated in >Tell patient to aviod activities
e reduce nausea >Stimulates motility patients that require alertness
andvvomiting from of upper GI tract hypersensitive to
Hydrochloride IV emetogenic increases drugs and in for 2 hours after doses.
MALAXONCLOP cancer lower esophageal those
RA chemotherapy. sphincter pheochro,ocytoma or
tone, and block >Urge patient to report
dopamine seizure disorders. persistent or serious
>To prevent or receptors at the Also contraindicated
reduce trigger zone. in those for adverse effect promptly.
postoperative whom stimulation of
nausea and GI motility
might be dangerous >Adice patient to aviod alcohol
vomiting (ex. Those ingestion during
>To facilitate small- with hemorrhage,
bowel obstruction or therapy.
intubation, to aid in >When oral solution is used
radiologic perforation. dilute in pudding,
applesauce juice or water just
examinations. before using.

>Gastroesophageal >Safety and effectiveness of


reflux dse. drug haven't been
established for therapy lasting
longer than 12 wks.
>Emesis during
pregnancy.
> Monitor bowel sounds.
NURSING CARE PLAN
ASSESSM DIAGNOSI INFERENC PLANNING INTERVENTI EVALUATI
SUBJECTIVE:
ENT Fluid
S Renal Efailure After 8 Independent;
ON GoalONmet,
“Namamanas •Record accurate
Volume hours of patient
ako at ang intake and output
hina ng excess r/t Decrease nursing (I&O). has
katawan ko” blood flow to intervention, •Weigh daily at displayed
Compromis
as verbalized kidneys the patient same time of day, appropriat
by the patient. ed on same scale,
OBJECTIVE: regulatory will display with same e urinary
Decrease
•Venous appropriate equipment and output
mechanism perfusion in
distension urinary clothing with
•Generalized
(renal kidney
output with •Assess skin, specific
edema failure) face, dependent
•Patient Decrease specific areas for edema
gravity/lab
reports of urinary gravity/labor •Plan oral fluid oratory
Fatigue, output atory replacement with studies
weakness, and
studies near patient, within near
malaise multiple
•V/S taken as
Water normal; restrictions normal;
follows; retention stable Dependent; stable
T: 35˚ weight, vital •Administer/restri weight,
CP: 50 Fluid volumes signs within ct fluids as vital signs
R: 13 excess indicated.
BP: 130/90 patient’s •Administer within
normal medication as patient’s
range; and indicatedDiuretics normal
, e.g., furosemide
absence of (Lasix), mannitol range; and
DISCHARGE PLAN
MEDICATION
• Ranitidine 50 mg
• Metochlopromide
• Ceftriaxone 500mg
• Kalium durule, 1 tab daily
• Paracetamol 500mg
EXERCISE
• May exhibit what the body is tolerated
TREATMENT
• Take the medication exactly as prescribed on
regular days
HEALTH TEACHINGS
• encourage only enough fluid intake to replace
urine output to avoid an edema caused by
excessive fluid intake.

• encourage the client to reduced potassium


intake to help prevent elevated potassium
levels

• Tell patient to avoid over fatigue


OUT-PATIENT
• Advise to avoid ‘miracle cures’ drugs that are
not prescribed by the physician and other forms
of quackery

• Advise to have a follow up checkup

• Advice to report to the physician or clinic


regularly for evaluation
DIET
• Low salt, low fat with green leafy vegetables

• Encourage to eat nutritious and vitamins rich


food
SPIRITUALLY
• Encourage to pray always, and ask for
guidance to our almighty GOD.

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