acute renal failure 2003

8/7/2019 Acute Renal Failure 2003

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Holy Angel University

College of Nursing

A.Y 2009-2010

A Case Analysis about:

Submitted by:

Group 2B N-304

Dingal, Paolo Junelle S.

Diwa Jelyn V



Diwa Jelyn V

I. INTRODUCTION

Acute kidney failure or Acute Kidney Injury as it is now referred to in the literature is

defined as the abrupt or sudden decline in renal filtration function. This condition is usually

marked by a rise in serum creatinine concentration or azotemia (a rise in blood urea nitrogen

[BUN] concentration). However, immediately after a kidney injury, BUN or creatinine levels

may be normal, and the only sign of a kidney injury may be decreased urine production. AKI

may be classified into three categories: prerenal, intrarenal and postrenal. Prerenal causes of

ARF are those interfere with renal tissue perfusion. Kidney function depends on the adequate

supply of blood to be filtered. Therefore, if the blood supply is not sufficient, it may cause

ischemia which decreases the glomerular filtration rate (GFR) and may lead to Acute Renal

Failure (ARF). Conditions that contribute to decrease blood flow includes; decrease blood

volume which may cause by diarrhea, vomiting, hemorrhage, excessive use of diuretics, burns or glycosuria. Cardiac diseases may also decrease blood flow as a response to the decrease cardiac

output. Decreased peripheral vascular resistance (PVR) as from spinal anesthesia, septic shock or

anaphylaxis as well plays a role to the decrease blood flow. Other factors consist of vascular

obstruction such as bilateral renal artery occlusion and vasodilation. On the other hand, intrarenal

causes of ARF involve parenchymal changes causes by disease or nephrotoxic substances. Acute

tubular necrosis is the most common cause of intrarenal ARF which comprises of about 75% of

the cases. This necrosis may be cause by decrease renal perfusion or direct damage by



influenced by many non-renal events that regulate creatinine generation, volume of distribution,

and creatinine excretion. Each of these can be dramatically altered in acute renal failure. For

example, patients with ARF are often edematous, which dilutes creatinine and slows recognition

of ARF. Also, creatinine is excreted by glomerular filtration and tubular secretion. As GFR

decreases, the amount of tubular secretion becomes an increasingly important fraction of

creatinine excretion, such that creatinine clearance overestimates GFR by 50 to 100% once the

true GFR is less than 15 ml/min7. The dynamic relationship between creatinine and GFR further

erodes our ability to both detect and quantify renal dysfunction during ARF. Moran and Myers

noted that a sudden fall in GFR to a constant low level causes a slow increase in plasma

creatinine; the rate of rise depends on the new GFR but also on the rate of creatinine generation

and the volume of distribution of creatinine. A new steady state is reached when the creatinine

generation equals creatinine excretion. During recovery from ARF, the reverse occurs. This

dynamic relationship has several consequences. First, it is difficult to estimate GFR from plasma

creatinine during these non-steady state conditions. The continued rise in plasma creatinine does

not indicate that renal function has worsened; rather, it indicates that a steady state has not been

achieved. GFR is a complicated function of the rate of rise of the plasma creatinine, the patient's

baseline GFR, and the presence of edema and altered creatinine production. Second, large

changes in GFR are initially manifested as small changes in creatinine in the first one to two

days after renal injury. Since these changes are near the detection limits of a clinical laboratory,

the diagnosis of ARF may be delayed especially in the setting of malnutrition or edema Third

http://www.nature.com/ki/journal/v54/n6/full/4490427a.html#bib7%23bib7

http://www.nature.com/ki/journal/v54/n6/full/4490427a.html#bib7%23bib7



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.

Approximately 1% of patients admitted to hospitals have AKI at the time of admission,

and the estimated incidence rate of AKI is 2-5% during hospitalization. AKI develops within 30

days postoperatively in approximately 1% of general surgery cases; it develops in up to 67% of

intensive care unit patients. Approximately 95% of consultations with nephrologists are related to

AKI. Feest and colleagues calculated that the appropriate nephrologist referral rate is

approximately 70 cases per million population.

