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Acute Renal Failure Case Study

Our kidneys are incredible organs that get rid of toxins, retain substances needed by our bodies, and maintain the right balance of electrolytes, minerals, and water. Find out what happens to this 27-year-old when toxins accumulate in her kidneys leading to acute renal failure.

Module 11: Acute Tubular Necrosis

A 27 year old female was seen by medical personnel at an after...

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The patient was admitted to the hospital by the patient's...

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End Stage Renal Failure Case Study

Info: 4939 words (20 pages) Nursing Case Study Published: 18th Oct 2021

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Introduction

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Medical history

Present status, pathophysiology, peripheral vascular disease, inflammatory cytokines and susceptibility to infection, current medication, 1. aspirin 100mg daily with food., 2. injection piperacillin/tazobactum 4.5gram twice a day, 3. calcitriol 0.25 mcg daily per oral, 4. gliclazide 120mg daily with meal, 5. calcium carbonate tablet 1250mg three times per day with meal, 6. metoprolol 50mg per oral, 7. clopidogrel 75mg oral per day, 8. bactrim antibiotic, 9. vitamin tablets, 10. darbepoetin alfa injection 80mcg iv once weekly on dialysis, current medical treatment.

• Kathy is on regular haemodialysis, three times per week as her renal replacement therapy. Kathy was admitted to the hospital with diabetic foot ulcer and missed three dialysis. On arrival to the hospital she was very unwell and her blood results showed hyperkalaemia, anaemia and uraemia and definite signs of infection by an elevated CRP. Kathy received emergency haemodialysis and was admitted in the renal ward for further dialysis and wound management.
• Treatment for hyperkalaemia: In the emergency department Kathy received treatment for hyperkalaemia as her serum potassium was 6.8mmol/l. Hyperkalaemia is actually a  life threatening condition in which serum potassium exceeds 5.5mmol/l ( Lehnhardt & Kemper, 2011 ). Kathy was given Calcium Resonium prior to emergency dialysis to treat her hyperkalaemia. Calcium Resonium helps to remove the excessive amounts of potassium from the blood (AMH online).
• Haemodialysis: Haemodialysis is one of the treatment options for a patients with End stage renal disease which helps to remove the excess fluid, waste products and in turn balances electrolytes in the body (Daugirdas & Blake 2007).Kathy was given emergency dialysis to stabilise her urea, creatinine and electrolytes. As she missed three dialysis sessions together, she underwent missed dialysis protocol as per hospital guidelines. According to Top End Renal guideline (2015), patient who has missed three or more consecutive dialysis treatments should be dialysed in the acute dialysis unit with three gentle dialysis using low pump speed and low flux dialyzer for two hours and subsequently increasing to three and then to four hours in the next consecutive days. Kathy underwent haemodialysis for three consecutive days to complete her missed dialysis protocol. Through the missed dialysis protocol more fluid was removed and had stabilised serum electrolyte levels. Kathy continued to have haemodialysis three times in a week after completing missed dialysis protocol.
• Wound swab: The wound swab was sent withno organism found.
• High risk foot team: High risk foot team service also reviewed Kathy and she had debridement on her right foot and was started on antibiotics.
•   ECHOCARDIOGRAM: Kathy has history of coronary artery disease and hence an ECHO was performed as per cardiology team. It showed left ventricular (LV) normal in size with mild segmental systolic dysfunction and mild to moderate left ventricular hypertrophy (LVH).

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Acute Renal Failure

Learn about the nursing care management of patients with acute renal failure in this nursing study guide .

Table of Contents

• What is Acute Renal Failure? 

Pathophysiology

Statistics and incidences, clinical manifestations, complications, urine tests, blood tests, other tests, medical management, nursing assessment, nursing diagnosis, nursing care planning & goals, nursing interventions, discharge and home care guidelines, documentation guidelines, what is acute renal failure.

Renal failure results when the kidneys cannot remove the body’s metabolic wastes or perform their regulatory functions.

• Acute renal failure ( ARF ) is a rapid loss of renal function due to damage to the kidneys.
• Acute renal failure is also known today as acute kidney injury ( AKI ) .
• It is a problem seen in hospitalized patients and those in outpatient settings.
• A healthy adult eating a normal diet needs a minimum daily urine output of approximately 400 ml to excrete the body’s waste products through the kidneys. An amount lower than this indicates a decreased GFR.

Although the pathogenesis of ARF and oliguria is not always known, many times there is a specific underlying problem.

• Underlying problems. There are underlying problems that cause the development of ARF such as hypovolemia , hypotension , reduced cardiac output and failure, and obstruction of the kidney.
• Blood flow. As these underlying problems affect the body, the blood flow to the kidneys reduces.
• Decreased kidney function. With inadequate blood flow to the kidney, there is impaired kidney function.
• Failure. If the underlying conditions are not treated and corrected, they can lead to permanent damage of the kidneys.

Here’s the statistics and incidences for acute renal failure :

• ARF affects approximately 1% of patients on admission to the hospital, 2% to 5% during the hospital stay, 4% to 15% after cardiopulmonary bypass surgery , and 10% of cases acute renal failure occurs in isolation (i.e. single organ failure).
• In the United States, the annual incidence of acute renal failure is 100 cases for every million people . It’s diagnosed in 1% of hospital admissions. Hospital-acquired acute renal failure occurs in 4% of all admitted patients and 20% of patients who are admitted to critical care units.

Acute renal failure (ARF) has four well-defined stages: onset, oliguric or anuric, diuretic , and convalescent. Treatment depends on stage and severity of renal compromise. ARF can be divided into three major classifications, depending on site:

• Prerenal failure is caused by interference with renal perfusion (e.g., blood volume depletion, volume shifts [“third-space” sequestration of fluid], or excessive/too-rapid volume expansion), manifested by decreased glomerular filtration rate (GFR).
• Disorders that lead to prerenal failure include cardiogenic shock , heart failure (HF), myocardial infarction (MI), burns , trauma , hemorrhage , septic or anaphylactic shock , and renal artery obstruction.

Renal (or intrarenal)

• Intrarenal causes for renal failure are associated with parenchymal changes caused by ischemia or nephrotoxic substances.
• Acute tubular necrosis (ATN) accounts for 90% of cases of acute oliguria.
• Destruction of tubular epithelial cells results from (1) ischemia /hypoperfusion (similar to prerenal hypoperfusion except that correction of the causative factor may be followed by continued oliguria for up to 30 days) and/or (2) direct damage from nephrotoxins.
• Postrenal failure occurs as the result of an obstruction in the urinary tract anywhere from the tubules to the urethral meatus.
• Obstruction most commonly occurs with stones in the ureters , bladder , or urethra ; however, trauma , edema associated with infection , prostate enlargement, and strictures also cause postrenal failure.

There are four phases of ARF: initiation, oliguria, diuresis, and recovery.

• Initiation. The initiation period begins with the initial insult, and ends when oliguria develops.
• Oliguria. The oliguria period is accompanied by an increase in the serum concentration of substances usually excreted by kidneys.
• Diuresis. The diuresis period is marked by a gradual increase in urine output, which signals that glomerular filtration has started to recover.
• Recovery. The recovery period signals the improvement of renal function and may take 3 to 12 months .

The causes of ARF depend on its categories: prerenal, intrarenal, and postrenal.

• Prerenal. Examples of prerenal causes are volume depletion, impaired cardiac efficiency, and vasodilation.
• Intrarenal. Examples of intrarenal causes are prolonged renal ischemia , nephrotoxic agents, and infectious processes.
• Postrenal. An example of a postrenal cause is urinary tract obstruction.

Almost every system of the body is affected by the failure of the normal renal regulatory mechanisms.

• Lethargy. Since waste products cannot be filtered, it slowly accumulates in the different parts of the body.
• Dryness. The skin and mucous membrane are dry from dehydration .
• Central nervous system symptoms. This include drowsiness, headache, muscle twitching, and seizures .
• Increased creatinine . All phases of ARF exhibit an increase in creatinine.

Preventing renal failure involves the following:

• Hydration. Provide adequate hydration to patients at risk for dehydration .
• Shock. Prevent and treat shock promptly with blood and fluid replacement.
• Close monitoring. Monitor central venous and arterial pressures and hourly urine output of critically ill patients to detect the onset of renal failure as early as possible.
• Blood administration. Take precautions to ensure that the appropriate blood is administered to the correct patient in order to avoid severe transfusion reactions.
• Infections. Prevent and treat infections promptly because they can produce progressive renal damage.
• Toxic drug effects. To prevent toxic drug effects, closely monitor dosage , duration of use, and blood levels of all medications metabolized or excreted by the kidneys.

Depending on the duration and severity of ARF, a wide range of potentially life-threatening complications can occur.

• Metabolic acidosis.  Waste products could not be eliminated by the kidneys and they can contribute to metabolic acidosis.
• Fluid and electrolyte imbalances . Imbalances may occur due to hemorrhage , renal losses, and gastrointestinal losses.

Assessment and Diagnostic Findings

Assessment and diagnosis of a patient with ARF include evaluation for changes in the urine, diagnostic tests that evaluate the kidney contour, and a variety of normal laboratory values .

