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Pathophysiology and Aetiology
Acute renal failure or ARF means any abnormality with the function of kidneys. Kidney performs multiple functions thus ARF is also termed as acute renal injury (ARI). Now medicine and healthcare have advanced to a higher level integrated with different drug therapies and dialysis treatments though the mortality rate with such condition is still high; that is 50% of kidney patients and up to 85% of patients with other co-morbidities (Doenges, Moorhouse & Murr, 2014). The Pathophysiology of ARF includes a rapid fall in Glomerular Filtration Rate (GFR) with an increase in serum creatinine and urea nitrogen. Often it takes two days to develop and sometimes few hours are sufficient. The mandatory urine output of a healthy adult is 400 ml to eliminate the toxins from the body, when it goes below this range it indicates a lowered GFR. ARF can be classified into following four stages, onset, oliguric or anuric, diuretic, and convalescent. The oliguric stage is manifested by the urine output below 400ml/day, uremic symptoms, and hyperkalemia. Diuretic stage presents steady augment in urine output indicating improved GFR. The convalescent period may last for three months to 12 months showing improvement in functions (Doenges, Moorhouse & Murr, 2014).
i) Prerenal: It is associated with the perfusion of kidneys while they are structurally normal, such as blood volume depletion, volume shifts, low GFR, rapid volumetric expansion. Causative factors may include myocardial infarction (MI), burns or trauma, septic or anaphylactic shock, hypovolaemia and renal artery obstruction.
ii) Renal (intrinsic): Linked to the destruction of renal parenchyma due to intrarenal ischemia or nephrotoxic substances. Primary causes are Glomerulonephritis, vascular and intratubular.
iii) Postrenal: Develops due to a hindrance in the urinary tract that may be located anywhere from the tubules to the urethral meatus and manifested through aberrant urinary drainage of either kidneys or a single kidney (Doenges, Moorhouse & Murr, 2014).
ARF stats, symptoms and management
Global stats of ARF states that 10% of the population is influenced by this problem and millions death occur annually due to the lack of proper treatment (Jha et al., 2013). In the US ARF ratio is 100 cases per million. According to a report of Global Burden of Disease study, 2010 kidney disease is ranked 18th in the list of causes of total deaths worldwide (Uchino et al., 2004; The National Kidney Foundation, 2015).
Clinical Symptoms of ARF are lethargy with constant nausea, vomiting, diarrhea, dry skin and mucous membranes, drowsiness, headache, seizures, low urine output scanty with low gravity, increases in blood urea nitrogen (BUN), phosphate concentrations and creatinine serum, low calcium levels, hyperkalemia, progressive acidosis, and anemia (Doenges, Moorhouse & Murr, 2014). Treatment of ARF includes the management of homeostasis and electrolyte balancing as well as acid–base balance and secretion of nitrogenous waste products, acidosis, uraemia hyperkalaemia, and volume overload. To treat ARF Dialysis is the most appropriate intervention that can avert morbidity and support kidney to its recovery phase. It is necessary to diagnose the degree of ARF and make a proper assessment plan before designing a nursing diagnosis and care plan (Doenges, Moorhouse & Murr, 2014).
Nursing Diagnosis
ICD-10 Diagnoses/Client Problems:
The problem of ARF comes under the ICD-10 diagnosis codes N17.9 that is billable code and can be filed for the patient’s problems. It can also be covered under
N17.0- ARF with tubular necrosis
N17.1- ARF with acute cortical necrosis
N17.2- ARF with medullary necrosis
N17.8 –ARF with other acute kidney failures
N17.9 – ARF, unspecified
T14.90- Specified renal injury type (Icd10data.com, 2016)
Advanced Practice Nursing Intervention Plan (including interdisciplinary collaboration, community resources and follow-up plans):
The advanced practice nursing intervention planning for the patients of ARF will be conducted in following categories, disease prevention and health promotion, disease/medication management, community referrals, interdisciplinary collaboration, and follow-up planning. It is mandatory to understand the patient’s readiness to learning through an interview that will facilitate in designing a person-centered nursing intervention plan with teaching interventions (Doenges, Moorhouse & Murr, 2014).