The mortality rate estimates for AKI vary from 25-90%. The in-hospital mortality rate is

40-50%; in intensive care settings, the rate is 70-80%. Increments of 0.3 mg/dL in serum

creatinine have important prognostic significance.

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



Pasay City (50.7%), Muntinlupa City (50.6%), Las Pinas (49.1%), Davao Oriental (44.8%),

Catanduanes (40.9%) and Kalinga (39.3%).

II. NURSING HEALTH HISTORY

1. Personal History

a. Demographic Profile

Mrs. Kelly Clamp is 77 years old female, second to the five children of Mr. and

Mrs. Babcock. She was born on October 28, 1932 at their house in San Nicholas, Lubao

Pampanga. A Filipino and devoted Roman Catholic and has been married to Mr. Old

Clamp. They were blessed with 11 children but unfortunately her husband died on the

year 1970 due to heart attack. She is currently residing at Purok 1 Del Carmen Lubao

Pampanga with her 4 grandchildren.

b. Socio Economic, Cultural and Environmental Factors

Mrs. Kelly Clamp did not finish her elementary due to financial constraint.

According to her, during her time females are not really expected to be at school but

instead they were trained to do household chores. At present, she is the care taker of her



Kelly Clamp consults albularyo instead of doctors. She also delivered her 11 children

with the aid of a hilot. According to her their residence is a quiet and peaceful place.

There are no smokers in their house and they have harmonious relationship with their

neighbors.

2. Family Health Illness History

.er

ock

Mrs.Super

Babcock

D. 1971

Junior

Babcock

Mr.Allis

MAl

D. 1976

Baby

Allis

Billy

1932

Kelly

77

Willy Shelly Belly

Legend:



3. History of Past Illness

Mrs. Kelly Clamp is a hypertensive patient with usual blood pressure of 150/100.

However, she does not take antihypertensive drugs instead she avoids eating fatty to prevent

further increase of her blood pressure. She had measles at the age of 5 and chickenpox when

she was 10. She also experienced fever, headaches and sometimes colds and cough. Mrs.

Kelly Clamp does not consult a doctor during illness instead she resorts to self-medication.

Usual medicines that she is taking include paracetamol and mefenamic acid.

4. History of Present Illness

Based on the statement of Mrs. Kelly Clamp, two days before her hospitalization, she

experienced frequent dizziness and headache. Last July 30, 2010, she was rushed to the

hospital due to severe headache and dizziness. Upon arrival, oxygen inhalation was

administered to her and she was advised to stay at the hospital for observation and

examination. Complete Blood Count, blood chemistry and blood typing was ordered by her

physician. The results showed decrease of her hematocrit and hemoglobin thus she

undergone blood transfusion. Blood chemistry results showed elevation of her blood urea

nitrogen and creatinine level which indicates renal failure. Mrs. Kelly Clamp is still in the

hospital for further treatment with diagnosis of Acute Renal Failure.



1. Integumentary

Skin

• Yellowish in color

• Pale palms, soles, nail beds, lips

• Wrinkled texture

• Dry and scaly

• Poor skin turgor, skin recoil beyond 2secs.

• With presence of edema

Hair and Scalp

• Grayish in color and not properly distributed

• Dry

• No lesion, tenderness

• No pediculosis

Nails

• Pale nail beds

• Capillary refill of 2 secs.



• Eyelashes are well distributed and slightly curled outward

•

Bulbar conjunctiva clear • Pink palpebral conjunctiva with no discharge

• Clear sclera

• Moist cornea

• Pupils are equally round and reactive to light accommodation

• Non tender lacrimal apparatus and with no discharge noted

• Both eyes move in smooth, coordinated manners

Ears

• Equal in size and position

• Same color as the face

• No discharge noted

• No lesions

• Non tender auricles

• Pinna recoils after folded

Mouth, Nose and Throat

• Lips are moist, smooth with no lesion

i k h i i h l i b l



• No palpable lymph nodes

•

No tenderness

3. Respiratory

• Chest symmetric

• No tenderness

• No masses or lesion noted

4. Digestive

• Skin is pale

•

No scar present• No tenderness

• Rounded abdomen

• Hyperactive bowel sounds ranging from 5-35 times per minute

5. Peripheral vascular system

Arms



Mental status

• Consciousness

o Awake

o Alert

o Responds appropriately

• Grooming/hygiene

o Clean skin and nails

o Appropriate clothing

• Facial expression

o Good eye contact

o Smiles and frowns appropriately.