• Volume:  Usually less than 100 mL/24 hr (anuric phase) or 400 mL/24 hr (oliguric phase), which occurs within 24–48 hr after renal insult. Nonoliguric (more than 400 mL/24 hr) renal failure also occurs when renal damage is associated with nephrotoxic agents (e.g., contrast media or antibiotics ).
• Color: Dirty, brown sediment indicates the presence of RBCs, hemoglobin , myoglobin, porphyrins.
• Specific gravity:  Less than 1.020 reflects kidney disease, e.g., glomerulonephritis , pyelonephritis with loss of ability to concentrate; fixed at 1.010 reflects severe renal damage.
• pH:  Greater than 7 found in urinary tract infections (UTIs), renal tubular necrosis, and chronic renal failure (CRF).
• Osmolality:  Less than 350 mOsm/kg is indicative of tubular damage, and urine/serum ratio is often 1:1.
• Creatinine (Cr) clearance:  Renal function may be significantly decreased before blood urea nitrogen (BUN) and serum Cr show significant elevation.
• Sodium : Usually increased if ATN is cause for ARF, more than 40 mEq/L if a kidney is not able to resorb sodium , although it may be decreased in other causes of prerenal failure.
• Fractional sodium  (Fe Na ): Ratio of sodium excreted to total sodium filtered by the kidneys reveals the inability of tubules to reabsorb sodium. Readings of less than 1% indicate prerenal problems, higher than 1% reflect intrarenal disorders.
• Bicarbonate:  Elevated if metabolic acidosis is present.
• Red blood cells (RBCs):  May be present because of infection, stones, trauma , tumor , or altered glomerular filtration (GF).
• Protein:  High-grade proteinuria (3–4+) strongly indicates glomerular damage when RBCs and casts are also present. Low-grade proteinuria (1–2+) and white blood cells (WBCs) may be indicative of infection or interstitial nephritis. In ATN, proteinuria is usually minimal.
• Casts:  Usually signal renal disease or infection. Cellular casts with brownish pigments and numerous renal tubular epithelial cells are diagnostic of ATN. Red casts suggest acute glomerular nephritis.
• BUN/Cr:  Elevated and usually rise in proportion with ratio of 10:1 or higher.
• Complete blood count  (CBC):  Hemoglobin (Hb) decreased in presence of anemia . RBCs often decreased because of increased fragility/decreased survival.
• Arterial blood gases ( ABGs ):  Metabolic acidosis (pH less than 7.2) may develop because of decreased renal ability to excrete hydrogen and end products of metabolism. Bicarbonate decreased.
• Sodium:  Usually increased, but may vary.
• Potassium :  Elevated related to retention and cellular shifts (acidosis) or tissue release (red cell hemolysis).
• Chloride, phosphorus, and magnesium :  Usually elevated.
• Calcium :  Decreased.
• Serum osmolality:  More than 285 mOsm/kg; often equal to urine.
• Protein:  Decreased serum level may reflect protein loss via urine, fluid shifts, decreased intake, or decreased synthesis because of lack of essential amino acids.
• Radionuclide imaging:  May reveal calicectasis, hydronephrosis, narrowing, and delayed filling or emptying as a cause of ARF.
• Kidney, ureter, bladder (KUB) x-ray:  Demonstrates size of kidneys/ureters/bladder, presence of cysts, tumors, ad kidney displacement or obstruction (stones).
• Retrograde pyelogram:  Outlines abnormalities of renal pelvis and ureters.
• Renal arteriogram:  Assesses renal circulation and identifies extravascularities, masses.
• Voiding cystoureterogram:  Shows bladder size, reflux into ureters, retention.
• Renal ultrasound:  Determines kidney size and presence of masses, cysts, obstruction in upper urinary tract.
• Nonnuclear computed tomography  (CT) scan:  Cross-sectional view of kidney and urinary tract detects presence/extent of disease.
• Magnetic resonance imaging  (MRI):  Provides information about soft tissue damage.
• Excretory urography  (intravenous urogram or pyelogram):  Radiopaque contrast concentrates in urine and facilitates visualization of KUB.
• Endourology:  Direct visualization may be done of urethra, bladder, ureters, and kidney to diagnose problems, biopsy , and remove small lesions and/or calculi.
• Electrocardiogram  ( ECG ):  May be abnormal, reflecting electrolyte and acid-base imbalances.
• Urinalysis: Analysis of the urine affords enormous insight into the function of the kidneys.
• Twenty–four–hour urine tests: This test requires you to collect all of your urine for 24 consecutive hours. The urine may be analyzed for protein and waste products (urea nitrogen and creatinine). The presence of protein in the urine indicates kidney damage. The amount of creatinine and urea excreted in the urine can be used to calculate the level of kidney function and the glomerular filtration rate (GFR).
• Glomerular filtration rate (GFR): The GFR is a standard means of expressing overall kidney function. As kidney disease progresses, GFR falls. The normal GFR is about 100–140 mL/min in men and 85–115 mL/min in women. It decreases in most people with age. The GFR may be calculated from the amount of waste products in the 24–hour urine or by using special markers administered intravenously. Patients are divided into five stages of chronic kidney disease based on their GFR.
• Urine Specific Gravity:  This is a measure of how concentrated a urine sample is.  A concentrated urine sample would have a specific gravity over 1.030 or 1.040
• Creatinine is a breakdown product of normal muscle breakdown.
• Urea is the waste product of breakdown of protein.
• The level of these substances rises in the blood as kidney function worsens.
• High potassium ( hyperkalemia ) is a particular concern.
• The acid–base balance of the blood is usually disrupted as well.
• Decreased production of the active form of vitamin D can cause low levels of calcium in the blood. Inability to excrete phosphorus by failing kidneys causes its levels in the blood to rise.
• Blood cell counts: Because kidney disease disrupts blood cell production and shortens the survival of red cells, the red blood cell count and hemoglobin may be low ( anemia ). Some patients may also have iron deficiency due to blood loss in their gastrointestinal system . Other nutritional deficiencies may also impair the production of red cells.
• In general, kidneys are shrunken in size in chronic kidney disease , although they may be normal or even large in size in cases caused by adult polycystic kidney disease, diabetic nephropathy, and amyloidosis.
• Biopsy: A sample of the kidney tissue (biopsy) is sometimes required in cases in which the cause of the kidney disease is unclear. Usually, a biopsy can be collected with local anesthesia only by introducing a needle through the skin into the kidney.

The objectives of treatment of ARF are to restore normal chemical balance and prevent complications until repair of renal tissue and restoration of renal function can occur.

• Pharmacologic therapy. Cation-exchange resins or Kayexalate  can reduce elevated potassium levels; IV dextrose 50%, insulin , and calcium replacement may be administered to shift potassium back into cells; diuretic agents are often administered to control fluid volume.
• Nutritional therapy. Replacement of dietary proteins is individualized to provide the maximum benefit and minimize uremic symptoms; likewise, caloric requirements are met with high-carbohydrate meals, because carbohydrates have a protein-sparing effect; foods and fluids containing potassium or phosphorus are restricted; and after diuretic phase, the patient is placed on a high-protein , high-calorie diet.

Nursing Management

The nurse has an important role in caring for the patient with ARF.

Assessment usually focuses on the characteristics of the urine.

• Assess urine output. Urine output varies from scanty to a normal volume.
• Assess blood in the urine. Hematuria may be present in patients with ARF.
• Assess laboratory results. Laboratory results may increase, decrease, or stabilize and these may indicate each phase of ARF.

Based on the assessment data, appropriate nursing diagnoses for a patient with ARF include:

• Electrolyte imbalance related to increased potassium levels.
• Risk for deficient volume related to increased in urine output.

Main Article:   6 Acute Renal Failure Nursing Care Plans

The goals for a patient with ARF are:

• Improve nutritional intake.
• Restore fluid balance .
• Reduce metabolic rate.
• Promote pulmonary function.
• Prevent infection.

Nursing interventions are aimed at restoring renal function and reducing potential causes of increased renal injury.

• Monitor fluid and electrolyte balance. The nurse monitors the patient’s fluid and electrolyte levels and physical indicators of potential complications during all phases pf the disorder.
• Reducing metabolic rate. Bed rest is encouraged and fever and infection are prevented or treated promptly.
• Promoting pulmonary function. The patient is assisted to turn, cough , and take deep breaths frequently to prevent atelectasis and respiratory tract infection.
• Preventing infection. Asepsis is essential with invasive lines and catheters to minimize the risk of infection and increased metabolism.
• Providing skin care . Bathing the patient with cool water, frequent turning, and keeping the skin clean and well moisturized and keeping the fingernails trimmed to avoid excoriation are often comforting and prevent skin breakdown.
• Provide safety measures.  Patient with CNS involvement may be dizzy or confused.

A successful nursing care plan has achieved the following:

• Improved nutritional intake.
• Restored fluid balance.
• Reduced metabolic rate.
• Promoted pulmonary function.
• Prevented infection.

The nurse plays an important role in teaching the patient and family with ARF.

• Nutrition . A referral to the nutritionist is made because of the dietary changes required.
• Problems to report. The patient and family must know what problems to report to the healthcare provider.
• Follow-up examinations. The importance of follow-up examinations and treatment is stressed to the patient and family because of changing physical status and renal functions.

