Thursday, December 9, 2010

Nursing Care Plans For Acute Renal Failure

Nursing Care Plans For Acute Renal Failure

  • Determine if there is a history of cardiac disease, malignancy, sepsis, or intercurrent illness.
  • Determine if patient has been exposed to potentially nephrotoxic drugs (antibiotics, NSAIDs, contrast agents, solvents).
  • Conduct an ongoing physical examination for tissue turgor, pallor, alteration in mucous membranes, blood pressure, heart rate changes, pulmonary edema, and peripheral edema.
  • Monitor intake and output
Diagnostic test
  • Urinalysis reveals proteinuria, hematuria, casts
  • Rising serum creatinine and BUN levels
  • Urine chemistry examinations to distinguish various forms of acute renal failure; decreased sodium
  • Renal ultrasonography for estimate of renal size and to exclude a treatable obstructive uropathy

Nursing diagnosis that could be found in patient with renal failure: acute
  • Excess Fluid Volume
  • Risk for Decreased Cardiac Output
  • Risk for imbalanced Nutrition: Less than Body Requirements
  • Risk for Infection
  • Risk for deficient Fluid Volume
  • Deficient Knowledge [Learning Need] regarding condition prognosis, treatment, self-care, and discharge needs

Nursing Intervention with Rationale:

Nursing Diagnosis Excess fluid volume may be related to compromise regulatory mechanism (renal failure). Desired Outcomes/Evaluation Criteria (Client Will):
Fluid Overload Severity: Display appropriate urinary output with specific gravity and other laboratory studies near normal; stable weight and vital signs within client’s normal range; and absence of edema.
Nursing Intervention:

  • Record accurate intake and output (I&O). Include “hidden” fluids, such as intravenous (IV) antibiotic additives, liquid medications, ice chips, and frozen treats. Measure GI losses and estimate insensible losses, such as diaphoresis. Rationale Low urine output less than 400 mL/24 hours may be first indicator of acute failure, especially in a high-risk client. Accurate I&O is necessary for determining fluid replacement needs and reducing risk of fluid overload. Note: Hypervolemia occurs in the anuric phase of ARF.
  • Monitor urine specific gravity. Rationale Measures the kidney’s ability to concentrate urine. In intrarenal failure, specific gravity is usually equal to or less than 1.010, indicating loss of ability to concentrate the urine.
  • Weigh daily at same time of day, on same scale, with same equipment and clothing. Rationale Daily body weight is best monitor of fluid status. A weight gain of more than 0.5 kg/day suggests fluid retention.
  • Assess skin, face, and dependent areas for edema. Evaluate degree of edema. Rationale Edema occurs primarily in dependent tissues of the body, such as hands, feet, and lumbosacral area. Client can gain up to 10 lb (4.5 kg) of fluid before pitting edema is detected. Periorbital edema may be a presenting sign of this fluid shift because these fragile tissues are easily distended by even minimal fluid accumulation.
  • Monitor heart rate, BP, and CVP. Rationale Tachycardia and hypertension can occur because of (1) failure of the kidneys to excrete urine, (2) excessive fluid resuscitation during efforts to treat hypovolemia or hypotension, and (3) changes in the renin-angiotensin system, which helps regulate long-term blood pressure and blood volume. Note: Invasive monitoring may be needed for assessing intravascular volume, especially in clients with poor cardiac function.
  • Auscultate lung and heart sounds. Rationale Fluid overload may lead to pulmonary edema and HF, as evidenced by development of adventitious breath sounds and extra heart sounds.
  • Assess level of consciousness; investigate changes in mentation and presence of restlessness. Rationale May reflect fluid shifts, accumulation of toxins, acidosis, electrolyte imbalances, or developing hypoxia.
  • Plan oral fluid replacement with client, within multiple restrictions. Intersperse desired beverages throughout 24 hours. Vary offerings, such as hot, cold, and frozen. Rationale Helps avoid periods without fluids, minimizes boredom of limited choices, and reduces sense of deprivation and thirst.
  • Correct any reversible cause of ARF, such as replacing blood losses, maximizing cardiac output, discontinuing nephrotoxic drug, and removing obstruction via surgery. Rationale Kidneys may be able to return to normal functioning, thus preventing or limiting long-term residual effects.
  • Insert and maintain indwelling catheter, as indicated. Rationale Catheterization excludes lower tract obstruction and provides means of accurate monitoring of urine output during acute phase; however, indwelling catheterization may be contraindicated because of increased risk of infection.
  • Monitor laboratory and diagnostic studies Rationale Assesses progression and management of renal dysfunction, failure. Note: Dialysis is indicated if ratio is higher than 10:1 or if therapy fails to correct fluid overload or metabolic acidosis.
  • Administer and restrict fluids, as indicated. Rationale Fluid management is usually calculated to replace output from all sources as well as estimate insensible losses due to metabolism and diaphoresis. Prerenal failure is treated with volume replacement and vasopressors. The oliguric client with adequate circulating volume or fluid overload who is unresponsive to fluid restriction and diuretics requires dialysis.
  • Prepare for dialysis as indicated, such as hemodialysis, peritoneal dialysis (PD), or continuous renal replacement therapy (CRRT). Rationale Done to reduce volume overload, correct electrolyte and acid-base imbalances, and remove toxins. The type of dialysis chosen for ARF depends on the degree of hemodynamic compromise and client’s ability to withstand the procedure.