7. Sensory System

• correctly identifies light touch

• correctly differentiates dull and sharp sensations

•correctly identifies hot and cold temperature throughout the body

• correctly identifies direction, movements and sensations



Result:

Color: Yellow

Character: clear

pH:6.0

Protein: Negative

Sugar: Negative

Sp. Gravity: 1.010

RBC: Negative

Epithelial Cell: Few

• Hematology

Result Normal Value

Hematocrit 0.26 0.37-0.47(37-47%)

Hemoglobin 86g/dL 140-180g/dL

WBC 11.2 5-9x10g/dL

POLYS 0.62 0.40-0.60

LYMPHOS 0.38 0.20-0.40



• #2 D5LRS 1L x 8˚ (time started: 12:00 AM)

• Medication ordered: Beartec 10mg/tab OD

Serc 16mg/tab q8˚

Transferron tab OD x 3orders

Day 3 (August 1, 2010)

• #3 D5LRS 1L x 32gtts/min (time started: 8:00 AM)

• #4 D5LRS 1L x 32gtts/min (time started: 4:00 PM)

• BP precaution

• Follow up Blood Transfusion

• Continue Monitoring

•

Medication ordered: Furosemide 20 mg IV q12




• #1 PNSS 1L x 100cc/hr (time started: 9:00 AM)

• Consent for Blood Transfusion

• Carry out Blood Transfusion: PRBC 500cc

• Decrease Beartec to 1/2 tab OD

• Paracetamol 500mg/tab q4˚


• Hematology:

Results Normal Values

Hematocrit 0.27 0.37-0.47

Hemoglobin 90g/dL 140-180g/dL

• Blood Chemistry:

Results Normal Values



• Ketosteril 1tab TID

• Transferron 1 tab ODx30 days

• Simvastatin 20mg/tab OD

• Furosemide 20mg IV q12˚

• Beartec ½ tab OD

B. Summary of Laboratory and Diagnostic Procedures

1. Hematology

2. Blood Chemistry

3. Urinalysis

C. Summary of Medications

1. Allopurinol

2. Serc

3. Ketosteril



IVF: D5LRS and PNSS

BEFORE:

Check doctor’s order

Explain the procedure to the pt.

Inform pt. that the procedure required vein puncturing thus may cause discomfort or pain

Prepare the correct IVF

DURING:

Apply sterile to sterile technique

Regulate IVF

AFTER:

Check the puncture site for signs of bleeding, edema or thrombophlebitis

Always make sure that the IVF is patent and regulated properly

Chart the procedure done.

BLOOD TRANSFUSION

BEFORE:

Compare the request to the doctor’s order to check that you request the correct blood



Double-check the label for accuracy and make sure the unit blood type is compatible with

the patient’s type

Check the expiration date and time on the compatibility report to be sure the

compatibility testing has not expired

Do not start the transfusion unless all the comparisons are exactly match

DURING:

Start the transfusion slowly at a rate of 5ml/minute for the first 15 minutes. If vital signs

are stable after 15 minutes of transfusion, adjust the rate as ordered.

Remain at the patient’s side for the first 15 minutes of the transfusion. Monitor for

increase of temperature or chills, hypotension, dyspnea, headache or skin rashes.

AFTER:

Document the starting time of the transfusion, the type of blood component and unit

number.

HEMATOLOGY:



Collect 5-7 ml of blood sample in a examination tube.

AFTER:

Apply pressure to the puncture site.

Check the site for bleeding or swelling.

Send the sample to the laboratory immediately.

Document the procedure done.

CROSS MATCHING

BEFORE:

Verify doctor’s order.

Check patient’s history for recent blood administration.

Explain the procedure to the patient.