The focus of documentation in a patient with ARF include:

• Vital signs.
• Muscle strength and reflexes.
• Results of laboratory tests and diagnostic studies.
• Degree of deficit and current sources of fluid intake.
• I&O and fluid balance.
• Plan of care.
• Teaching plan.
• Client’s responses to treatment, teaching, and actions performed.
• Attainment or progress towards the desired outcomes .
• Modifications to plan of care.
• Long term needs.

Posts related to this care plan:

• 6 Acute Renal Failure Nursing Care Plans
• Chronic Renal Failure
• 11 Chronic Renal Failure Nursing Care Plans
• Renal Disorders Nursing Management NCLEX Practice Quiz 1 (50 Items)

17 thoughts on “Acute Renal Failure”

Good information and content

Please provide examples of such patient cases with a proper care plan. THANK YOU

Check out our nursing care plan section.

Great information. Thank you!

Very informative and easy to understand

How can I get more AKI practice questions please?

Hi SF, Great to see your enthusiasm for AKI practice questions! Currently, we have a set of questions available on our website available here: Urinary Disorders NCLEX Practice Quiz (150 Questions)

Great topic. Thank you for the information above.

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Thank you so much for all the great info. I truly appreciate it.

Alot of good information condensed into a nice size article, Hit all the important main points.

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Dialysis and Fatigue: Implications for Nurses – A Case Study Analysis

Ann horigan.

Duke University School of Nursing, Harrisonburg, VA

Judith Rocchiccioli

James Madison University, Harrisonburg, VA

Donna Trimm

Fatigue is one of the most common symptoms experienced by patients receiving dialysis. When patients with chronic kidney disease (CKD) and end-stage renal disease are admitted to acute care settings, they require management of their often profound fatigue. CKD, renal pathology, and renal fatigue are examined in relation to a case study.

Caring for patients with chronic kidney disease (CKD) and end-stage renal disease (ESRD) challenges all health care providers. While a great deal of the maintenance care for patients with ESRD occurs at hemodialysis centers in the community, admission of affected patients to the hospital requires nurses to demonstrate knowledge of renal disease and renal pathology, and expertise in the identification and management of the debilitating fatigue that often impacts patients’ quality of life. Research suggests fatigue is one of the most common symptoms experienced by patients receiving dialysis ( Jablonski, 2007 ; Weisbord et al., 2005 ). Prevalence of fatigue ranges from 60% to 97% ( Murtaugh, Addington-Hall, & Higginson, 2007 ; Weisbord et al., 2005 ). Assessment and management of fatigue thus are important in improving clinical outcomes and quality of life for patients receiving dialysis.

Several factors may be associated with fatigue in patients receiving dialysis. These include depression ( Leinau, Murphy, Bradley, & Fried, 2009 ; Liu, 2006 ), female sex ( Liu, 2006 ; O’Sullivan & McCarthy, 2007 ), and anemia ( Williams, Crane, & Kring, 2007 ). While the cause of renal fatigue remains unclear, it is clearly problematic. An understanding of how patients receiving dialysis describe and experience fatigue, the similarities and differences in fatigue experienced by patients receiving hemodialysis and peritoneal dialysis, and knowledge of the cultural differences in the experience of fatigue are critical in order to assess it accurately and intervene appropriately. Chronic kidney disease, renal pathology, and renal fatigue are discussed and related to the case of Mary R.

Overview of Renal Pathology and Renal Disease

Incidence and prevalence of end-stage renal disease.

End-stage renal disease, the last stage of chronic kidney disease, is a common chronic illness that is increasing in incidence and prevalence. The incidence of ESRD in 2006 was 360 per million, an increase of 2.1% since 2005. Patients receiving dialysis now live longer, with the mortality rate decreased by 10%. Additionally, the rate of kidney transplantation has not kept pace with the incidence of ESRD, and increasing numbers of patients with failed transplants are returning to hemodialysis. In 2006, the number of new patients receiving dialysis or transplant in the United States exceeded 100,000; over 350,000 patients were receiving dialysis ( National Institute of Diabetes and Digestive and Kidney Disease [NIDD KD], 2008 ). As the number of affected patients continues to grow and medical advances allow patients to lead longer lives, symptom management becomes an important part of care for patients receiving dialysis.

Overview of Chronic Kidney Disease

The current National Kidney Foundation (NKF) guidelines define chronic kidney disease as irreversible kidney damage or decreased kidney function for at least 3 months ( Castner, 2010 ; Murphy, Jenkins, Chamney, McCann, & Sedgewick, 2008 ; NKF, 2002 ), which ultimately affects all kidney functions. The nephrons, the functional unit in the kidneys, lose their ability to filter wastes and extra fluid, creating fluid and electrolyte imbalances. Loss of kidney function occurs slowly, with the kidneys initially adapting well to the underlying causes of kidney damage ( Castner, 2010 ). Symptoms of kidney failure, such as alterations in salt and fluid balance, protein-urea, and anemia, do not appear until renal function decreases significantly ( Molzahn & Butera, 2006 ).

The severity of kidney disease is determined by the individual’s glomerular filtration rate (GFR), which is the best measure of the overall health and function of the kidneys ( Kinzner & Hain, 2007 ). The glomerulus is a collection of capillaries in the nephron, and the glomerular membranes act as the filtering mechanism for wastes and fluid. The rate at which the glomerulus filters wastes and fluid is an indication of its health. A GFR of 90 mL/minute per 1.73 m 2 or higher is considered normal. A decreasing GFR signifies increasing kidney damage. A GFR less than 60 mL/minute per 1.73 m 2 indicates a loss of approximately half the kidney’s normal function in an adult. As the GFR continues to decrease in kidney failure, occurrence of complications related to kidney disease, such as anemia, bone disease, and malnutrition, increases ( Castner, 2010 ; NKF, 2002 ).

Five stages of chronic kidney disease have been identified ( NKF, 2002 ) (see Table 1 ). A healthy kidney is able to differentiate between protein and wastes when filtering the blood. A damaged kidney is unable to do this, and thus protein is excreted inappropriately along with the wastes in the urine. The early stages of CKD are characterized by protein-urea and decreasing GFR. Many complications, such as anemia and bone disease, become evident as CKD progresses ( NKF, 2011 ). During the later stages of CKD, continued management of complications as well as preparation for renal replacement therapy (dialysis or transplantation) are important. When the kidneys have failed completely and irreversibly, renal replacement therapy is necessary to sustain life. At this point, most patients experience symptoms of uremia ( NKF, 2002 ), including decreased appetite, malnutrition, drowsiness, shortness of breath, and palpitations ( Murtaugh et al., 2007 ).

Stages of Chronic Kidney Disease

GFR = glomerular filtration rate

Adapted from National Kidney Foundation, 2002 .

Common Causes of Chronic Kidney Disease

One of the most common causes of CKD is diabetes. Other causes include hypertension and glomerulonephritis ( NIDDKD, 2010 ). When a patient has diabetes, the glomerulus is damaged. The exact mechanism of damage is unknown, but the most likely cause is denaturization of proteins caused by high blood glucose. This leads to a thickening of the membranes of the capillaries in the glomerulus that eventually results in scarring and stenosis of the capillaries ( Bakris, 2011 ; Redmond & McClelland, 2006 ). The stenosis of glomerular capillaries causes an inability to filter wastes properly, and contributes to fluid and electrolyte imbalances in the body.

Another common cause of CKD is untreated hypertension ( NIDDKD, 2010 ). Normal regulatory processes in the kidney are compromised when the systemic blood pressure remains elevated over a long period of time, as in untreated or inadequately treated hypertension. First, untreated systemic hypertension causes damage to the systemic blood vessels by causing them to thicken and strengthen to withstand the increased pressure. These vessels become permanently narrowed due to thickening. The arteries that feed the kidneys respond to high systemic pressures by constricting, thus decreasing the amount of blood circulating through the kidneys. The kidneys in turn interpret this as a deficit in blood flow. In response, renin and aldosterone secretion are stimulated, leading to sodium and water retention in order to increase blood volume. This response only perpetuates the systemic hypertension ( Hill, 2008 ). Over time, as the kidneys lack appropriate perfusion due to arterial constriction, nephron damage results and efficient filtration of water and wastes is lost.

Glomerulonephritis is another common cause of kidney failure ( NIDDKD, 2010 ). Cellular, immunologic, and inflammatory factors that damage the glomerulus (capillaries in the nephron) often are triggered by changes in tissue or infections ( Redmond & McClelland, 2006 ). Glomerulonephritis can range from mild to severe, and damage to the glomeruli differs from person to person. Nephrons are destroyed in a predictable pattern that begins with cellular infiltration and exudative reactions. Damage then progresses to macrophage infiltration with differing levels of parenchymal cell proliferation. These changes eventually lead to sclerotic structural changes in the nephron, damaging it and resulting in an inability to function properly ( McCance & Huether, 2010 ).

Complications of Chronic Kidney Disease

As kidney function declines, multiple body systems are affected detrimentally by the accumulation of toxins in the blood (uremia) ( Alper, Shenava, & Young, 2010 ). These symptoms usually begin to appear in stage 3 kidney disease and worsen as kidney function declines to ESRD. The kidneys lose the ability to excrete electrolytes, causing serum electrolyte imbalances. As serum phosphate increases, the additional phosphate binds with calcium and a decrease results in serum calcium levels. The body responds by pulling calcium from the bone to maintain appropriate serum calcium ( McCarley & Arjomand, 2008 ). Bone demineralization, pain, and spontaneous fractures thus can occur as kidney disease progresses ( NIDDKD, 2009a ).

