Acute Renal Failure Symptoms- rapid onset of oliguria, with rise in nitrogenous waste (azotemia), BUN,

and creatinine that is usually reversible.

Causes of Acute Renal Failure

1. Pre – Renal Cause

– from factors outside of kidneys

- circulatory collapse, cardiovascular disorders, hypovolemia, severe vasoconstriction

2. Intra – Renal Cause

- renal parenchyma failure or disease, nephrotic damage (due to poisons, antibiotics); blood transfusion
reaction; acute pyelonephritis.

3. Post – Renal Cause

- obstruction in collecting system: renal calculi, prostatic tumor, gynecological or urological problems.

Phases of Acute Renal Failure

1. Oliguric Phase
- decrease urine output (<400 ml for 24 hours) caused by acute renal ischemia and tubular necrosis. This
retains waste products and leads to metabolic acidosis.
- last for 1 to 8 weeks

2. Diuretic Phase

- return of GFR and level of BUN signal diurertic phase (1,000 to 2,000 ml per day of urine output that
may cause dehydration).

3. Recovery Phase

- return to pre-renal failure activity level

- recovery last for 3 to 12 months

Assessment or Acute Renal Failure Symptoms

• Changes in urine output

• Sudden weight gain
• Headache
• Nausea and vomiting
• Elevated BP
• Changes in LOC
• Uremic smell (halitosis)
• Dry itchy purpuric skin
• Increased potassium, BUN, creatinine
• Decreased pH, Hct, and Hgb
• Hyperkalemia is the most dangerous imbalance because of its effect in cardiac activity
• Hyponatremia is an effect of dilution rather than a true lack of sodium

Nursing Care for Acute Renal Failure

• Daily weight, vital signs, and CVP monitoring

• Fluids and diuretics (lasix, mannitol) as ordered
• High carbohydrates diet with low protein, low potassium and low sodium
• Management of hyperkalemia
• Insulin (to force potassium back in the intracellular compartment)
• Sodium bicarbonate (K and H ions are best friends)• Kayexalate enema or orally (exchange resins for K
elimination); or dialysis
• Supportive management

Chronic Renal Failure Symptoms

- it is Irreversible progressive reduction of functioning renal tissue that can’t maintain body’s internal
environment.
- Most common causes of CRF are diabetic and hypertensive nephropathy, glomerulonephritis, chronic
pyelonephritis.

Types of Chronic Renal Failure

1. Reduced Renal Reserve – high BUN but there is no clinical symptoms

2. Renal Insufficiency – mild azotemia with impaired urine concentration with nocturia

3. Renal Failure – severe azotemia, acidosis, impaired urine dilution, severe anemia, electrolyte
imbalance

4. End-Stage Renal Failure – deranged excretory and regulatory mechanism; and distinctive groupings of
symptoms

Assessment for Chronic Renal Failure

• Oliguria
• Increased BUN, creatinine
• Uriniferous breath odor
• Stomatitis and GI bleeding (Urea is converted back to ammonia which irritates the mucous membrane)
• Uremic frost
• Decreased libido, impotence, infertility

Management for Chronic Renal Failure

• Monitor I and O
• High CHO, limit Na, K, P, CHON
• Administer phosphate-binding agents as prescribed such as AlOH (Amphogel)
• Meticulous skin care
• Dialysis
Renal Calculi
- Common name; Kidney Stones

- It is most common in men (they have physiologic hypertrophy of the prostate at age 50 and above,
increasing residual urine volume of stasis and predisposing precipitation of organic crystals).

- Calcium stone is the most common constituent of this condition (hypercalcemia or hyperthyroidism
predisposes this condition).

- 99% of calcium is in the bone and teeth and resorption occurs during immobility (which is why
incidence is high among bedridden patients).

Risk Factors

• Infection
• Urinary stasis
• Obstruction
• Other metabolic conditions
Subjective Findings are:

• Flank pain (dull to excruciating)

• It is radiating depending on the stone movement

Objective Findings are:

• Crystals in urine (calcium, struvite, uric acid or cystine); increased serum calcium, phosphorus or uric
acid

Types of Stones

1. Calcium phosphate

• Caused by supersaturation of urine with calcium and phosphate

• Diet includes acid ash foods because calcium stones have an alkaline chemistry
• Phosphate sources include vitamin D rich foods

2. Calcium oxalate

• Caused by supersaturation of urine with calcium and oxalate

• Oxalate food sources include tea, almonds, cashews, chocolate, cocoa, beans, spinach, and rhubarb

3. Struvite

• Also called triple phosphate, composed of magnesium and ammonium phosphate

• Forms in alkaline urine

4. Uric Acid

• Due to excess dietary purine or gout

• Forms in acidic urine

5. Cystine

• Due to increased amounts of methionine (an essential amino acid that forms cystine)
Assessment