DURING:



Send the sample to the laboratory immediately.

URINALYSIS

BEFORE:

Check doctor’s order. Explain the procedure to the patient.

Instruct the patient to obtain clean sample by collecting the midstream urine.

AFTER:

Label the specimen

Bring the specimen at the laboratory immediately.

• Document the procedure done.



↓ Blood Flow

Ischemia

Glomerular Injury Vasoconstriction

↓ Glomerular Permeability

↓ GFR

↓ Urine Production

↓ Renal Excretion

Fluid Retention

↑serum

creatinine↑BUN

EdemaDizzines



VI. EVIDENCED-BASED FOCUS

Acute renal failure in an AIDS patient on tenofovir: a case report

Published: 31 March 2008

Journal of Medical Case Reports 2008, 2:94 doi:10.1186/1752-1947-2-94

Received: 11 June 2007

Accepted: 31 March 2008

Abstract

Tenofovir is a potent nucleotide analogue reverse-transcriptase inhibitor used with other

antiretroviral agents for the treatment of human immunodeficiency virus (HIV) infection.

Despite the absence of renal toxicity observed in the major clinical trials of tenofovir, several

case reports of acute renal failure (ARF) and proximal tubule dysfunction have been described.

Case presentation: We report a patient who developed ARF and Fanconi syndrome during

treatment with tenofovir. Despite severe metabolic acidosis associated with a creatinine of 9.8



(organic anion transporters located on the basolateral side of the tubule) and decreased efflux

into tubular lumen mediated by the MRP 2 (Multidrug- Resistance-Protein) [3]. Similar effects

were not expected with tenofovir due to decreased interaction with human organic transporter 1

and minimal mitochondrial toxicity in vitro [2,3]. Twenty seven cases of tenofovir related

tubular dysfunction and Fanconi syndrome have been described in the medical literature. We

describe another case of a patient in whom ARF and Fanconi syndrome developed during

treatment with tenofovir.

Case presentation

A 53-year-old woman with AIDS of 6 years duration developed progressive weakness, dyspnea

on exertion and constipation. Her symptoms also included decreased appetite, weight loss and

episodes of lightheadness. She had a history of drug and alcohol addiction, seizure disorder,

stroke, pancreatitis and chronic low back pain and she was known to have been Hepatitis B and

C positive since 2002. Antiretroviral therapy, consisting of abacavir, lamivudine and zidovudine,

had been started in March 2002, when she was found to have Pneumocystis jirovecii pneumonia.

She had not developed any other opportun-istic infections. Eighteen months later, in October

2003, her HAART regimen was switched to tenofovir (300 mg/ day), sustiva (600 mg/day) and

Epivir (300mg/day). At that time, her creatinine was 0.8 mg/dL (71 μmol/L). A recheck in

December 2005 revealed a creatinine of 0.9 mg/dL (80 μmol/L) corresponding to Egfr 75

ml/min She had been on this regimen without any change in the dose of tenofovir until she



rates of fractional excretion of phosphorus and uric acid were 58% and 37% respectively. The

findings of renal ultrasound were normal, as were the findings for all serologic tests. Her CD4+

lymphocyte count was 241 and her viral load 460 HIV RNA copies/ml. Tenofovir therapy was

discontinued and her HIV regimen was adjusted to abacavir, sustiva and epivir. Intravenous

bicarbonate therapy was initiated with simultaneous potassium supplementation. Within the next

few days, there was slow improvement in serum creatinine and bicarbonate levels but

hypokalemia (minimum 2.5 mEq/L) recurred, requiring discontinuation of bicarbonate. Five

days after her admission to our hospital, the patient discharged herself against medical advice. At

that time she still had hypokalemia (2.7 mEql/L), low bicarbonate level (16 mEq/L) and a

creatinine of 6.1 mg/dl (539 mmol/L). At follow-up at 7 months, her kidney function had

returned to normal.