Serum potassium continues to rise, even to critical levels, as CKD continues. Hyperkalemia can result in muscle weakness, increased neuromuscular irritability manifested as tingling in the fingers and lips, restlessness, stomach cramping, and diarrhea. At critically high levels, potassium can cause changes in the EKG complex, often in the form of bradyarythmias. Conduction is slowed through the heart muscle, resulting in prolonged PR intervals and a widening QRS complex, often resulting in ventricular fibrillation or cardiac arrest ( Putcha & Allon, 2007 ).

Erythropoietin secretion is controlled by the kidneys and is compromised as kidney failure progresses. Red blood cell production in the bone marrow then decreases, resulting in anemia. Additionally, the red cells that are produced have a shortened life span due to the build-up of toxins in the blood ( Alper et al., 2010 ).

Another complication of CKD is impaired creatinine and urea clearance ( Broscious & Castagnola, 2006 ). Creatinine is released constantly from the muscle. As the GFR decreases, the serum creatinine values increase. High serum creatinine is an indicator of kidney dysfunction ( NIDDKD, 2009b ). Urea, the end product of protein metabolism, also increases as the kidneys fail. Retention of urea can cause loss of appetite, nausea, vomiting, and pancreatitis ( McCance & Huether, 2010 ).

Dialysis in Chronic Kidney Disease

Complications of CKD worsen as renal failure progresses. Eventually, hemodialysis (HD) or peritoneal dialysis (PD) must be initiated to replace kidney function in most patients. Approximately 100,000 new patients began receiving HD in the United States in 2006; over 325,000 patients received hemodialysis treatments that year. These numbers accounted for approximately 92% of the total dialysis population. Patients on PD accounted for 6.2% of new dialysis cases, and 8.2% of the total dialysis cases ( NIDDKD, 2008 ).

The debate continues over which treatment modality is more effective and has better outcomes. No conclusive evidence indicates one form of dialysis is better than the other ( Lee, Sun, & Wu, 2009 ). Many factors must be considered when choosing a dialysis modality, including physician recommendation, patient preference, and availability of the treatment ( Shahab, Khanna, & Nolph, 2006 ). Dialysis modality selection often is based on the patient’s clinical and social status ( Shahab et al., 2006 ). In general, patients who are younger and adherent to therapy; have some residual renal function, cardiovascular disease, and family or social support; and are independent in self-care are more likely to be recommended for peritoneal dialysis. Peritoneal dialysis is contraindicated in patients who have ostomies, or a ventro-peritoneal shunt. Older adults, obese persons, and individuals without social support also are less likely to be recommended for peritoneal dialysis ( Shahab et al., 2006 ).

Fatigue in ESRD

The need to identify and assess fatigue in patients receiving dialysis is vital to patient health and quality outcomes. Fatigue frequently is unrecognized and therefore under-treated ( Jhamb, Weisbord, Steel, & Unruh, 2008 ). Physical exercise, epoetin use, and L-carnitine infusion have all been used successfully to alleviate fatigue in patients receiving hemodialysis. Physical exercise also can help with the physiological and functional deterioration that can result from aging, illness, and sedentary lifestyle ( Gordon, Doyle, & Johansen, 2011 ; Kosmadakis et al., 2010 ), all of which can contribute to dialysis-related fatigue.

Trials have shown physical exercise is safe for patients on dialysis, but exercise is not offered or recommended routinely for patients receiving dialysis. While physical exercise may be safe and help alleviate fatigue, few patients participate in these programs when offered, and many often drop out after beginning ( Kosmadakis et al., 2010 ). Additionally, exercise may not be appropriate for a select group of patients receiving dialysis. Patients with functional limitations, poor cardiac health, or bone disease, and persons who are hemodynamically unstable during dialysis should not be considered for participation in exercise programs ( Bayliss, 2006 ).

Epoetin is used regularly to combat anemia, a common cause of dialysis-related fatigue. Some patients do not respond well to epoetin therapy ( Bamgbola, 2011 ) as demonstrated by no increase in their hemoglobin and hematocrit levels. Unfortunately, increasing doses of epoetin to help reduce anemia in these patients has proven detrimental, as it increases their risk for cardiovascular and cerebrovascular events ( Drueke et al., 2006 ; Singh et al., 2006 ). Therefore, epoetin use may not be successful in alleviating fatigue in all patients receiving hemodialysis.

Another intervention to lessen the effects of fatigue is the use of L-carnitine, which is important for appropriate muscle function. Patients receiving hemodialysis are deficient in L-carnitine, and supplementation has proven effective in ameliorating dialysis-related fatigue, particularly in patients who are unresponsive to epoetin therapy ( Lynch et al., 2008 ). The Centers for Medicare and Medicaid Services (CMS) only reimburses for L-carnitine used for epoetin-resistant anemia and intradialytic hypotension. Continued use of the drug is not covered if there has been no improvement in anemia or hypotension 6 months after treatment initiation ( CMS, 2011 ).

Interventions that have been successful in alleviating fatigue may not be appropriate or safe for all patients. A significant need exists for the management of fatigue in order to reduce its impact on the lives of patients receiving hemodialysis. Nurses are in a strategic position to assess dialysis-related fatigue and help patients develop strategies to manage its effects. The following case study describes a patient admitted to the medical-surgical unit for management of hyperglycemia. The assigned nurse meets the patient for the first time immediately after her dialysis session. Patient symptoms, assessment of fatigue, evaluation of patient medications and lab results, and nursing interventions are discussed.

Mrs. R. is a 33-year-old African-American female with type 1 diabetes, cataracts, and ESRD who has received hemodialysis for 2 years. She was admitted in the morning for hyperglycemia and management of medications, and was taken to dialysis prior to her arrival on the medical-surgical unit. After arrival to her room, she is lethargic, replies to repeated questions slowly, and slurs words at times. She demonstrates delayed response to commands with appropriate one-word answers. When asked how she feels, she responds, “I’m so tired. Please just leave me alone.” Dialysis removed 5 kg of fluid. Vital signs include oral temperature 98.3° F, blood pressure 88/40 mm Hg, pulse 96 beats per minute, respirations 12 breaths per minute, and oxygen saturation 97% on room air. See Table 2 for the patient’s routine medications, and Table 3 for current laboratory results. The patient’s height is 5′5″ and weight 145 lbs. Mrs. R.’s history includes childhood non-adherence to diabetic diet and medications, which contributed to her current health status. She lives with her mother, receives disability payments and is unemployed, and has a 9-year-old daughter. She is unable to drive due to poor vision.

Current Medications

Current Lab Values

Nursing Management

Fatigue assessment.

Mrs. R. presents as a typical patient with ESRD. Her fatigue is the result of both physiological and psychological influences as well as dialysis treatment inadequacy. When questioned further about her fatigue, the patient explains, “It’s ok; I’m always like this after dialysis.” Emergency interventions are not needed, but assessment of the fatigue should be completed. A simple visual analogue scale could be used to establish Mrs. R.’s baseline perception of fatigue; the scale includes a 100 mm line anchored at the left end with No Tiredness and at the right end with Complete Exhaustion . This type of measurement is a reliable assessment of fatigue in patients receiving dialysis ( Brunier & Graydon, 1996 ; Williams et al., 2007 ), and can be performed quickly in the clinical setting.

Evaluate How Fatigue Impacts Patient’s Daily Living

Because fatigue can be extremely debilitating, assessing its effects on Mrs. R. is important in helping her improve her quality of life. Assessment can include asking the patient to describe her daily routine or keep a journal for review with the nurse at the dialysis unit at a later date. Mrs. R. explains that she sleeps for 4–6 hours after dialysis because she is completely exhausted. She is unable to work due to her extreme dialysis-related fatigue, and therefore receives disability payments. She lives with her mother to save rent money and receive help from her mother in caring for her 9-year-old daughter. Reviewing a time or event when fatigue was at its greatest intensity may help with planning interventions to minimize fatigue. Mrs. R. states that at times, particularly on dialysis days, she is unable to fix her daughter meals or help with her homework. The nurse can help Mrs. R. identify her support systems and collaborate with her to identify ways she can incorporate these support systems into her life. For instance, could Mrs. R.’s mother help her granddaughter with homework after school and cook evening meals? If Mrs. R. is able, making meals on her non-dialysis days and refrigerating or freezing them will help her mother and make food available when she is unable to prepare it.