Nursing Diagnosis Risk for decreased cardiac output
Risk factors may include:
• Fluid overload kidney dysfunction or failure, overzealous fluid replacement
• Fluid shifts, fluid deficit (excessive losses)
• Electrolyte imbalance (potassium, calcium), severe acidosis
• Uremic effects on cardiac muscle, oxygenation
Desired Outcomes/Evaluation Criteria Client Will:
Circulation Status: Maintain cardiac output as evidenced by BP and HR and rhythm within client’s normal limits and peripheral pulses strong and equal, with adequate capillary refill time.
Nursing Intervention:

  • Monitor Blood Pressure BP and heart rate. Rationale Fluid volume excess, combined with hypertension, which often occurs in renal failure, and effects of uremia increase cardiac workload and can lead to cardiac failure. In ARF, cardiac failure is usually reversible.
  • Observe ECG or telemetry for changes in rhythm. Rationale Changes in electromechanical function may become evident in response to accumulation of toxins and electrolyte imbalance. For example, hyperkalemia is associated with a peaked T wave, wide QRS complex, prolonged PR interval, and flattened or absent P wave. Hypokalemia is associated with flattened T wave, peaked P wave, and appearance of U waves. Prolonged QT interval may reflect calcium deficit.
  • Auscultate heart sounds. Rationale Development of S3/S4 is associated with congestive HF. Pericardial friction rub may be only manifestation of uremic pericarditis, requiring prompt intervention and, possibly, acute dialysis.
  • Assess color of skin, mucous membranes, and nail beds. Note capillary refill time. Rationale Pallor may reflect vasoconstriction or anemia common in ARF, whether associated with actual blood loss or abnormalities in life of RBCs. Cyanosis is a late sign and is related to pulmonary congestion or cardiac failure. A long capillary refill time is associated with hypovolemic states.
  • Investigate reports of muscle cramps, numbness or tingling of fingers, with muscle twitching and hyperreflexia. Rationale Investigate reports of muscle cramps, numbness or tingling of fingers, with muscle twitching and hyperreflexia.
  • Maintain bed rest or encourage adequate rest and provide assistance with care and desired activities. Rationale Reduces oxygen consumption and cardiac workload.