Discussion

In short-term clinical trials, tenofovir did not exhibit more frequent nephrotoxicity compared to

placebo [4]. Recently, however several case reports documenting nephrotoxicity have been

described in the literature [5-8]. A number of different manifestations of kidney disease have

been reported with tenofovir, including ARF, rhabdomyolysis, Fanconi syndrome and diabetes

insipidus[6]. Many patients diagnosed with AIDS develop acute or chronic diarrheal syndromes

with associated non-anion gap metabolic acidosis from bicarbonate loss in the stool. However,

our patient did not report any episodes of diarrhea and the positive urine anion gap was not



and the close temporal relationship between discontinuation of tenofovir and improvement of

renal function suggest that tenofovir-induced nephrotoxicity was the most likely diagnosis. The

creatinine of 9.8 mg/dL (866 mmol/L) and bicarbonate of 8 mEq/L are the highest and lowest

respectively reported in the literature among the non-hemodialysis requiring cases of ARF

secondary to tenofovir. The first case of hemodialysis requiring ARF secondary to tenofovir was

of a 40 year-old HIV man who presented with oliguria, acidemia (pH 7.10, HCO3 6 mEql/L),

lactate 7 mmol/L and creatinine of 20 mg/dL (1768 mmol/L)[7]. However, this patient was also

receiving metformin, which could be implicated particularly in the setting of high lactate levels.

The second case of hemodialysis in ARF induced by tenofovir was a 65 year-oldman with

diabetes and AIDS who was admitted with creatinine, 7.1 mg/dL (628 mmol/L, GFR 6.8

ml/min), blood urea nitrogen, 68 mg/dL (24 mmol/L) and bicarbonate, 10 mEq/L [7]. This

patient received two hemodialysis treatments for azotemia. Expecting recovery of kidney

function after discontinuation of tenofovir treatment, we did not dialyse our patient, as she was

asymptomatic. In a recent review, Zimmermann et al. analyzed the findings for the 27 patients

described in the literature with tenofovir-associated ARF since December 2002 [8]. The mean

age was 45.5 years, with a ratio of men to women 3.5:1. The mean duration of tenofovir

treatment was 11 months (range, 1–29 months). Our patient was taking tenofovir for 32 months,

which is to our knowledge the latest presentation of tenofovir- induced ARF. There are no

known predictors of which patients will develop ARF associated with tenofovir. There was no

correlation of CD4 cell count and plasma HIV load with the development of ARF [8] However



tenofovir causes CYP1A2 inhibition, and drug levels may be increased when given with other

antiretroviral medication. Administration of ritonavir alone or with lopinavir has been shown to

increase the maximum serum concentrations of tenofovir by 30%, while didanosine and

atazanavir also have been described to have potential interactions with tenofovir [10]. Notably,

our patient was not receiving tenofovir concurrently with any of the above listed medications.

Until recently, no long-term renal impairment was expected as a consequence of tenofovir-

related nephrotoxicity. However the incomplete recovery of kidney function in 5 out of 27

reported cases after a mean duration of follow- up of 7.5 months raises serious concerns for

occurrence of chronic kidney disease after discontinuation of tenofovir [8]. A follow-up of serum

creatinine, urinalysis and electrolytes should be performed in patients taking tenofovir. Early

diagnosis is important so that this medication can be discontinued in a timely manner and life-

threatening electrolyte imbalances can be avoided. Hemodialysis will not be necessary in the

majority of cases, given the rapid resolution of ARF with the discontinuation of tenofovir.

Physicians should continue to be vigilant in screening patients well after initiation of tenofovir

due to possible late appearance of renal failure. In cases of ARF occurrence, persistence of

kidney damage should be considered as a possibility so that early optimization of coexistent risk

factors can be attempted.

Conclusion

We describe the case of a patient in whom ARF and Fanconi syndrome developed during



VII. NURSING CARE PLANS

Nutritional imbalance: less than body requirements

Cues Nursing

Diagnosis

Scientific

explanation

Planning Interventions Rationale Evaluation

S: “Ala kung

ganang mangan”

O:

-Hyperactive

bowel sound

-Muscle

weakness

-Seemed to be

tired/ lack of

energy

-Dry buccal

cavity

-Decreasedmuscle mass

Imbalance

nutrition less

than body

requirements

related to

anorexia and

altered metabolic

state secondary

to renal failure

A common

diagnosis for

clients with

acute renal

failure. An ARF

patient may have

a bitter taste due

to the decrease

excretion of urea

which is

converted into

ammonia that

causes the

unpleasant taste

of the patient. In

this case, patient

appetite will

decrease thus

patient’s intake

After 2 hours of

nursing

interventions

patient will be

able to verbalize

understanding of

why she should

eat adequate

food so as to

regain energy

and to meet

metabolic needs.