Evaluating Laboratory Results and Medications

Irregularities in laboratory results and medication side effects may contribute to Mrs. R.’s fatigue. Evaluation of the patient’s laboratory results reveals serum sodium, calcium, phosphorus, and magnesium are all within normal range albeit slightly low. Her slight hypokalemia could be related to the stress of dialysis. Dialysis can return many electrolyte values to normal ranges, but also may remove insulin. Her serum glucose is elevated, which can lead to cell dehydration due to osmotic pressure in the extracellular fluid. She may need regular insulin for glucose correction. The presence of insulin affects protein (amino acids), glucose, potassium, magnesium, and phosphate uptake by the cells. Without insulin, the cells do not have the adequate glucose and amino acids to function, and weakness and/or fatigue can result. Mrs. R.’s protein and albumin values are already low, which also can cause edema. This in turn can lead to swelling and weight gain, causing tightly fitting clothes and shoes that can affect movement and increase feelings of fatigue. Dialysis removed 5 kg of fluid, which most likely included toxic levels of electrolytes, a small amount of blood, and other waste products. Mrs. R.’s hemoglobin and hematocrit are low, often typical for a patient in ESRD. With low protein and albumin, she also may lack elements to produce red blood cells. The kidney’s ability to make erythropoietin, which stimulates red blood cell production, is compromised and could contribute to Mrs. R.’s fatigue. Epoetin has been prescribed to supplement her kidneys’ failing ability to produce erythropoietin. Supplemental iron and vitamin B 12 also may be given. By increasing hemoglobin, patients may experience less lethargy.

Mrs. R. also takes alprazolam (Xanax ® ) twice a day as needed for restless leg syndrome. This drug also may be contributing to daytime sleepiness and fatigue. The nurse should encourage Mrs. R. to investigate medications other than benzodiazapines for restless leg syndrome with her care provider to alleviate some of the fatigue. Mrs. R. also takes the anti-depressant venlafaxine (Effexor ® ). Depression has been associated with dialysis-related fatigue in several studies ( Kim & Son, 2005 ; Leinau et al., 2009 ; Liu, 2006 ; McCann & Boore, 2000 ), and it is important that depression is identified and treated. Treating depression could help lessen fatigue levels in patients receiving dialysis. In Mrs. R.’s case, the nurse should ask if she believes her current medication is treating her depression effectively. If depression is under-treated, her fatigue may persist.

Teaching the Patient

After examining the patient’s laboratory results and medications, the nurse should teach the patient the importance of diet, exercise, and healthy sleep routines to decrease symptoms of fatigue. Diet is critically important for patients receiving dialysis. Mrs. R.’s diet should be low in potassium, sodium, and phosphate, and her fluid intake restricted. She needs adequate calories as well as moderate intake of complete protein, low fat, vitamins A and C, and carotinoids. Over time, patients affected with ESRD tend to become malnourished, so aggressively restricting their protein intake may be more detrimental to their health ( Arora & Verrell, 2009 ). Because Mrs. R. also has diabetes, she needs high-complex, fiber-rich carbohydrates with low glycemic index and load necessary for calorie intake ( Taillefer, 2008 ). Collaborating with a registered dietitian and designing menus for Mrs. R. may decrease the burden of planning meals.

Exercise is another essential component of patient teaching. Mrs. R. has none of the previously mentioned complications that would prevent her from participating in exercise. Collaborating with her in planning simple exercises is a must. Suggesting an exercise routine during the dialysis appointment can encourage adherence as well as socialization with others. Thirty minutes of low-intensity exercise, such as modified yoga, should be the goal ( Yurtkuran, Alp, Yurtkuran, & Dilek, 2007 ). Some exercise plans include 30 minutes of cycling with devices adapted to the patient’s bed during dialysis ( Quzouni, Kouidi, Sioulis, Grekas, & Deligiannis, 2009 ). Exercise can lead to significant improvements in the patient’s physical abilities, as well as decreased perception of pain, fatigue, depression, and insomnia.

Sleep disorders, such as apnea and restless leg syndrome, are common among patients receiving dialysis. In addition to management with medication, the patient may need to make behavioral changes, such as staying awake during dialysis and eliminating caffeine, nicotine, and alcohol intake. Some units provide overnight dialysis, which might be helpful. Sleep studies should be performed for sleep apnea and restless leg syndrome with the appropriate interventions of continuous positive airway pressure usage or medications ( Unruh, 2008 ).

Evaluating this patient’s sleep and her participation in routine exercise can improve feelings of depression as well. Her loss of self, a change of status in her family, the inability to care for her daughter, her physical losses, and a loss of a social network can contribute to depression. The nurse should help the patient identify support people and local support groups, listing ways she has coped with crisis in the past. The nurse also can help her establish goals to give her a sense of hope. She may need a professional therapist, guidance in time management, and a social worker to find resources for caring for herself and daughter.

Fatigue is a real problem for patients receiving dialysis. While the specific cause of fatigue remains unknown, multiple conditions are associated with its occurrence. Nursing assessment of fatigue is important in the care of patients receiving dialysis in order to improve their quality of life. Nurses are in an excellent position to review patients’ medications and laboratory results, and collaborate with patients to determine how to use their support systems and individual strengths to help alleviate the effects of fatigue.

Acknowledgments

This project was supported by a grant from the National Center for Research Resources, Duke CTSA, NIH, grant number 1TL1RR024126. Its contents are solely the responsibility of the authors and do not necessarily represent the official view of NCRR or NIH.

Contributor Information

Ann Horigan, Duke University School of Nursing, Harrisonburg, VA.

Judith Rocchiccioli, James Madison University, Harrisonburg, VA.

Donna Trimm, James Madison University, Harrisonburg, VA.

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Acute Renal Failure

Submitted by Beth Stroud, RN, BSN

Tags: acute renal failure Case Study critical care health care nurse patient concern patient outcomes

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Beth Stroud, RN, BSN is a Graduate Student at Murray State University.

Acute renal failure (ARF) has become increasingly common in patients with critical illnesses. Up to two-thirds of intensive care unit (ICU) patients develop ARF with the leading cause being sepsis (Kosinski, 2009). Treatment of ARF has been associated with higher costs and the following adverse outcomes: increased length of stay, excess mortality of 30-71%, need for chronic dialysis in the patients who survive, and the requirement of discharge to short-term or long-term care facilities (Uchino, Kellum, Bellomo, Doig, Morimatsu, Schetz, Tan, Bouman, Macedo, Gibney, Tolwani, & Ronco, 2005). Despite the prevalence of the disease and the need for evidence-based guidelines, over 57 different definitions exist for the critical condition.

Early recognition of ARF has been instrumental in improving patient outcomes. Interdisciplinary collaboration is essential for prompt identification of risks and for completing accurate ongoing assessments. Treatment of ARF includes multiple pharmacological and non-pharmacological components such as mechanical ventilation, vasoactive intravenous medications, nutritional support, and dialysis.

Based on the complexity of ARF, healthcare institutions are challenged with the need to provide complex care to obtain optimal patient outcomes. The American Association of Critical Care Nurses’ (AACN) Synergy Model provides a framework for institutions to correlate the patients’ characteristics and care needs with the nurses’ competencies in order to achieve optimal outcomes (Kaplow & Hardin, 2007). The purpose of this article is to demonstrate the use of the Synergy Model in obtaining optimal patient outcomes in the following case study.

Case Study: Acute Renal Failure and Sepsis

John is a 43 year old, white male who is single, has no children, is unemployed, and is  uninsured. He has been treated for hypertension and erectile dysfunction for the past 3 years and  has presented to the emergency department four times in the last month with complaints of not being able to urinate. His home medications include Aspirin 81 mg daily, Plavix 75 mg daily, Metoprolol 50 mg twice a day, and Viagra as needed; however, he has only been taking his Viagra since he lost his job three months ago. He has developed urinary retention and has been catheterizing himself at home for approximately one week with the foley catheter he pulled out of the trash at his last emergency room visit.

His older sister, the only surviving relative, has brought him to the emergency department with confusion, hypothermia, tachycardia, tachypnea, hypotension, neutropenia, bandemia, anemia, and thrombocytopenia. His admitting blood urea nitrogen (BUN) and creatinine were 65 and 7.5 mg/dl, respectively. His urinalysis revealed white blood cells (WBC) too numerous to count and trace of red blood cells (RBC). His potassium level was 5.8. Blood cultures revealed a gram-negative septicemia.

After being admitted and transferred to the ICU, John had a rapid decline in respiratory status and was intubated and mechanically ventilated. Fluid replacement was started using crystalloid solutions. Norepinephrine was started IV to manage the hypotension and maintain an adequate blood pressure. An infectious disease practitioner was consulted and John was started on aggressive antibiotic, antifungal, and antiviral therapy. The nephrologist ordered continuous renal replacement therapy (CRRT) to treat John’s ARF since he was too unstable to tolerate hemodialysis.

AACN Synergy Model   The American Association of Critical Care Nurses’ (AACN) Synergy Model for Patient Care is a conceptual framework used to guide nursing practice. The Synergy Model places the patient as the central focus and suggests matching the competencies and skills of the nurse to the patient’s care needs. The model identifies eight patient characteristics and eight nursing competencies and describes the relationship to outcomes for the patient, nurse, and the healthcare system. The Synergy Model is particularly important in critical care areas which require nurses to have greater competencies and skill sets to meet the needs of the critically ill patients such as John.

Patient Characteristics   The Synergy Model’s eight characteristics help nurses identify patient needs across the continuum of health to illness and are as follows: resiliency, vulnerability, stability, complexity, resource availability, participation in care, participation in decision making, and predictability.