Nursing Diagnosis Risk for imbalanced nutrition: less than body requirements risk factors may include :
• Protein catabolism, dietary restrictions to reduce nitrogenous waste products
• Increased metabolic needs
• Anorexia, nausea and vomiting, ulcerations of oral mucosa
Desired Outcomes/Evaluation Criteria Client Will Maintain or regain weight as indicated by individual situation; is free of edema.
Nursing Intervention :

  • Assess and document dietary intake. Rationale Aids in identifying deficiencies and dietary needs. Uremic symptoms (such as, nausea, anorexia, altered taste) and multiple dietary restrictions affect food intake.
  • Provide frequent, small feedings. Rationale Minimizes anorexia and nausea associated with uremic state and diminished peristalsis.
  • Give client and SO a list of permitted foods and fluids and encourage involvement in menu choices. Rationale Provides client with a measure of control within dietary restrictions. Food from home may enhance appetite.
  • Offer frequent mouth care and rinse with dilute (0.25%) acetic acid solution; provide gum, hard candy, or breathe mints between meals. Rationale Mucous membranes may become dry and cracked. Mouth care soothes, lubricates, and helps freshen mouth taste, which is often unpleasant because of uremia and restricted oral intake. Rinsing with acetic acid helps neutralize ammonia formed by conversion of urea.
  • Weigh daily, preferably in the morning before breakfast. Rationale The fasting and catabolic client normally loses 0.2 to 0.5 kg/day. Changes in excess of 0.5 kg may reflect shifts in fluid balance.
  • Monitor laboratory studies, such as BUN, prealbumin or albumin, transferrin, sodium, and potassium. Rationale Indicators of nutritional needs, restrictions, and necessity for, and effectiveness of, therapy.
  • Consult with dietitian or nutritional support team. Rationale Determines individual calorie and nutrient needs within the restrictions and identifies most effective route and product oral supplements, enteral or parenteral nutrition.

Nursing Diagnosis Risk for infection risk factors may include
• Depression of immunological defenses (secondary to uremia)
• Invasive procedures or devices, such as urinary catheter
• Changes in dietary intake, malnutrition
Desired Outcomes/Evaluation Criteria Client Will:
Immune Status: Experience no signs or symptoms of infection.
Intervention :

  • Promote good hand washing by client and staff. Rationale Reduces risk of cross-contamination.
  • Avoid invasive procedures, instrumentation, and manipulation of indwelling catheters whenever possible. Use aseptic technique when caring for IV and invasive lines. Change site and dressings per protocol. Note edema and purulent drainage. Rationale Limits introduction of bacteria into body. Early detection and treatment of developing infection may prevent sepsis.
  • Provide routine catheter care and promote meticulous perinea care. Keep urinary drainage system closed and remove indwelling catheter as soon as possible. Rationale Reduces bacterial colonization and risk of ascending UTI.
  • Encourage deep breathing, coughing, and frequent position changes. Rationale Prevents atelectasis and mobilizes secretions to reduce risk of pulmonary infections.
  • Assess skin integrity. Rationale Excoriations from scratching may become secondarily infected.
  • Monitor vital signs. Rationale Fever higher than 100.4°F (38.0°C) with increased pulse and respirations is typical of increased metabolic rate resulting from inflammatory process, although sepsis can occur without a febrile response.

Nursing Diagnosis Risk for deficient Fluid Volume Risk factors may include:
Excessive loss of fluid (diuretic phase of ARF, with rising urinary volume and delayed return of tubular reabsorption capabilities)
Desired Outcomes/Evaluation Criteria Client Will :
Fluid Balance : Display I&O near balance, good skin turgor, moist mucous membranes, palpable peripheral pulses, stable weight and vital
signs, and electrolytes within normal range.
Nursing Intervention 