> Determine

client’s ability to

chew, swallow

and taste food.

> Note

availability/ use

of financial

resources and

support system.

> Discuss eating

habits, including

food preferences,

intolerances/

aversion.

> Asses body

fats and muscle

mass via triceps

skin fold and

> This are

factors that may

affect ingestion

and/or digestion

of nutrients

> To determine

ability to acquire

and store various

types of food.

> To appeal to

client’s

likes/dislikes

> To establish

baseline

parameters.

After 2 hours of

nursing

intervention, the

patient was able

to enumerate

importance of

adequate food

intake to regain

energy and to

meet metabolic

needs.

26



of nutrients is

less than what

the body

requires to meet

its metabolic

needs. Due to

decreased

metabolism of

nutrients patient

may suffer from

fatigue as well.

mid-arm muscle

circumference or

other

anthropometric

measurements

> Provide diet

modifications

such as several

small meals and

snacks daily.

> Use flavoring

agents on foods,

like lemon and

herbs because

salt is restricted.

> Provide a

pleasant

environment at

meal time and

prepare the food

in an attractive

manner.

> To enhance

food satisfaction

and stimulate

appetite.

> This may help

to enhance

intake.

> This may aid

in increasing

patient’s appetite

27



> Administer

prescribed

medications

> To improve

the nutritional

value of foods

taken by the

patient

28



Anxiety

Cues Nursing

Diagnosis

Scientific

Explanation


S: “Eku

mipapatudtud

uling isipan ku

ing kundisyun

ku ngeni”

O:

-Teary eyes

-Seemed to be

preoccupied

diminished

concentration

with the topic

Anxiety related

to unknown

outcome of

disease process

Anxiety is

characterized as

a vague uneasy

feeling of

discomfort or

dread

accompanied by

an autonomic

response. A

feeling of

apprehension

caused by

anticipating

danger.

After 2 hours of

nursing

interventions

patient will be

able to verbalize

feelings of

anxiety, would

appear to be

relaxed and

would be able to

identify ways to

deal with and

express anxiety.

> Determine

current

prescribed

medications and

recent drug

history of

prescribed or

OTC medication.

> Identify

client’s

perception of the

treat represented

by the situation.

> Monitor vital

signs

> This

medications can

heighten

feelings/sense of

anxiety

>To know

appropriate

intervention

> To identify

physical responses

associated with

both medical and

emotional

conditions

After 2 hours of

nursing

interventions,

the patient was

able to verbalize

feelings of

anxiety, identify

ways to deal

with anxiety and

appeared

relaxed.

29



> Observe

patient’s

behavior like

restlessness,

irritable, wakeful,

and reports

insomnia.

> Note reports of

insomnia or

excessive

sleeping,

limited/avoidance

interactions with

others.

> Review results

of diagnostic

tests.

> Establish a

therapeutic

relationship,

conveying

empathy and

> Points theclient’s level of

anxiety

> May be

behavioral

indicators of use

of withdrawal to

deal with

problems

> This may point

to physiological

source of anxiety

> To avoid the

contagious

effect/transmission

of anxiety.

30



unconditional

positive regard.

> Provide

accurate

information

about the

situation.

> Encourage

client to develop

an exercise/

activity program.

> Helps client to

identify what is

reality based

> This may serve

to reduce level of

anxiety by

relieving tension.

31



Excessive fluid volume

Cues Nursing

diagnosis

Scientific

explanation


S: Ø

O:

-Bilateral edema

on the lower

extremities

-oliguria

Excess fluid

volume related

to inability of the

kidneys to

produce urine

secondary to

ARF

Presence of ARF

decreases the

ability of the

kidneys to

excrete waste

products. Urine

production is

decreased which

causes fluid

retention thus

resulting into

excess interstitial

fluid.

