Pathophysiology

Also known as acute kidney injury (AKI), is measured by the buildup of waste in your body and
altered fluid levels because the kidneys are failing to do their job. The cause of the renal failure
can also change the pathophysiology. There are three main causes: 1) decreased blood flow to
the kidneys, 2) direct injury to the kidney/tissues, and 3) blockage of urine excretion.
Inflammation to the kidneys or their structures (nephrons) can cause the kidneys to fail.
Blockage of urine can cause a backup in the kidney, not allowing them to continue to filter out
waste from the body or manage fluid levels.

Etiology
There are many causes of kidney failure. For example, low blood perfusion to the kidneys can
cause acute kidney failure from causes such as an infection/antibiotic use, hypotension
potentially from blood loss (hemorrhage) or fluid loss (vomiting/ diarrhea), or even other organ
failure (heart attack, liver failure). Another reason for kidney failure could be direct damage to
the structures of the kidney itself. The biggest offender of kidney damage is sepsis, but also
anything that can cause inflammation in the vessels of the kidneys (Vasculitis) as well as the
attempt to treat it with too many NSAIDs can cause direct damage to the kidneys. Lastly, if the
urine cannot be excreted, this can cause kidney failure. Kidney stones, enlarged prostates and
some cancers can present problems for the urinary tract’s ability to excrete urine.

Desired Outome
Return normal functioning of the kidney’s, including the nephrons, blood vessels, urethra, and
ureters. Have the kidney labs be within normal limits and hopefully not have the patient on
dialysis.

Acute Renal Failure Nursing Care Plan

Subjective Data:

 Increased thirst
 Dizziness
 Flank pain
 Hematuria
 Oliguria
 Recent antibiotic usage
 Over usage of NSAIDs
 Recent blood transfusion
 Chest pain/pressure
  Confusion

Objective Data:

 Hypertension
 Orthostatic Hypotension
 Atrial fibrillation
 JVD
 Pulmonary Edema/Rales
 Edema

Nursing Interventions and Rationales:

1. Strict intake and output measurement
o It is important if the kidney’s are not functioning to measure the patient’s I&Os.
Notify the physician if there is a deficit greater than 5-10%.
2. Medications to watch: Statins, NSAIDS, Aspirin
o Be mindful of medications that can become toxic when the kidneys aren’t
functioning at their prime.

Try to limits these drugs, watch labs and antibiotic troughs. Look out for signs
3. Statins NSAIDS Aspirin Acetaminophen Insulin Some antibiotics Herbal supplements
o Be mindful of medications that can become toxic when the kidneys aren’t
functioning at their prime.

Try to limits these drugs, watch labs and antibiotic troughs. Look out for signs
and symptoms of overdose.

Here are the most common signs and symptoms of overdose. *note this is not a
comprehensive list*

Statins: muscle pain and weakness.

NSAIDS: N/V, headache, dizziness and blurred vision.

Aspirin: ringing in the ears (tinnitus), decreased hearing.

Acetaminophen: N/V/D, irritability, convulsions, coma.

Insulin: Hyperinsulinemia from the body building up resistance to insulin.

Some antibiotics: Neuro symptoms like seizures, confusion, neuropathy.

 Herbal supplements: Various, depends on the herbal supplement.
4. Monitor lung sounds and edema
o You want to make sure fluid balance is carefully monitored. A backup in the lungs
would cause crackles and a back up systemically would cause pitting edema in
the legs.
5. Diuretic administration: Furosemide (Lasix) Bumetanide (Bumex) Spironolactone (Aldactone)
o This is very important… diuretics are going to make the patient PEE… lots and lots
of PEE. Do not under any circumstances administer a diuretic without a bathroom
plan. And a word to the wise, have a backup plan. Meaning if you have a walkie
talkie patient with functioning arms and a strong call light finger, I still would set
up a bedside commode just.in.case. I walk them to the bathroom or assist them
in any way needed, but it is possible that they do not know how urgent their
situation is and I can clean up pee, but you can’t clean up that patients dignity.

Diuretics work on different parts of the nephrons. The goal of diuretics is to help
the kidneys rid the body of salt (notice I didn’t say sodium (Na+)?) and fluids. It is
important to note for every Na+ molecule there is a compound of one water
(H20) that follows it. Psssst: potassium is a salt...

There are three kinds of diuretics: Loop, Thiazide, and potassium sparing.

Loop: works on the loop of henle and excretes Na+, K+, and Ca-. (Yikes! Watch
your patient’s electrolytes!)

Thiazide: Works on the distal convoluted tubule and blocks the Na+/Cl- symporter
(which reabsorbs...you guessed it Na+ and Cl-). This symporter is responsible for
about 5% of Na+ reabsorption. So monitor your patient’s sodium and chloride.
Oh, and your K+...Why? Because K+, Cl- and Na+ have direct relationships!

Potassium-Sparing: Works on the Na+/K+ pumps in the collecting ducts of the

kidney by blocking the effects of aldosterone at that site. Aldosterone has the
collecting ducts reabsorbing Na+ and thus water, and for ever Na+ absorbed, one
molecule of K+ is excreted. So this diuretic does the opposite of that, saves a K+
and excretes a Na+ and H20.

Most commonly used diuretics in acute kidney failure:

-Furosemide: Loop
-Bumetanide: Loop
-Spironolactone: Potassium-Sparing
6. Monitor Potassium Potassium (K+) Normal range: 3.5 - 5.0 mEq/L
o As Furosemide is the front line and best treatment for kidney failure, nurses must
be careful to watch the patient’s potassium levels (Remember: Furosemide is
potassium wasting).
 Potassium (K+): is the most abundant intracellular cation and plays a vital role in
the transmission of electrical impulses in cardiac and skeletal muscle. It plays a
role in acid base equilibrium. In states of acidosis hydrogen with enter the cell as
this happens it will force potassium out of the cell, a 0.1 decrease in pH will cause
a 0.5 increase in K+
7. Diet changes and control Fluid restriction Salt restriction
o Educating the patient on decreased sodium intake as well as strict fluid intake is
vital when in any sort of kidney failure.

However, if patient is on a potassium wasting diuretic, educate about potassium

(bananas, sweet potatoes, etc.)
8. Monitor Kidney Labs Blood Urea Nitrogen (BUN) Normal Range: 7-20 mg/dL Creatinine (Cr) Normal
Range: 0.7-1.4 mg/dL
o This measures how well treatment is working, you want the labs to be moving
back to normal limits.

Blood Urea Nitrogen (BUN): measures the amount of urea in the blood. When
protein is broken down ammonia is formed. Ammonia is converted to urea in the
liver and is eventually excreted in the kidneys.

Creatinine (Cr): is a byproduct of creatine metabolism, and it is excreted by the

kidneys. Creatinine is created in proportion to muscle mass and usually stays
stable.
Scenario

A 65 year old patient is admitted with renal failure. The patient is alert and oriented times 3.
The patient reports he decided to go to his doctor’s office because he has been unable to “pee”
for the past 4 days and he was sent here to the ER. He states he has “may be peed three drops”
of urine over the past 4 days and that the “drops” were very dark brown. The patient also
states he has been forcing fluids because he thought may be he was dehydrated but says that
the fluids seems to be going into his legs and he has gained 12 lbs over the past 3 days. He
states he normally weighs 165 lbs. You note the patient has 4+ pitting edema in his legs and fine
crackles through out his lungs. The patients VS are BP 180/110, HR 85, oxygen saturation 91%
on RA, Temp 99.6, and RR 19. The patient labs are Potassium 6.0, Hgb 8.0, Hct 29.3, BUN 6.5,
and Creat 52. The MD ordered for the patient to have dialysis today.

Nursing Diagnosis

Excess fluid volume related to compromised regulatory mechanisms secondary to acute renal
failure as evidence by peripheral edema and weight gain.

Subjective Data

Patient reports he decided to go to his doctor’s office because he has been unable to “pee” for
the past 4 days and he was sent here to the ER. He states he has “may be peed three drops” of
urine over the past 4 days and that the “drops” were very dark brown. The patient also states
he has been forcing fluids because he thought may be he was dehydrated but says that the
fluids seems to be going into his legs and he has gained 12 lbs over the past 3 days.

Objective Data

A 65 year old patient is admitted with renal failure. The patient is alert and oriented times
3. You note the patient has 4+ pitting edema in his legs and fine crackles through out his lungs.
The patients VS are BP 180/110, HR 85, oxygen saturation 91% on RA, Temp 99.6, and RR 19.
The patient labs are Potassium 6.0, Hgb 8.0, Hct 29.3, BUN 6.5, and Creat 52. The MD ordered
for the patient to have dialysis today.

Nursing Outcomes

-The patient will have negative or equal intake and output during hospitalization.

-The patient will have decreased peripheral edema of 1+ or less within 48 hours.

-The patient will have 30 cc or greater of urinary output during a 24 hour period.

-The patients BUN and creatinine will be within normal range within 36 hours.
-The patient will weigh 165lbs or less by discharge.

-The patient will verbalized the importance of daily weights and limiting salt intake by
discharge.

-The patient will name 5 foods that contain high salt intake to avoid by discharge.

-The patient will verbalize understanding about how hemodialysis works before dialysis.

Nursing Interventions

-The nurse will monitor the patient intake and output every shift.

-The nurse will assess the patient’s peripheral edema every shift.

-The nurse will monitor the patients urinary output every shift.

-The nurse (if needed per md order) will place foley catheter to monitor urinary output more
closely.

-The nurse will call any abnormal BUN and creatinine result to the md.

-The nurse will weigh the patient daily.

-The nurse will educate the patient about the importance of daily weights and limiting salt
intake by discharge.

-The nurse will educate the patient about 5 foods that contain high salt intake to avoid by
discharge.

-The nurse will educate the patient about how hemodialysis works before patient has dialysis.