  • Measure I&O accurately. Weigh daily. Calculate insensible fluid losses. Rationale Helps estimate fluid replacement needs. Fluid intake should approximate losses through urine, nasogastric (NG) or wound drainage, and insensible losses diaphoresis and metabolism. Note: Some sources believe that fluid replacement should not exceed two-thirds of the previous day’s output to prevent prolonging the diuresis.
  • Encourage fluid intake. Provide allowed fluids throughout 24-hour period. Rationale Diuretic phase of ARF may revert to oliguric phase if fluid intake is not maintained or nocturnal dehydration occurs.
  • Monitor BP, noting postural changes, and heart rate. Rationale Orthostatic hypotension and tachycardia suggest hypovolemia.
  • Note signs and symptoms of dehydration, such as dry mucous membranes, thirst, and dulled sensory and peripheral vasoconstriction. Rationale Note signs and symptoms of dehydration, such as dry mucous membranes, thirst, and dulled sensory and peripheral vasoconstriction.
  • Control environmental temperature; limit bed linens, as indicated. Rationale May reduce diaphoresis, which contributes to overall fluid losses.

Nursing Diagnosis Deficient knowledge [learning need] regarding condition prognosis, treatment, self-care, and discharge needs may be related to:
• Lack of exposure or recall
• Information misinterpretation
• Unfamiliarity with information resources
Desired Outcomes/Evaluation Criteria Client Will:
Knowledge: Disease Process
• Verbalize understanding of condition, disease process, prognosis, and potential complications.
• Identify relationship of signs and symptoms to the disease process and correlate symptoms with causative factors.
Knowledge: Treatment Regimen
• Verbalize understanding of therapeutic needs.
• Initiate necessary lifestyle changes and participate in treatment regimen.

Nursing Intervention:

  • Review disease process, prognosis, and precipitating factors, if known. Rationale Provides knowledge base from which client can make informed choice
  • Explain level of renal function after acute episode is over. Rationale Client may experience residual defects in kidney function, which may or may not be permanent.
  • Discuss renal dialysis or transplantation if these are likely options for the future. Rationale Although these options would have been previously presented by the physician, client may now be at a point when options need to be considered and decisions made and may desire additional input.
  • Review dietary plan and restrictions. Include fact sheet listing food and fluid restrictions. Rationale Adequate nutrition is necessary to promote healing and tissue regeneration; adherence to restrictions may prevent complications.
  • Encourage client to observe characteristics of urine and amount and frequency of output. Rationale Changes may reflect alterations in renal function and need for dialysis.
  • Establish regular schedule for weighing. Rationale Useful tool for monitoring fluid and dietary status and needs.
  • Review fluid intake and restriction. Remind client to spread fluids over entire day and to include all fluids (e.g., ice) in daily fluid counts. Rationale Depending on the cause and phase of ARF, client may need to either restrict or increase intake of fluids.
  • Discuss activity restriction and gradual resumption of desired activity. Encourage use of energy-saving and relaxation techniques and diversion activities. Rationale Client with severe ARF may need to restrict activity and may feel weak for an extended period during lengthy recovery phase, requiring measures to conserve energy and reduce boredom and depression.
  • Discuss reality of continued presence of fatigue. Rationale Decreased metabolic energy production, presence of anemia, and states of discomfort commonly result in fatigue.
  • Determine and prioritize activities of daily living (ADLs) and personal responsibilities. Identify available resources and support systems. Rationale Helps client manage lifestyle changes that may be needed to meet personal and family needs.
  • Recommend scheduling activities with adequate rest periods. Rationale Prevents excessive fatigue and conserves energy for healing and tissue regeneration.
  • Review medication use. Encourage client to discuss all medications, including over-the-counter (OTC) drugs and herbal supplements, with healthcare provider. Rationale Medications that are concentrated in or excreted by the kidneys can cause toxic cumulative reactions and permanent damage to kidneys. Some supplements may interact with prescribed medications and may contain electrolytes.
  • Stress necessity of follow-up care and laboratory studies. Rationale Renal function can be slow to return up to 12 months following ARF and deficits may persist, requiring frequent monitoring to avoid complications.
  • Identify symptoms requiring medical intervention, such as decreased urinary output, sudden weight gain, presence of edema, lethargy, bleeding, signs of infection, and altered mental status. Rationale Prompt evaluation and intervention may prevent serious complications and progression to chronic renal failure (CRF).


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