Understanding these characteristics as they change with the patient’s condition helps determine the competencies essential to deliver optimal care. John’s patient characteristics are outlined in the following table:

• Stability (decreasing) Hypothermia, hypotension, tachycardia, tachypnea, confusion
• Complexity (increasing) Two or more body systems entangled, systemic infection, respiratory compromise
• Predictability (uncertain) Instability and uncertainty in the patient’s life
• Resiliency (decreased) Very rapid decline with sepsis, unresponsive 30 minutes upon arrival to ICU
• Vulnerability (increased) Little if no financial reserve from loss of job and limited resources
• Participation in decision making and care (absent shortly after admission) Confusion and cognitive impairment from advanced sepsis. Sister was very emotional and apologetic. She was not “close” to the patient in general as she identified in the history
• Resource availability (decreased) Limited financial resources. No assistance possible from family Unknown available community resources.

John was experiencing a decrease in stability and resiliency based on the sepsis, renal failure, respiratory failure, and rapid physical decline. His complexity and vulnerability as a patient was drastically increasing because of the disease process as well as the lack of resource availability. The predictability is not certain as well as his willingness to participate in care.

The nursing characteristics and competencies of the Synergy Model will be addressed as it relates to patient outcomes. Understanding and applying the Synergy Model to John’s patient characteristics first requires knowledge of the pathophysiology and treatment modalities for ARF and sepsis.

Pathophysiology of acute renal failure

According to Kosinski (2009), acute renal failure is “a sudden decline in both glomerular and tubular function, resulting in the failure of the kidneys to excrete nitrogen and waste products with a corresponding failure to maintain fluid, electrolyte and acid-base balance” (p.4). ARF may be associated with decreased urinary output of less than 30 ml/h. Prerenal failure may not result in kidney damage with early identification and prompt treatment. The focus of this discussion will be on prerenal caused by the alteration in renal systemic vascular resistance ratio as a result of sepsis.

The normal functions of the kidneys are to filter and excrete wastes and toxins by regulating fluids, electrolytes, and acid-base balance. The kidneys receive 20% to 25% of cardiac output and the amount of blood that flows through the renal arterioles depends on renal blood flow. Any alteration in the renal blood flow alters the glomelular filtration rate (GFR) (Broden, 2009).

The chemical and humoral mediators released during sepsis contribute to a pro-inflammatory response and systemic vasodilation. The resulting decrease systemic pressure stimulates the sympathetic nervous system, leading to renal artery constriction and a decrease in both filtration and excretion. 

Systems Assessment

Impairment of renal function affects multiple body systems, making the care needs of ARF complex and challenging. Ongoing comprehensive assessments are critical; the caregiver must be attentive to the signs and symptoms of renal disease as well as complications with other organs and systems. The complexity of ARF demonstrates the need for correlating patient characteristics and nursing competencies in the Synergy Model to obtain optimal outcomes.

The primary effect of ARF is a decrease in urinary output that leads to fluid retention and edema. Oliguria is the classic sign with an output of less than 400 ml in 24 hours. The decrease in filtration leads to BUN and creatinine build up in the blood as the kidney loses its ability to remove waste products. Other lab results that may be abnormal include metabolic acidosis, hyperkalemia, hyponatremia, hyperphosphatemia, hypocalcemia, and hypermagnesemia.

Cardiovascular

In general, the fluid volume overload experienced in ARF may lead to hypertension, pulmonary edema, peripheral edema, and arrhythmias. The kidneys fail to excrete excess potassium which may lead to the following: muscle weakness, neuromuscular irritability, bradycardia, heart block, asystole, or other arrhythmias (Campbell, 2003).

Respiratory

Dyspnea may result from the decrease in oxygenation either from associated anemia or from fluid volume overload and pulmonary edema associated with ARF. The dyspnea may be at rest or worsen with exertion. Auscultation of lung field may reveal crackles.

Hematologic

ARF patients are anemic secondary to the impaired RBC production, hemolysis, bleeding, hemodilution, and decrease RBC survival. Damaged kidneys produce less erythropoietin to stimulate RBC production and the damaged red blood cells are not replaced. The decrease in hemoglobin leads to insufficient oxygenation manifested by dyspnea.

Gastrointestinal   Uremia may cause nausea, vomiting, anorexia, gastric ulcers and colitis which places the patient at risk for GI bleeding. The increase in urea may also cause the patient’s breath to smell like foul urine.

Exceptions for John’s case study

John exhibited the majority of the above symptoms; however, he did not experience hypertension, pulmonary edema, peripheral edema, and arrhythmias common to ARF due to the vasodilation effect of the sepsis. Conversely, he was hypotensive and required volume replacement and intraveneous vasopressors. His blood gases revealed metabolic acidosis, resulting from the lactic acid produced from the sepsis.

Diagnostic Tools

Conventional Biomarkers   The conventional methods of diagnosing ARF are urine output, creatinine, and urea. However, the presence or absence of urine does not necessarily denote renal malfunction. The output is more indicative of renal hemodynamics than actual renal function. The excretion of sodium and urea has not been proven to be sensitive in early ARF because the tubular functions may remain intact unless clinical conditions such as sepsis alter tubular function. Urine protein is present in other diseases such as diabetes, shock, and chronic kidney disease (Kosinski, 2009).

New Biomarkers   Acute renal failure can be diagnosed earlier utilizing the following biomarkers in addition to the conventional markers listed above: Cystatin C, Interlukin 18 (IL 18), Neutrophil Gelatinas-Associated Lipocalin (NGAL), and Kidney injury Molecule (KIM-1). Cystatin C is a marker of the glomelular filtration rate and is independent of age, sex, and muscle mass. Cystatin C has a small molecular mass and can be filtered more freely at the glomerulus. Interlukin 18 is an inflammatory cytokine which enters urine in the proximal tubule. NGAL propagates with injured endothelium of the lungs, stomach, colon, and kidneys and rises with acute infections. Kidney injury molecule (KIM-1) is a transmembrane protein that is excreted in the proximal tubule and detected in ischemic kidney disease. Cystatin C and NGAL are measured in the serum. IL-18, KIM-1, and NGAL are measured in the urine.

Diagnostic Imaging   Diagnostic imaging may also be needed in determining the underlying disease and differentiating between acute and chronic disease. The following may be utilized as diagnostic procedures: X rays, computed tomography scan (CT), magnetic resonance imaging (MRI), ultrasound, arteriogram, and renal biopsy. Ultrasounds of x rays of the ureters and bladder may also be included.

Rifle Criteria   The RIFLE criteria (Thurman, 2009) is evidence-based practice tool used for the diagnosis of ARF. The diagnosis of ARF can be the result of changes in the serum creatinine level, a change in the urinary output, or both. The RIFLE tool assesses the following: risk of renal dysfunction, injury to the kidney, failure of kidney function, loss of kidney function and end-stage kidney disease.

Treatment Modalities and Best Practice   The ultimate goals for treating ARF caused by sepsis are to eliminate the cause and to support the patient’s renal function. The primary focus in treatment of prerenal disease is restoring the blood flow with adequate pressure to the kidney. However, some of the treatments such as mechanical ventilation bring about further complications for the renal system, requiring greater need for the following supportive measure: maintaining fluid and electrolyte balance, removing nitrogenous wastes, sustaining nutrition, and providing emotional support and teaching to the patient and his family.

Mechanical Ventilation   Renal blood flow (RBF) is decreased as a result of permissive hypercapnea, hypoxemia and positive end-expiratory pressure (PEEP) associated with the use of mechanical ventilation. Decreased RBF caused by constriction in permissive hypercapnea results from both direct and indirect mechanisms. According to Broden (2009), the direct mechanism of hypercapnea is the stimulation of the sympathetic nervous system and release of norepinephrine, causing vasoconstriction and decrease in renal blood flow and GFR. The indirect mechanism is the effect of systemic vasodilatation and decrease vascular resistance, leading to further release of norepinephrine.

The use of lung-protective mechanical ventilation with optimal combination of lower tidal volumes and PEEP is currently standard of practice for preventing acute lung injury. The use of PEEP has not been directly linked to impairment of renal function. Healthcare providers need to recognize the stress of mechanical ventilation on the renal system and conduct frequent ongoing thorough assessments to identify potential complications.

Fluid replacement and vasoactive drugs   Vasoactive medications are frequently used to increase the mean arterial pressure and blood flow to the kidneys once the autoregulation of the kidneys is lost. Norepinephrine has been shown to be the most advantageous in patients with acute kidney injury and failure caused by sepsis (Kosinski, 2009). The norepinephrine increases the mean arterial pressure which, in turn, controls renal function and urine output. Norepinephrine has been shown to decrease renal blood flow in hypovolemic patients; therefore, it is critical to treat hypovolemia with crystalloid solutions prior to administration.

Dialysis   Acute renal failure can be treated by intermittent dialysis, peritoneal dialysis, or continuous renal replacement therapy (CRRT). The treatment modality is determined based on the patient’s diagnosis and condition. Many patients who are hemodynamically unstable do nottolerate intermittent dialysis as they often become hypotensive during treatment. Repeated episodes of hypotension may cause further injury and ischemia to the nephrons. Likewise, peritoneal dialysis is contraindicated in unstable patients because the pulmonary function may be compromised by the large volume of fluid instilled into the peritoneal cavity. CRRT is tolerated best in unstable, critically ill patients because it removes volume and solutes slowly, avoiding the rapid changes associated with hemodialysis. The goals of CRRT are to maintain optimal fluid balance and to correct electrolyte and metabolic abnormalities.