After 2 hours of

nursing

interventions

patient will be

able to maintain

balanced fluid

intake and

output and

would also

identify

importance of

fluid restriction.

> Note

amount/rate of

fluid intake from

all sources

> Instruct the

patient to

decrease intake

of fluids.

>Explain the

relevance of

fluid restriction

> Monitor input

and output

>Inform patient

to Low Salt Diet

> This may serve

as baseline data

> To prevent

further

worsening of

edema

>Increase

patient’s

awareness and

participation

>To evaluate

prognosis of

problem

>Increase

sodium intake

may aggravate

edema

After 2 hours of

nursinginterventions,

patient was ableto maintain

balance fluid

intake and outputand identify

importance of

decreasing fluidintake.

32



Altered Renal Tissue Perfusion

Cues Nursing

diagnosis

Scientific

explanation


S: Ø

O:

Increase BUN

and serum

creatinine level

Altered renal

tissue perfusion

r/t glomerular

malfunction

secondary to

renal failure

AEB elevation

of BUN and

serum creatinine

level

Decrease blood

supply will

cause the

glomerulus to

malfunction

which may lead

to decrease

permeability

thus decreasing

its ability to

filter waste

products such as

BUN and

creatinine.

Unfiltered waste

will remain to

the blood which

may cause

further injury to

After 4 hours of

nursing

intervention, the

patient will be

able to manifest

willingness of

treatment

program and

lifestyle changes

compliance for

regulating blood

chemistry level

and preventing

complications.

>Monitor vital

signs

>Ascertain

voiding pattern

>Assess mental

status and

review

laboratory

results such as

BUN and

creatinine.

>Monitor BP

>Observe

presence of

edema

>Monitor urine

output

>To have

baseline data

>to compare

with current

situation

>Increase BUN

and creatinine

levels alter

mental status.

>↓GFR may

increase BP

>To evaluate

degree of kidney

impairment

> To assess renal

perfusion and

After 4 hours of

nursing

interventions,

patient was able

to comply to

treatment

program and

lifestyle

modification.

33



the patient.

>Provide diet

restriction such

as Low ProteinLow Salt diet,

while providing

adequate calories

>Administer

medications as

ordered

function

>Restriction of

protein helps

limit BUN;decrease in salt

intake may

prevent fluid

excess while

calories meet

body needs.

>To

treat/manage the

patient’s

condition

34



Fatigue

Cues Nursing

diagnosis

Scientific

explanation


S: Ø

O:

-generalized

body weakness

-pale

-dizzy

-Hgb count of

90g/dL

Fatigue related

to decreased

hemoglobin

count

A decrease in

Hgb count

would be a

factor in having

fatigue because

RBC plays an

important role in

our cells and

muscle to

function

normally.

Patient with

ARF may suffer

to anemia

because our

kidney is one of

the producers of

erythropoietin

that is one

After 4 hours of

nursing

intervention, the

patient will

demonstrate an

improve ability

to participate in

desired activities

and he will

verbalize an

increase energy

level.

>Establish rapport

>Discuss with the

patient the need

for activity. Plan

schedule with the

patient and

identify the

activities that leads

to fatigue.

>Monitor vital

signs

>Encourage the

>to facilitate

client and

student nurse

interaction

>education may

provide

motivation to

increase activity

level through

patient may feel

too weak

initially

>indicates

physiological

level of

tolerance

>to gain energy

After 4 hours of

nursingintervention,

goal was met asevidenced by:

*clients

verbalization of feeling of less

fatigue and

weakness*patient

participates insome activities

as much as shecould

*patient is

awake

35



component for

RBC production

and RBC are the

one who carriesoxygen and

nutrients to other

cells and

muscles for

them to function.

A decrease in

erythropoietin

production will

tend to produce

a small amount

of RBC that

would lead to a

decreased supply

of oxygen to

different cells

and muscles in

the body.

Therefore,

patient to eat

>Administer

medications such

as ferrous sulfateas prescribed

>Encourage/advise

the patient to

perform ROM

exercise

>Encourage the

patient to rest

>Promote overall

health measures

such as proper

nutrition, adequate

fluid intake and

appropriate

vitamin/iron

>for the body to

have enough

RBC to supplythe muscles and

cells enough

nutrients to

function

properly

>to increase the

patients activity

level in a step-

by-step manner

>restoration of

energy

>to correct the

need of supply

of RBC and to

reduce fatigue

by gaining

energy

36



leading to poor

muscle tone and

a problem with

musclecontractility that

could make the

client feel that

he is weak.

supplement.

>Maintain

strenuous activity

restrictions.

>to improve

activity

tolerance, avoidactivities that

requires too

much energy

37



Impaired Urinary Elimination

Cues Nursing

diagnosis

Scientific

explanation


S: Ø

O:

-oliguria

-irritability

-decreased urine

output

Impaired urinary

elimination

related to

decreases urine

production

secondary to

renal failure

Decrease in

GFR, reduces

kidney’s ability

to excrete excess

fluids and waste

products. Fluid

retention and

remained waste

products further

contributes to

kidney damage

which may

result to

decrease

production of

urine causing

impairement in

elimination.

After 4 hours of

client and

student nurse

interaction the

client will be

able to verbalize

understanding of

condition

>Monitor vital

signs

>Review

laboratory tests for

renal changes

>Determine

patient’s pattern of

elimination

>Palpate Bladder

>Investigate pain,

noting location

>Determine

patient’s usual

daily fluid intake

>Encourage to

verbalize fear or

>To have

baseline data

>To determine

causative factors

>To evaluate

degree of

interference

>To assess for

possible urinary

retention

>To determine

extent of

interference

>To determine

level of

dehydration

>Open

expressions

Goal was met as

evidenced by the

clients

verbalization of

understanding of

condition

38



concern

>Emphasize the

need to adhere

with prescribed

diets

>Emphasize the

importance of

having good

hygiene and

adherence to

treatment program

allows patient to

deal with

feelings and

begin problemsolving

>To prevent

worsening of

disease

condition

>to prevent

infection and

promote

wellness

39



Knowledge Deficit

Cues Nursing

diagnosis

Scientific

explanation


S: “Eku balu

nukarin ku ikwa

ini, enaku man

mapamangan

malat ampong

mataba”

O:

-seemed to be

confused

-narrowed focus

-frequently ask

about disease

condition

Knowledge

Deficit r/t lack

of information

Acute Renal

Failure is not an

ordinary disease

thus community

people does not

have sufficient

information

regarding the

disease.

After 4 hours of

nursing

interventions,

the patient will

be able to

verbalize

understanding of

disease process,

potential

complications,

and therapeutic

needs and

participate in

treatment

program.

>Review disease

process/prognosis

and future

expectations.

>Fluid and

Sodium restriction

if indicated.

>Discuss diet

modification such

as Low salt, Low

fat and high

protein

>Discuss drug

therapy including

>To provide

knowledge base

from which the

patient can make

informed

choices

>Sodium may

further increase

water retention

and BP

>salt and fats

may contribute

to hypertension

while protein

may aid in

wound healing

of the kidney

>To prevent

hypertension

After 4 hours of

nursing

interventions,

the patient was

able to

verbalized

understanding of

disease

condition,

possible

complication

and treatment

program

compliance.

40



anti-hypertensive

drugs and diuretics

>Instruct self-

monitoring of BP,

including taking

rest before BP

taking and proper

positioning

>Establish routine

exercise within

patient’s ability

and intersperse

rest periods within

activities

>Discuss the signs

and further

damage to

kidney’s arteries

and to preventexcess fluid

accumulation.

>ARF patient

are usually

hypertensive

>Helps in

maintaining

muscle tone and

joints flexibility

and reduces risk

associated with

immobility

while preventing

fatigue.

>suggestive of

41



and symptoms

including

headache, blurring

of vision anddizziness.

poor control of

hypertension

42

acute renal failure 2003

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