• Renal colic that starts in the lumbar region that radiates to the testicles in men and bladder in women
• Ureteral colic that radiates toward genitalia and thigh
• Sharp severe pain of sudden onset
• N/V, pallor, urinary frequency with alternating retention
• Low grade fever, signs of UTI
• Hematuria

Diagnostic and Laboratory Findings for Renal Calculi

• Urinalysis may reveal hematuria, pyuria, and crystal fragments

• 24-hour urine levels for calcium, uric acid, and oxalate
• Serum calcium, phosphorus, and uric acid levels
• KUB, IVP, retrograde pyelography, renal ultrasound, CT scan, cystoscopy, and MRI

Nursing Interventions

• Strain urine (for passage of small stones that should be sent to laboratory for studies)
• Force fluids up to 3-4 L/day, unless contraindicated
• Encourage activity
• Warm soaks to reduce spasms
• Administer analgesics as prescribed on regular schedule
• Diet modification

FOODS THAT ACIDIFY URINE ACID ASH DIET (FOR ALKALINE STONES)

• Cheeses
• Cranberries
• Eggs
• Fish
• Grains (beans and cereals)
• Meats
• Plums
• Poultry
• Prunes
• Gelatin
• Ascorbic acid

FOODS THAT ALKALINIZE URINE ALKALINE ASH DIET (FOR ACID STONES)

• All fruits except cranberries, prunes, plums

• Most vegetables including rhubarb
• Milk

Overview of Benign Prostatic Hypertrophy

• A slow enlargement of the prostate gland, with hypertrophy and hyperplasia of normal tissue
• The enlargement causes narrowing of the urethra and results in partial or complete obstruction
• The cause is unknown, theory is that hormonal (testosterone) alteration is responsible and the
disorder usually occurs in men older than 50 years

Assessment of Benign Prostatic Hypertrophy

– Urgency, frequency, and hesitancy
– Changes in the size and force of urinary stream
– Retention
– Dribbling
– Nocturia
– Hematuria
– Urinary stasis
– UTIs

Nursing Implementation of Benign Prostatic Hypertrophy

– Increased fluid intake of up to 2000 to 3000 ml per day

– Avoid administering medications that cause urinary retention, such as anticholinergics, antihistamines,
and decongestants
– Administer finasteride (Proscar) as prescribed to shrink the prostate gland and improve urine flow
– Surgery: TURP

URINARY CATHETERIZATION

Purposes of Urinary Catheterization

- To determine residual urine and obtain sterile specimen

Nursing Alert for Urinary Catheterization

 the procedure is sterile

 maintain a close system

 the drainage bag must always be below the bladder to avoid back flow of urine

 the catheter bag should not be allowed to lie on the floor

 do not allow the drainage spout to touch the collection receptacle or on the toilet bowl when
draining it

 provide urine acidification

CYSTOSCOPY
Purpose of Cystoscopy
- To assess the bladder and urethra

Nursing Keypoints for Cystoscopy

  check for the informed consent
 If general anesthesia will be used, have the client on NPO; liquid diet if local anesthesia
will be used
 monitor intake and output
 after the procedure, force fluids as prescribed
 administer sitz bath for abdominal pain
 pink-tinged or tea-colored urine is expected within 24-48 hours
 notify the doctor if bright red urine or clots occur

INTRAVENOUS PYELOGRAPHY (IVP)

Purpose of Intravenous Pyelography (IVP)

- visualization of the urinary tract

Nursing Keypoints for Intravenous Pyelography (IVP)

 check for informed consent

 NPO for 8-10 hours before the procedure

 administer laxative to clear bowels before the procedure

 check for allergy to iodine, seafoods or shellfish before the procedure since the procedure
requires the use of iodine based dye

 keep epinephrine at the bedside to counteract possible allergic reaction. IVP requires the use of
a contrast medium while KUB does not

 inform the patient about the possible salty taste that may be experienced during the test

 increase fluid intake after the procedure to facilitate excretion of the dye

KIDNEY, URETER AND BLADDER (KUB)

Purpose of KUB
- determines the size, shape, and position of kidneys, ureters, and bladder

Nursing Keypoints for KUB

  no special preparation needed

URINALYSIS

Purpose of Urinalysis
- to assess characteristics of urine

Nursing Keypoints of Urinalysis

 first voided morning sample

 preferred: 15 ml

 use clean container

 decreased specific gravity: diabetes insipidus

 increased specific gravity: diabetes mellitus, dehydration, SIADH

 (+) protein: PIH, nephrotic syndrome

 (+) glucose: diabetes mellitus, infection

URINE COLLECTION, 24 HOUR

Purpose of Urine Collection, 24 hour

- determines the excretion of substances from the kidneys, adrenal glands and the stomach

Nursing Keypoints of Urine collection, 25 hour

 required for ACTH test and schilling's test

 discard the first voided urine