Frequent assessments are required for patients who are on CRRT. Vital signs need to be monitored for hypotension that may occur as a result of hypovolemia during therapy and for hypothermia that may occur as a result of the amount of blood that is in the tubing outside the body. Perfusion and hemodynamic status should be assessed by observing capillary refill, peripheral pulses, and skin temperature and color. The catheter site must be assessed for warmth, redness, edema, drainage, and tenderness. Accurate monitoring of the patient’s electrolyte levels, acid-base balance, and fluid balance are essential with CRRT. Hourly calculations must be performed to determine adjustments in fluid volumes.

Caring for CRRT patients requires knowledge of the CRRT system for troubleshooting alarms when they occur. For instance, if the patient is not receiving anticoagulant therapy and/or replacement fluids, the risk of clotting of the hemofilter is increased.

Critically ill patients often experience catabolism due to stress, further contributing to increased risks of ARF. The BUN and creatinine levels are increased as the body breaks down muscle for protein; however, nutrition should be low in protein and sodium and high in fats and carbohydrates to prevent the protein burden on the patient’s kidneys (Campbell, 2003). Fluids are generally restricted to the amount of the patient’s urine output plus 500 to 700 ml. Parental nutrition is recommended if the gastrointestinal tract is not functional.

Provision of emotional support and teaching   Acute renal failure is often very sudden and unexpected for both the patient and the family members. Thorough patient teaching about nutritional needs, fluid restrictions, medications, and the role of dialysis is essential in providing emotional support patients and family members.

Success story as it relates to the AACN synergy model

Nurse competencies   The complex care needs identified in John’s case exemplar should be correlated with the assigned nurse’s skill set and competencies according to AACN Synergy Model. The eight nursing competencies of the Synergy Model are as follows: clinical judgment, advocacy and moral agency, caring practice, collaboration, systems thinking, response to diversity, facilitator of learning, and clinical inquiry. Each competency is important in providing care; however, the competencies that take priority for John are clinical judgment, clinical inquiry, collaboration, and response to diversity.

The nurse would need strong clinical judgment to interpret and make decisions based on assessment findings that indicate John is in ARF caused by sepsis. John’s complex care requires his nurse to be clinically competent in assessment skills and additional skill sets for mechanical ventilation, pharmacology, and CRRT.

The clinical inquiry in John’s case incorporates ongoing questioning and evaluation of practice to direct John’s care through the use of evidence based guidelines. The use of Norepinephrine and CRRT are currently standard of practice for ARF.

Collaboration with multiple caregivers was also essential based on John’s complex needs for mechanical ventilation, IV vasopressor, and dialysis. John’s rapid decline and loss of consciousness warrants an advocate acting in his behalf to resolve both ethical and clinical concerns. Both response to diversity and caring practice are important due to the embarrassment of his erectile dysfunction, frequent partners, and use of Viagra.

Outcomes   The AACN Synergy Model measures nursing outcomes based on the dimensions of nursing practice. According to Kaplow and Hardin (2007), when the nursing competencies are properly assigned based on the patient characteristics, the expected outcomes should include “the extent to which care objectives are met, management of physiological changes, and the presence or absence of preventable complications” (p. 4). The outcomes from John’s case exemplar were very favorable.

Forty-eight hours after CRRT was started, John’s potassium level was 3.5, his creatinine level was 6.3, and his BUN was 61. Potassium was added to his intravenous fluids and his electrolytes continued to trend toward normal.

After five days of the initiation of antibiotic, John’s sepsis was slowly resolving and he was weaned from both the ventilator and his vasoactive drips. Total parenteral nutrition and IV antibiotics were continued until day 14 of hospitalization. John’s renal function returned and he was discharged from the hospital on day 18.

Conclusion   The AACN Synergy Model is especially applicable in critical care areas where patient care is very complex. ARF occurs in two-thirds of intensive care patients and those who are treated with CRRT have a mortality rate of 40-60% even with correction of biomarkers. Utilization of nursing competencies in the AACN Synergy Model for screening, treatment options, and measureable outcomes in ARF will provide optimal patient outcomes as evidenced by decreased length of stay, decrease costs, and decreased mortality.

•  Broden, C. (2009, April 1). Acute renal failure and mechanical ventilation: reality or myth?Critical Care Nurse, 29(2), 62-75.
•  Campbell, D. (2003, January 1). How acute renal failure puts the brakes on kidney function. Nursing 2003, 33(1), 59-63.
•  Kaplow, R., & Hardin, S. (2007). Critical care nursing: Synergy for optimal outcomes. Sudbury, Massachesetts: Jones and Bartlett Publishers. 
• Kosinski, M. (2009). What's old is new again: AKI and ARF. Presented at the 2009 NTI and Critical Care Exposition. AACN. 
• Murray, P., & Hall, J. (2000). Renal replacement therapy for acute renal failure. American Journal of Respiratory Care Medicine, 162, 777-781. 
• Pannu, N., Klarenbach, S., Wiebe, N., Manns, B., & Tonelli, M. (2008, February 20). Renal replacement therapy in patients with acute renal failure a systematic review. JAMA, 299(7), 93-805. 
• Paton, M. (2007, September 1). CRRT: Help for acute renal failure. Nursing Made Incredibly Easy! pp. 28-38. 
• Thurman, P. (2009) Ins and outs of continuous renal replacement therapies: a case study approach. Presented at the 2009 NTI and Critical Care Exposition. AACN. 
• Uchino, S., Kellum, J., Bellomo, R., Doig, G., Morimatsu, H., Morgera, S., Schetz, M., Tan, I., Bouman, C., Macedo, E., Gibney, N., Tolwani, A., & Ronco, C. (2005, August 17). Acute renal failure in critically ill patients: A multinational, multicenter study. JAMA, 294(7), 813-818. 

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Day 1:  A 62-year old, recently widowed male Hispanic patient, named Mr. Kevin Ulyses Blanco (K. U. B.) was brought in to the emergency department (ED) by his daughter for progressively worsening shortness of breath, fatigue, a lingering non-productive cough, and generalized edema. One month prior, he noticed dyspnea upon exertion, loss of appetite, nausea, vomiting and malaise, which he attributed to the flu. In the emergency department, he appeared anxious and pale, and had a dry yellow tint to the skin. He denied any chest pain, and he could not recall the last time he urinated. He has history of benign prostatic hyperplasia, diabetes mellitus type 2, hypertension, dyslipidemia, and renal insufficiency for the past two years. His ED assessment findings included: 1+ pedal edema, basilar crackles in the lungs bilaterally, and a scant amount of urine according to a bladder scan. His lab results indicated a glomerular filtration rate (GFR) of 12. Based on his subjective and objective symptoms, he was admitted with a diagnosis of progression of chronic kidney disease (CKD) to end-stage renal disease (ESRD). The plan of care was focused on managing his symptoms and consulting with his nephrologist regarding need for hemodialysis.

Day 3:  Mr. K.U.B had an AV graft placed in his forearm to receive dialysis and a dual-lumen hemodialysis catheter for temporary use. His symptoms were worsening despite medical interventions and hemodialysis was needed urgently. The plan was to continue his medications to manage anemia, HTN, diabetes, and renal disease. The nurse identified psychosocial stressors of financial concern and having to live alone with his worsening health condition. With his daughter living far away, he was worried he wouldn’t have support. He stated that he was worried about the financial burden of hemodialysis and struggled with facing the reality of his diagnosis and what his quality of life would be like in the next few years of his life. A recommendation was made for a social worker and psychiatric consult.

Day 8:  By the end of day 8, most of his acute symptoms had been relieved and he was stable enough to be discharged. He had been in contact with case management for his follow up appointment had been made with his primary physician and discharge teaching was given.

• What modifiable factors could Mr. K.U.B. have addressed to slow the progression of his renal disease?
• What collaborative interventions could be used to enhance his care and ensure continuity of care after discharge?
• What affect did uncontrolled hypertension and poor medication compliance have on his disease process?

Nursing Case Studies by and for Student Nurses Copyright © by jaimehannans is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License , except where otherwise noted.

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Effectiveness of educational interventions for nurses caring for patients with chronic kidney disease in improving nurse outcomes: A systematic review

Affiliations.

• 1 Nursing Division, Singapore General Hospital, Singapore, Singapore.
• 2 Alice Lee Centre for Nursing Studies, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore.
• PMID: 37953494
• DOI: 10.1111/jocn.16929

Aim: The aim of the study was to evaluate the effectiveness of educational interventions for nurses caring for patients with chronic kidney disease in improving knowledge, nurse-patient interaction, performance, skills competence and clinical decision-making.

Design: Systematic review.

Methods: Search of literature for randomised controlled trials, quasi-experimental studies and pre-experimental studies on chronic kidney disease-related educational interventions for nurses was conducted across 10 databases. Two reviewers independently screened articles, appraised studies and extracted data.

Data sources: PubMed, Cochrane, Embase, CINAHL Complete, ERIC, Social Science Database, ASSIA, Scopus, Web of Science and ProQuest Thesis and Dissertations Global databases were searched from date of inception to 21 December 2022.

