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COLLEGE OF NURSING SILLIMAN UNIVERSITY Dumaguete City

ACUTE RENAL FAILURE RESOURCE UNIT

Submitted to: Mr. Dominique Ablir

Submitted by: Lee, Jiyeong Mejorada, Tarah Stefi Anne T.

Silliman University
Dumaguete City

Vision: As a leading Christian Institution in Asia, Silliman University is committed to total human development for societal and environmental well-being. Mission: In this regard, the University:  Provides opportunities for all members of the academic community to seek justice, truth, and love.  Pursues excellence in every dimension of inquiry, learning, and teaching.  Instills in all members of the University community including all its integral units an enlightened social consciousness, profound sense of involvement, and a genuine compassion for every person.  Enhances national development and unity by making its life and programs relevant to the total development.

Silliman University College of Nursing Dumaguete City

Placement: 1st Semester 2011-2012, Level III Time Allotment: 1 hour Venue: EC 201 Topic Description: This topic focuses on an overview of the treatment of a client with acute renal failure. This embodies essential information regarding acute renal failure, the various phases of anemia, etiology, clinical manifestations, medical managements, and nursing managements. Central Objective: At the end of the one hour, the learners shall have a comprehensive understanding of acute renal failure and the various methods of treatment for a client with acute renal failure.

SPECIFIC OBJECTIVES
At the end of 1 hour, the learners, through active participation in all learning activities, shall:

CONTENT

T.A

T-L STRATEGIES
Lecture-discussion with powerpoint presentation

EVALUATION METHOD

I. Introduction to anemia Good morning everyone. Today, our ward class discussion topic is about acute renal failure. Acute kidney injury (AKI), previously called acute renal failure (ARF), is a rapid loss of kidney function. Its causes are numerous and include low blood volume from any cause, exposure to substances harmful to the kidney, and obstruction of the urinary tract. 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. As nurses we will undoubtedly be faced with the challenge of treating clients with acute renal failure and may do so this upcoming rotation. I hope that our discussion may help better prepare all of us for this inevitability.

2 min

1. Define the various terms associated with acute renal failure in their own words.

II. Definition of Terms A. Acute renal failure a rapid loss of renal function due to damage to the kidney. B. Creatine nitrogenous compound, helps to supply energy to cells in the body primarily muscle.

3 min

Lecture-discussion with powerpoint presentation

Oral questioning, Active participation in the discussion

2. Identify and be able to III. Causes of acute renal failure discuss 3 categories of A. Prerenal failure 10 mins acute renal failure. - It is the result of impaired blood flow that leads to hypoperfusion of the kidney and a decrease in the GFR. These include systemic causes, such as low blood volume, low blood pressure, and heart failure, as well as local changes to the blood vessels supplying the kidney. The latter include renal artery stenosis, which is a narrowing of the renal artery that supplies the kidney, and renal vein thrombosis, which is the formation of a blood clot in the renal vein that drains blood from the kidney. Renal ischaemia ultimately results in functional disorder, depression of GFR, or both. These causes the inadequate cardiac output and hypovolemia or vascular diseases causing reduced perfusion of both kidneys. B. Intrarenal failure - It is the result of actual parenchymal damage to the glomeruli or kidney tubules. Most common type of intrinsic ARF is acute tubular necrosis. C. Postrenal failure - It results from obstruction distal to the kidney. Pressure rises in the kidney tubules and eventually, the GFR decreases. This may be related to benign prostatic hyperplasia, kidney stones, obstructed urinary catheter, bladder stone, bladder, ureteral or renal malignancy. 3. Discuss 15 min comprehensively the IV. Concept Map of Anemia concept map on acute A. Risk Factors, Etiology renal failure y Diabetes y Hypertension y Blockage

Lecture-discussion with powerpoint presentation

Identify 3 categories of acute renal failure.

Socialized discussion with visual aid

Oral questioning, Active participation in the discussion

4. Identify and be able to discuss at least 3 medical managements for acute renal failure

y y y

Overuse of painkillers and Allergic Reactions to Antibiotics Drug Abuse Inflammation

5mins

Lecture-discussion with powerpoint presentation Lecture-discussion with powerpoint presentation Identify at least 3 medical managements for acute renal failure

B. Pathophysiology - as renal function declines, the end products of protein metabolism accumulate in the blood. Uremia develops and adversely affects every system in the body. The greater the buildup of waste products, the more severe the symptoms. C. Clinical Manifestations c.1 Accumulation of Nitrogen Wastes - Accumulation of nitrogenous wastes in the blood, as an early sign of renal failure, occurs before other symptoms become evident. Urea is the first nitrogenous wastes to accumulate in the blood and the BUN level becomes increasingly elevated as renal failure progresses. c. 2 Disorders of Water, Electrolyte, and Acid-base balance. - kidneys eliminate or conserve sodium and water. Chronic renal failure can produce dehydration or fluid overload, depending on the pathologic process of the renal disease. c. 3 Mineral and Bone Disorders - Abnormalities of calcium, phosphate, and vitamin D metabolism occur early in the course of chronic renal failure. c. 4 Hematologic Disorders - chronic anemia is the most profound hematologic alteration that accompanies renal failure. Kidneys are the primary site for the production of the hormone erythropoietin, which controls red blood cell production. In renal failure erythropoietin production usually is insufficient to stimulate adequate red blood cell production by the bone narrow. c. 5 Cardiovascular Disorders - is the major cause of death in patients with ESRD hypertension commonly is an early manifestation of chronic renal failure. c. 6 Gastrointestinal Disorders

