Acute vs.

Chronic Renal Failure

Renal failure is caused by conditions that diminish blood flow to the kidneys resulting in damage leaving the kidneys unable to function. Metabolic waste products ultimately build up in the body causing fluid, electrolyte and acid-base imbalances. Renal failure is classified as either acute or chronic based on onset and reversibility. Acute renal failure occurs within one to seven days and may be reversible. Chronic renal failure can take months to years to occur and is not reversible. The causative factors of acute and chronic renal failure are different as well. Acute renal failures causative factors are divided into 3 categories prerenal, intrarenal, and postrenal. The glomeruli need a systolic blood pressure of greater than 70 mmHg for adequate function. If SBP drops to less than 70 mmHg, prerenal damage can occur. Nephrotoxic agents, kidney infections, blockage of arteries inside the kidneys, hypertension, diabetes mellitus, or direct trauma to the kidney can cause intrarenal damage. Postrenal damage occurs when urine backs up due to obstruction past the kidneys caused by benign prostatic hypertrophy, and ureteral calculi. Acute renal failure can affect nearly every body system causing symptoms such as lethargy, nausea, vomiting, diarrhea, dehydration, drowsiness, headaches, muscle twitching and seizures. The progression of the condition follows four stages; onset, oliguric, diuresis, and recovery. The onset stage typically lasts 1-3 days and is when symptoms first occur. The oliguric stage lasts up to 14 days during which urine output is less than 400mL per day. During the diuretic stage urine output increases to over 400mL per day and may increase to around 4L per day. Despite excreting such large volumes of fluid, waste products are excreted causing additional electrolyte imbalances. The final stage is the recovery stage which can last up to 12 months. If during the recovery stage enough healing does not occur to resume normal function, chronic renal failure may develop. When assessing a patient in acute renal failure the most important aspect is monitoring fluid, electrolyte, and acid-base balances. During renal failure BUN and serum creatinine rise dramatically and are monitored frequently to assess kidney function and progression of the disease. Due to decreased kidney function potassium is not excreted causing hyperkalemia which can lead to cardiac dysrhythmias. Metabolic acidosis frequently occurs due to the inability of the kidneys to function as a buffering system and an increase in acidic components in the blood. In addition to fluids and electrolyte imbalances, erythropoietin production is reduced causing decreased red blood cell production which causes anemia. In order to measure fluid levels strict I&Os should be obtained however a more accurate method of

monitoring fluids is by taking the patients weight daily. When weighing the patient, make sure that variables such as amount of clothing, time, and specific scale used are kept the same to ensure accuracy. If a patients weight changes by one pound that is equivalent to 500mL of fluid. Treatment for acute renal failure is aimed at preventing further damage to the kidneys, resolving any causative factors, and to allow healing to take place. Supportive measures help to control symptoms and prevent additional complications. Supportive measures include fluid and diet adjustments, supplementation to restore electrolyte balance, and dialysis if needed. Conditions that warrant hemodialysis include hyperkalemia, severe metabolic acidosis, pulmonary embolism, and rising BUN. The initial cause of the kidney damage is determined and treated. Various medications are used to treat individual symptoms or complications. Some examples of this are diuretic agents are used to treat oliguria and IV hypertonic glucose and insulin, sodium bicarbonate, and calcium gluconate to treat hyperkalemia. Determination of changes to the patients diet is made based on the individual patients needs. Carbohydrate intake is usually increased to prevent the breakdown of fat and protein. The nurse caring for a patient with acute renal failure must monitor fluid balance, give medications as ordered, monitor for adverse effects, and monitor cardiac and respiratory function. Fear and anxiety may occur so it is important to provide honest answers to any questions the patient might have. Any specific questions about their prognosis should be referred to the physician. Due to electrolyte imbalances and reduced mobility, complications may arise in other body systems. It is important that the nurse be aware of these potential complications and performs the appropriate interventions to prevent them. It is important that the patient understand the reason for the interventions to increase compliance and improve self-care when discharged. Patient teaching is aimed at providing basic information about the disease and any diagnostic tests, procedures, or treatments. Provide patient teaching about diet, management of fluids, drug therapy, activity, and signs and symptoms that should be reported to the physician such as dyspnea, edema, or fever. Chronic renal failure is a progressive, irreversible decline in renal function in which the kidneys cannot maintain fluid and electrolyte balance. The most common causes of chronic renal failure are diabetes mellitus, hypertension, and vascular disorders. Chronic kidney infections, obstruction of urine, polycystic kidney disease, and nephrotoxic agents can lead to chronic renal failure as well. Chronic renal failure is divided into three stages; stage 1 also called reduced renal reserve, stage 2 or renal insufficiency, and stage 3 or end-stage renal disease. During the reduced renal reserve stage, nephron function loss is about 40%-70%. Typically the patient does not present with symptoms because the remaining nephrons are able to compensate for the decline in function. During the renal insufficiency stage, only 10%-25% of nephrons are functioning. Serum creatinine and BUN are elevated, urine output is significantly increased

and anemia typically develops. During the final stage of chronic renal failure or end-stage renal failure, less than 10% of the nephrons are functioning and the kidneys are unable to function properly. As with acute renal failure, chronic renal failure affects nearly every body system. Cardiovascular complications are the most severe and life threatening with cardiovascular disease being the most common cause of death in patients with end stage renal disease. Complications of the integumentary system include severe pruritus, and urea crystal deposits on the skin called uremic frost. Neurologic problems occur such as decreased level of consciousness, decreased concentration, muscle twitching and seizures. Assessment of the patient with chronic renal failure is similar the assessment for acute renal failure. I&Os, acidosis, electrolyte balance, fluid balance, anemia, and glomerular filtration rate should all be assessed and accurately documented. Treatment of chronic renal failure utilizes medications such as antacids, antihypertensive agents, ant seizure medications, and erythropoietin. Dietary changes include regulation of proteins, fluids, sodium, and potassium along with increased calorie consumption and vitamin supplementation. When chronic renal failure can no longer be managed using supportive measures dialysis is used to filter the patients blood. Eventually a kidney transplant may be required to resolve the disease. Nursing care of the patient with chronic renal failure is aimed at preventing complications, patient education, and assisting the patient with coping strategies for dealing with the disease. When the patient is on dialysis they are taught how to care for the port at home, special precautions, signs and symptoms to report to the health care provider, and how to check for patency. Self-care management and compliance with treatment is stressed. The patient will often need emotional support and encouragement from the nurse and those around them. Dialysis is a life-long commitment therefore constant encouragement and reinforcement of positive health status is important to keep the patient motivated.

Work Cited
Linton, A. D. (2011). Introduction to medical-surgical nursing. (5 ed.). San Antonio: W B Saunders Co. Smeltzer, S. C. O., & Bare, B. G. (2004). Brunner & suddarth's textbook of medical-surgical nursing. (10 ed.). philadelphia: