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Nursing Diagnosis for Acute Renal Failure : Etiology, Pathophysiology, and Treatment

Updated on April 25, 2014
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Trained in dentistry, Sree is currently studying lab sciences. She enjoys researching various health topics and writing about her findings.

The kidney is a bean-shaped organ which serves as the main organ of the urinary system. It is primarily responsible for the excretion of toxic substances that are not needed by the body. It has an essential role in the regulation of water and electrolyte balance, mean arterial pressure and acid-base balance as well as the secretion of hormones. Since these functions are important in promoting equilibrium in the body, impairment of the kidney can lead to a series of complications in other organ systems as well.

Statistics show an increasing incidence rate of renal impairment among individuals worldwide. Due to some vast changes in eating practices, lifestyle and behavior, the number of annual cases has risen to 100 patients for every 1 million individuals. Currently, acute renal failure (ARF) is one of the most prevalent kidney diseases in the world. In this article, the etiology, pathophysiology, diagnosis, prevention and treatment of ARF will be discussed extensively.

The kidney is a bean-shaped organ which serves as the main organ of the urinary system. It is primarily responsible for the excretion of toxic substances that are not needed by the body. It has an essential role in the regulation of water and electrolyte balance, mean arterial pressure and acid-base balance as well as the secretion of hormones. Since these functions are important in promoting equilibrium in the body, impairment of the kidney can lead to a series of complications in other organ systems as well.

Statistics show an increasing incidence rate of renal impairment among individuals worldwide. Due to some vast changes in eating practices, lifestyle and behavior, the number of annual cases has risen to 100 patients for every 1 million individuals. Currently, acute renal failure (ARF) is one of the most prevalent kidney diseases in the world. In this article, the etiology, pathophysiology, diagnosis, prevention and treatment of ARF will be discussed extensively.

Etiology

Some people classify the causes of acute renal failure into three, namely prerenal, renal and post-renal. Prerenal conditions mainly affect the glomerular filtration rate (GFR) and renal perfusion pressure (RPP). Renal failure is mainly rooted in the actual nephron and parenchymal damage in the structure of the kidney. Post-renal causes include conditions such as ureteric obstructions and kidney stones that affect the flow of urine.

Acute renal failure is most commonly caused by ischemia. Decreased blood flow in the kidney may be due to a thrombus, embolus or constriction of blood vessels. If blood flow is impeded for more than two hours, the GFR becomes severely impaired. Hence, the plasma will not be filtered normally and instead, be reabsorbed into the peritubular capillaries and the extracellular fluid.

Nursing Diagnosis for Acute Renal Failure : Etiology, Pathophysiology, and Treatment
Nursing Diagnosis for Acute Renal Failure : Etiology, Pathophysiology, and Treatment | Source

Pathophysiology

There are three distinct phases during the course of acute renal failure. The first stage is the onset, wherein an underlying condition causes decreased renal blood flow (RBF). Blood insufficiency then leads to apoptosis and necrosis because cells do not receive sufficient oxygen to carry out their normal functions. This impairs the GFR because fewer cells become capable of filtering wastes.

Hemorrhage is one of the underlying conditions that may trigger the onset of ARF. In order to compensate for the systemic loss of blood, vasoconstriction occurs. This decreases RBF and perfusion pressure. However, if the onset phase is immediately treated, there is a high chance of reversibility.

The second phase is maintenance, wherein a prolonged decrease in GFR leads to the subsequent death of renal cells. The proximal convoluted tubules, loop of Henle and distal convoluted tubules become severely damaged in this stage. The endothelia of renal capillaries are destroyed, leading to tubular obstruction. This causes a positive feedback mechanism wherein tubules become even more permeable to solutes. Proteins with high molecular weight can leak through the thick barrier.

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During this phase, oliguria also occurs. This is essential in the nursing diagnosis for acute renal failure because decreased GFR renders the kidney incapable of eliminating water, electrolytes and other metabolites. This leads to the production of a small amount of urine.

The maintenance phase is also characterized by azotemia, which is one of the first things to note during nursing diagnosis for acute renal failure. The presence of nitrogenous wastes in the blood indicates that the kidney has an abnormal filtration mechanism.

It is crucial that this phase becomes detected and treated early in order to prevent further complications. When left untreated, a patient is at risk for pulmonary edema and cardiovascular arrest due to the increased fluid retention. Electrolytes that remain in blood lead to diffusion of water inside the blood vessels. This increases the volume that circulates in the system, which leads to the accumulation of blood. The immune system also becomes weaker because the number of red blood cells substantially decreases.

The final stage is recovery, wherein nephrons start to regenerate. Renal function significantly improves when proper treatment is given. During the first twenty days of this phase, the GFR stabilizes. Laboratory workup also shows that BUN and serum creatinine levels return to normal.

Etiology, Pathophysiology and Nursing Diagnosis for Acute Renal Failure
Etiology, Pathophysiology and Nursing Diagnosis for Acute Renal Failure | Source

Diagnosis

The first step in the nursing diagnosis for acute renal failure is to perform a complete body examination. The patient history must also be obtained to determine possible risk factors. Some manifestations of individuals with ARF are fatigue, nausea, anorexia, pruritus and inability to respire normally. Physical workup also shows myoclonus, asterixis, pericardial and pleural edema and pulmonary rales.

Nursing diagnosis for acute renal failure can be conducted by measuring the blood urea nitrogen (BUN) level of an individual. BUN levels are abnormally high because of the decreased glomerular filtration rate. The kidney normally functions in filtering plasma and excreting wastes from this fluid. However, when the GFR is impaired, the kidney is unable to filter urea, leading to the accumulation of this waste product.

Blood creatinine levels indicate the rate of creatinine clearance. Levels are also increased among individuals with ARF because of the kidney's inability to eliminate this waste. The upper limit of normal creatinine level ranges from 1.6 to 1.9 mg/dL, which means if this waste product is present in high amounts, kidney function may be impaired.

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The nursing diagnosis for acute renal failure may also provide the definitive cause through a complete blood count (CBC). A CBC of an individual with acute renal failure becomes low because the blood cells can pass through the filtration barrier. Normally, a steady filtration barrier is present in the glomeruli and Bowman's capsule to prevent the release of big molecules into the urinary tract. Because red blood cells are excreted in the form of urine, this could lead to anemia. Other results shown in CBC are leukocytosis, leukopenia and thrombocytopenia and eosinophilia.

Cystatin C is another substance that can be detected during nursing diagnosis for acute renal failure. Cystatin C is constantly secreted by the renal tubules and can be excreted solely through the kidney. Hence, this serves as an important biomarker in identifying the presence of ARF.

Results of urinalysis also indicate the presence of ARF. Nursing diagnosis for acute renal failure is usually conducted through the dipstick leukocyte esterase test (LET) or nitrite production test (NPT). Gross and histological examination of hematuria is also conducted to confirm the presence of proteins in the urine. Laboratory results show that specific gravity is greater than 1.018 because of the presence of proteins in the urine. Urine osmolality is greater than 500 because of the excretion of electrolytes. In progressive cases of ARF, RBC and WBC casts may even be present in the urine.

Complete Blood Count : Nursing Diagnosis for Acute Renal Failure
Complete Blood Count : Nursing Diagnosis for Acute Renal Failure | Source

Prevention and Treatment

Despite the various causes of ARF, prevention can be done by limiting the risk factors. An individual must recognize underlying conditions to prevent the onset of ARF. For instance, an individual who has a cardiac dysfunction should immediately have his condition treated before it progresses to affect the kidney as well. Individuals who have ureteric stones must remove the obstruction before it impairs nearby organs such as the kidney. The presence of bacteria in the circulation may also impair renal blood supply, leading to dysfunction. Even prostate gland enlargement should be treated because this condition may lead to excessive storage of urine.

Prevention can be achieved by immediate treatment of an underlying disease. This is extremely important because inability to do so could lead to chronic kidney disease. When the condition becomes prolonged, majority of nephrons in the kidney are damaged and can no longer be treated.

If the cause is prerenal, treatment of the underlying condition usually leads to normal kidney function. However, treatment caused by renal and post-renal factors depend on the extent of the damage that affected the organs.

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