10 min

- Anorexia, nausea, and vomiting are common in patients with uremia, along with metallic taste in the mouth that further depresses the appetite. Ulceration and bleeding of the gastrointestinal mucosa may develop, and hiccups are common. c. 7 Disorders of Neural Function - Chronic renal failure patients have alterations in peripheral and central nervous system function. c. 8 Altered Immune function - Infection Is a common complication and cause of hospitalization and death in persons with chronic renal failure. Immunologic abnormalities 5. Identify at least 3 decrease the efficiency of the immune response to infection. 15 mins nursing management for c. 9 Disorders of Skin Integrity acute renal failure. - The skin often is pale owing to anemia and may have a sallow, yellow-brown hue. Skin and mucous membranes often are dry, and subcutaneous bruising is common. c. 9 Sexual Dysfunction - The cause of sexual dysfunction in men and women with chronic renal failure is unclear. The cause probably is multifactorial and may result 5. Discuss the nursing from high levels of uremic toxins, neuropathy, altered endocrine function, process in treating a psychological factors, and medications. patient with acute renal c. 10 Elimination of Drugs failure - The kidneys are responsible for the elimination of many drugs and their metabolites. Renal failure and its treatment can interfere with absorption, distribution, and elimination of drugs. At the end of the ward class presentation, the learners will be able to effectively understand and put into practice the methods of treatment of clients with acute renal failure V. Diagnostic findings A. BUN - BUN level becomes increasingly elevated. VI. Medical Management A. Maintain fluid balance Based on daily body weight, serial measurements of central venous pressure, serum and urine concentrations, fluid losses, blood pressure, and the clinical status of the patient.

Lecture-discussion with powerpoint presentation Lecture-discussion with powerpoint presentation

Identify at least 3 nursing management for acute renal failure

Lecture-discussion with powerpoint presentation

At the end of the report, the learners will be able to fairly evaluate the strong and weak points of the ward class presentation.

B. Avoid fluid excess Detected by the clinical findings of dyspnea, tachycardia, and distended neck veins. The patients lungs are auscultated for moist crackles. Adequate renal blood flow in patients with prerenal causes of ARF may be restored by IV fluids or transfusions of blood products. If ARF is caused by hypovolemia secondary to hypoproteinemia, an infusion of albumin may be prescribed. Dialysis may be initiated to prevent complications of ARF. C. Provide renal replacement therapy Hemodialysis (a procedure that circulates the patients blood through a dialyzer to remove waste products and excess fluid), Peritoneal dialysis (a procedure that used the patients peritoneal membrane as the semipermeable membrance to exchange fluid and solutes), or a variety of continuous renal replacement therapies (CRRTs) (methods used to replace normal kidney function by circulating the patients blood through a hemofilter) D. Pharmacologic therapy In prerenal AKI without fluid overload, administration of intravenous fluids is typically the first step to improve renal function. Volume status may be monitored with the use of a central venous catheter to avoid over- or under-replacement of fluid. Should low blood pressure prove a persistent problem in the fluid-replete patient, inotropes such as norepinephrine and dobutamine may be given to improve cardiac output and hence renal perfusion. While a useful pressor, there is no evidence to suggest that dopamine is of any specific benefit, and may be harmful. Toxin-induced prerenal AKI often responds to discontinuation of the offending agent, such as aminoglycoside, penicillin, NSAIDs, or acetaminophen. The use of diuretics such as furosemide, while widespread and sometimes convenient in ameliorating fluid overload, does not reduce the risk of complications or death. E. Nutritional therapy - Since the kidneys cannot easily remove excess water, salt, or potassium, these may need to be consumed in limited quantities. Foods high in potassium include bananas, apricots, and salt substitutes. Phosphorus is a forgotten chemical that is associated with calcium metabolism and may be elevated in the body in kidney failure. Too much phosphorus can

leech calcium from the bones and cause osteoporosis and fractures. Foods with high phosphorus content include milk, cheese, nuts, and cola drinks. V. Nursing Management A. Monitor fluid and electrolyte balance Monitor fluid status by paying careful attention to fluid intake, urine output, apparent edema, distention of the jugular veins, alterations in heart sounds and breath sounds,and increasing difficulty in breathing. Accurate daily body weights , as well as I&O records, are essential. B. Reduce metabolic rate Let client bedrest to reduce exertion and the metabolic rate during the most acute stage of the disorder. C. Promote pulmonary function Assist the patient to turn cough, and take deep breaths frequently to prevent atelectasis and respiratory tract infection. D. Prevent infection An indwelling urinary catheter is avoided whenever possible due to the high risk of UTI associated with its use. Asepsis is essential. E. Providing skin care Bathing the patient with cool water, frequent turning, and keeping the skin clean and well moisturized and the finger nails trimmed to avoid excoriation. F. Provide psychosocial support The patient with ARF may require treatment with hemodialysis, PD, or CRRT. The patient and family need assistance, explanation, and support during these treatment. The purpose of the treatment is explained by physician. However, high levels of anxiety and fear may necessitate repeated explanation and clarification by the nurse. G. Nursing care plan

Resources:  Black, J. & Hawks, J. (2009). Medical-Surgical Nursing Clinical Management for Positive Outcomes. 8th ed, vol. 2, St. Louis: Saunders Elsevier.  Smeltzer, S. & Bare, G. Textbook of Medical-Surgical Nursing. 10th ed. Vol 2, Philadelphia: Lippincott.  Smeltzer, S.(2010). Textbook of Medical-Surgical Nursing. 12th ed, vol 1, Philadelphia: Lippincott.  Porth, C. M. Essentials of Pathophysiology concepts of Altered Gealth States 2nd ed. Philadelphia: Lippincott.  http://emedicine.medscape.com/article/243492-overview, retrieved 06/20/2011.  http://en.wikipedia.org/wiki/Acute_kidney_injury, retrieved 06/19/2011.