Results: Three randomised controlled trials and eight pre-experimental studies were included in this review. Synthesis without meta-analysis was conducted due to high heterogeneity among studies. Interventions with teaching sessions, learning activities, self-study modules, discussion and a web-based training system were effective in improving nurses' knowledge, nurse-patient interaction, performance, skills competence and clinical decision-making. Patients experienced an improvement in nurse-patient interaction and no significant decrease in overall quality of life.

Conclusion: This review has shown the effectiveness of educational interventions for nurses caring for people with chronic kidney disease in improving outcomes for both nurses and patients, with sustained improvements up to a period of 1 year.

Implications for the profession and/or patient care: Study findings can guide the scope of future training for nurses caring for patients with chronic kidney disease.

Impact: Nurses often lack in-service training on how to improve care for patients with chronic kidney disease. This study found that training nurses on how to care for such patients can improve outcomes for nurses, which can translate to higher quality of patient care.

Reporting method: This paper adhered to the synthesis without meta-analysis (SWiM) reporting guideline.

Keywords: chronic kidney failure; nurse education; nurses; systematic review; training.

© 2023 John Wiley & Sons Ltd.

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Contributions of the communication and management of bad news in nursing to the readaptation process in palliative care: a scoping review.

1. Introduction

2. materials and methods, 2.1. selection criteria, 2.2. search strategy, 2.3. selection process and article eligibility criteria, 3.1. characteristics of included studies, contexts, and populations, 3.2. data presentation, 4. discussion, 4.1. intervenient factors in communication and management of bad news, 4.2. key points for improvement in the communication and management of bad news, 4.3. nursing-sensitive outcomes in the communication and management of bad news, 4.4. limitations and suggestions, 5. conclusions, author contributions, conflicts of interest.

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Moura, T.; Ramos, A.; Sá, E.; Pinho, L.; Fonseca, C. Contributions of the Communication and Management of Bad News in Nursing to the Readaptation Process in Palliative Care: A Scoping Review. Appl. Sci. 2024 , 14 , 6806. https://doi.org/10.3390/app14156806

Moura T, Ramos A, Sá E, Pinho L, Fonseca C. Contributions of the Communication and Management of Bad News in Nursing to the Readaptation Process in Palliative Care: A Scoping Review. Applied Sciences . 2024; 14(15):6806. https://doi.org/10.3390/app14156806

Moura, Teresa, Ana Ramos, Eunice Sá, Lara Pinho, and César Fonseca. 2024. "Contributions of the Communication and Management of Bad News in Nursing to the Readaptation Process in Palliative Care: A Scoping Review" Applied Sciences 14, no. 15: 6806. https://doi.org/10.3390/app14156806

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Acute Kidney Injury Case Study (60 min)

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Case Study Objectives

• Analyze and interpret clinical data and patient assessments to identify signs and symptoms of acute kidney injury (AKI) in a real-life patient scenario.
• Apply critical thinking skills to recognize the physiological mechanisms contributing to the development of AKI, considering factors such as dehydration, contrast dye exposure, and prolonged NPO status.
• Evaluate the appropriate nursing actions and interventions required at various stages of AKI management, including fluid resuscitation, diuretic therapy, and ongoing assessment.
• Anticipate and suggest potential preventive measures for AKI, emphasizing the importance of pre- and post-contrast scan IV fluid administration in vulnerable patients.
• Understand the significance of monitoring laboratory values, such as BUN, creatinine, GFR, and electrolytes, to assess kidney function and guide treatment decisions in AKI cases.

By actively engaging with this acute kidney injury case study, nursing students will enhance their clinical reasoning skills and gain valuable insights into the assessment, management, and prevention of AKI in real-world healthcare scenarios.

Kidney Injury Case Study

Ms. Barkley is a thin, frail 64-year-old female presenting from a nursing home for acute abdominal pain, nausea, and vomiting x 2 days. She receives a CT scan with IV contrast. Findings show no acute bleeding, but a possible small bowel obstruction.  She is admitted for bowel rest, with the following written orders from the provider:

• Continuous Telemetry
• Strict I&O measurements
• Keep SpO 2 > 92%
• Keep NPO (strict)
• Hydrocodone/Acetaminophen 5-325 mg PO q6h PRN moderate to severe pain
• Ondansetron 4mg PRN nausea

She is admitted to the unit at the beginning of shift, and the UAP reports the following vital signs: HR 103 RR 16 BP 118/68 SpO 2 96% Pain 6/10

Which order would you question or request clarification for? Why?

• The Ondansetron order is incomplete. There is no route or frequency ordered

What additional nursing assessments need to be performed?

• Assess abdomen – inspect, auscultate, palpate and percuss. Assess for tenderness over specific areas, feel for masses, and look for guarding.
• Listen to heart and lung sounds to ensure no cardiac involvement
• Assess pain with a detailed pain assessment so that pain can be treated appropriately
• Assess skin – the patient has had nausea/vomiting for 2 days, there may be some dehydration – check for tenting.

At the end of the 12-hour shift, vital signs are as follows: HR 96 RR 22

BP 147/80 SpO 2 93%

The nurse recognizes that the patient has not voided all day and assists the patient to the bathroom. The patient voids 200 mL dark, concentrated urine.

What nursing action(s) should be implemented at this time? Who should this information be passed on to?

• Document the output, notify the provider of the decreased urine output
• This information needs to be passed onto the oncoming nurse so that he or she can closely monitor the patient’s urine output.

What diagnostic tests would you expect the provider to order? Why?

• Expect an order for a Basic Metabolic Panel or a Renal Function panel
• It seems like her kidneys aren’t making urine as they should, or she may be severely dehydrated. A chemistry panel can tell us more information about the source of decreased urine output.

Provider orders a 500 mL bolus of Normal Saline (0.9%) IV over 1 hour and a renal function panel, which is drawn promptly by the nurse. After 6 hours, Ms. Barkley still has had no further urine output. A bladder scan shows approximately 60 mL of urine in the bladder. A head-to-toe assessment now reveals crackles in Ms. Barkley’s lungs and her SpO 2 is 89%

The renal function panel has resulted: BUN 56 mg/dL Na 132 mg/dL Cr 3.6 mg/dL Ca 7.7 mg/dL GFR 47 mL/min/m 2 Phos 4.8 mg/dL K 5.5 mEq/L Mg 1.4 mg/dL

What nursing action(s) should be implemented at this time?

• Administer O2 2 lpm via nasal cannula (to keep sats > 92%)
• Notify provider of lab results, especially BUN/Cr, GFR, and Potassium – as these indicate there is kidney involvement.

What orders should be anticipated from the provider?

• The patient may need more fluids, she’s been vomiting for 2 days and NPO for another 12 hours with no IV fluids.
• The patient may require diuretics to remove the excess fluid from her lungs and to determine the level of function of her kidneys

What is going on physiologically with Ms. Barkley at this time? Explain what contributed to the development of this condition

• Ms. Barkley seems to have developed an acute kidney injury or acute kidney failure.
• The likely contributors are the severe dehydration coupled with the IV contrast and 12+ hours of being NPO and having no IV fluids. This caused a low-flow state to the kidneys (pre-renal) as well as possible damage to the kidneys themselves because of the contrast (intra-renal).

The provider orders to give 1L bolus of Normal Saline (0.9%) over 1 hour, then 125 mL/hr of Normal Saline continuously. The provider also orders a one-time dose of 40 mg Furosemide IV push and to re-check the Renal Function Panel in 6 hours.  Ms. Barkley diuresis approximately 600 mL in 2 hours and her lungs now sound clear to auscultation.

Over the next two days, Ms. Barkley’s hourly urine output begins to improve and her BUN, Creatinine, and GFR return to normal ranges.  Her small bowel obstruction resolves on its own and she is able to begin taking PO food and fluids.

What could have been done, if anything, to prevent Acute Kidney Injury for Ms. Barkley?

• The best option would have been to give Ms. Barkley IV fluids before and after her contrast scan, and to make sure she had maintenance IV fluids infusing while she was NPO. 
• Depending on the patient’s kidney function, it isn’t always preventable, but in this case, it seems there was more that could have been done.

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Nursing Case Studies

This nursing case study course is designed to help nursing students build critical thinking.  Each case study was written by experienced nurses with first hand knowledge of the “real-world” disease process.  To help you increase your nursing clinical judgement (critical thinking), each unfolding nursing case study includes answers laid out by Blooms Taxonomy  to help you see that you are progressing to clinical analysis.We encourage you to read the case study and really through the “critical thinking checks” as this is where the real learning occurs.  If you get tripped up by a specific question, no worries, just dig into an associated lesson on the topic and reinforce your understanding.  In the end, that is what nursing case studies are all about – growing in your clinical judgement.

Nursing Case Studies Introduction

Cardiac nursing case studies.

• 6 Questions
• 7 Questions
• 5 Questions
• 4 Questions

GI/GU Nursing Case Studies

• 2 Questions
• 8 Questions

Obstetrics Nursing Case Studies

Respiratory nursing case studies.

• 10 Questions

Pediatrics Nursing Case Studies

• 3 Questions
• 12 Questions

Neuro Nursing Case Studies

Mental health nursing case studies.

• 9 Questions

Metabolic/Endocrine Nursing Case Studies

Other nursing case studies.