Disease Prevention and Health Promotion Plan:
Interventional scheduling for disease prevention and health promotion includes the preventive measures to be taken considering the risk factors of the clinical condition. The related risks with the patients are multifaceted, such as excessive fluid volume due to lower output than input, lowered cardiac output, imbalanced nutritional status, infection risks and lack of proper knowledge. Patients with acute renal failure are shifted to inpatient or surgical care units. The primary intervention should be centered on the diagnosis of the problem. Patients will be given accurate knowledge about nutritional status and relevant risks such as low or excessive body weight due to edema or dehydration and loss of nutrients. Health promotion teaching will target evading the fear and misconception about the disease, Fluid/Electrolyte Management and monitoring, intake of frequent and small feeds, explaining the level of renal failure, and the probability of required medical procedures like renal dialysis or transplantation (Doenges, Moorhouse & Murr, 2014).
Disease/Medication Management Plan:
Interventional planning for disease and medication management starts with reviewing the prescribed drugs in the past or current medication. The goal of the management plan in the case of ARF includes maintaining the fluid and electrolyte balance, avoiding further complexities, establishing an emotional relation with the patient and providing the patient complete information of the problem including disease process, diagnosis and treatment requirements. To achieve Homeostasis with minimized complications and planning follow-ups to sustain the recovery phase are an additional requirement of an apt management plan. Monitoring the input and output of urine is essential (Doenges, Moorhouse & Murr, 2014).
Community resources and referrals:
Community resources and referrals will facilitate in social and community-based help in coping with ARF. Such support group will help an affected person in recovery phase.
Interdisciplinary collaborations:
The subsequent interdisciplinary collaborations for the patient of ARF are:
Nutrition consult will offer a proper and adequate dietary pattern and post recovery lifestyle changes.
Social Services referral will help the patient in financial needs, especially in applying for insurance coverage for medical expenses.
Psychiatric referrals will help the patient in dealing with his fears, misconception, and anxiety.
Nephrology referrals are mandatory for proper check-ups on frequent times and monitoring the body stats and evading the related risks. Setting up the follow-up appointments with a physician will help the patient.
Follow-Up Planning:
Follow up the appointment of an ARF patient should be scheduled within 1 or 2 weeks post discharge and this interval will gradually increase until complete recovery. In the case of requirement of other procedures like dialysis, patients will need to visit every one or two months as per the severity of the condition. The patient can be educated on performing Dialysis at home if he is ready to learn. If patient does not need dialysis, the frequent monitoring of applicable body stats are highly necessary to avoid any severe condition (Doenges, Moorhouse & Murr, 2014).
References
Doenges, M. E., Moorhouse, M. F., & Murr, A. C. (2014). Nursing care plans: Guidelines for
individualizing client care across the life span. FA Davis.
Jha, V., Garcia-Garcia, G., Iseki, K., Li, Z., Naicker, S., Plattner, B., & Yang, C. W. (2013).
Chronic kidney disease: global dimension and perspectives. The Lancet, 382(9888), 260-
272.
Icd10data.com,. (2016). 2016 ICD-10-CM Diagnosis Codes N17.* : Acute kidney failure.
Retrieved 8 February 2016, from http://www.icd10data.com/ICD10CM/Codes/N00-
N99/N17-N19/N17-
The National Kidney Foundation,. (2015). Global Facts: About Kidney Disease. Retrieved 7
February 2016, from https://www.kidney.org/kidneydisease/global-facts-about-kidney-
Disease
Uchino, S., Doig, G. S., Bellomo, R., Morimatsu, H., Morgera, S., Schetz, M., & Tolwani, A.
(2004). Diuretics and mortality in acute renal failure. Critical care medicine, 32(8),
1669-1677.
