1. Acute glomerulonephritis:.

  2. Acute renal failure: broadly defined as rapid onset of oliguria accompanied by a rising BUN and serum creatinine; usually reversible.
    1. Pathophysiology: acute renal ischemia — tubular necrosis —> decreased urine output. Oliguric phase (<400 mL/24 hr)—waste products are retained —»metabolic acidosis water and electrolyte imbalances —> anemia. Recovery phase— diuresis —» dilute urine —» rapid depletion of sodium, chloride, and water —> dehydration.
    2. Types and risk factors:
      1. Prerenal - due to factors outside of kidney; usually circulatory collapse - cardiovascular disorders, hypovolemia, peripheral vasodilation, renovascular obstruction, severe vasoconstriction.
      2. Intrarenal - parenchymal disease from ischemia or nephrotoxic damage; nephrotoxic agents - poisons, such as lead (carbon tetrachloride); heavy metals (mercury); antibiotics (gentamicin); incompatible blood transfusion; alcohol myopathies; obstetric complications; acute renal disease - acute glomerulonephritis, acute pyelonephritis.
      3. Postrenal - obstruction in collecting system: renal or bladder calculi; tumors of bladder, prostate, or renal pelvis; gynecological or urological surgery in which ureters are accidentally ligated.
    3. Assessment:
      1. Subjective data:
        1. Sudden decrease or cessation of urine output (<400 mL/24 hr).
        2. Anorexia, nausea, vomiting from azotemia.
        3. Sudden weight gain from fluid accumulation.
        4. Headache.
      2. Objective data:
        1. Vital signs (vary according to cause and severity):
          1. BP - usually elevated.
          2. Pulse - tachycardia, irregularities.
          3. Respirations - increased rate, depth, crackles.
        2. Neurological: decreasing mentation, unresponsive to verbal or painful stimuli, psychoses, convulsions.
        3. Halitosis; cracked mucous membranes; uremic odor.
        4. Skin: dry, rashes, purpura, itchy, pale.
        5. Lab data:
          1. Blood: increased - potassium, BUN, creatinine, WBC; decreased - pH, bicarbonate, hematocrit, hemoglobin.
          2. Urine: decreased - volume, specific gravity (4-1.010); increased - protein, casts, red and white blood cells, sodium.
    4. Analysis/nursing diagnosis:
      1. Altered urinary elimination related to kidney malfunction.
      2. Fluid volume excess related to decreased urine output.
      3. Altered nutrition, less than body requirements, related to anorexia.
      4. Altered oral mucous membrane related to stomatitis.
      5. Altered thought processes related to uremia.
    5. Nursing care plan/implementation:
      1. Goal: maintain fluid and electrolyte balance and nutrition.
        1. Monitor: daily weight (should not vary more than ±1 lb); vital signs - include CVP;
          I blood chemistries (BUN 6-20 mg/dL; creatinine 0.6-1.5 mg/dL).
        2. Fluids: IV as ordered; blood: plasma, packed cells, electrolyte solutions to replace losses; restricted to 400 mL/24 hr if hypertension present or during oliguric phase to prevent fluid overload.
        3. Diet, as tolerated: high carbohydrate, low protein, may be low potassium and low sodium; hypertonic glucose (TPN) if oral feedings not tolerated; intravenous Lamino acids and glucose.
        4. Control hyperkalemia: infusions of hypertonic glucose and insulin to force potassium into cells; calcium gluconate (IV) to reduce myocardial irritability from K*; sodium bicarbonate (IV) to correct acidosis; polystyrene sodium sulfonate (Kayexalate) or other exchange resins, orally or rectally (enema), to remove excess K+; continuous renal replacement therapy, peritoneal or hemodialysis.
        5. Medications - diuretics (mannitol, furosemide [Lasix]) to increase renal blood flow and diuresis.
      2. Goal: use assessment and comfort measures to reduce occurrence of complications.
        1. Respiratory: monitor rate, depth, breath sounds, arterial blood gases; encourage deep breathing, coughing, turning; use > incentive spirometer or nebulizer as indicated.
        2. Frequent oral care to prevent stomatitis.
        3. Observe for signs of:
          1. Infection - elevated temperature, localized redness, swelling, heat, or drainage.
          2. Bleeding - stools, gums, venipuncture sites.
      3. Goal: maintain continual emotional support.
        1. Same caregivers, consistency in procedures.
        2. Give opportunities to express concerns, fears.
        3. Allow family interactions.
      4. Goal: health teaching.
        1. Preparation for dialysis (indications: uremia, uncontrolled hyperkalemia, or acidosis). Continuous renal replacement therapy (CRRT) may be used in ARF with fluid overload or rapidly developing azotemia and metabolic acidosis. Continuous ultrafiltration (8-24 hr) of extracellular fluid and uremic toxins. Patient’s BP powers system. Arterial and venous access required.
        2. Dietary restrictions: low sodium, fluid restriction.
        3. Disease process; treatment regimen.
    6. Evaluation/outcome criteria:
      1. Return of kidney function - normal creatinine level (<1.5 mg/dL), urine output.
      2. Resumes normal life pattern (about 3 mo after onset).

  3. Chronic renal failure: as a result of progressive destruction of kidney tissue, the kidneys are no longer able to maintain their homeostatic functions; considered irreversible.
    1. Pathophysiology: destruction of glomeruli—» reduced glomerular filtration rate —» retention of metabolic waste products; decreased urine output; severe fluid, electrolyte, acid-base imbalances —» uremia. Clinical picture includes:
      1. Ammonia in skin and alimentary tract by bacterial interaction with urea —» inflammation of mucous membranes.
      2. Retention of phosphate —» decreased serum calcium —» muscle spasms, tetany, and increased parathormone release —» demineralization of bone.
      3. Failure of tubular mechanisms to regulate blood bicarbonate —» metabolic acidosis —» hyperventilation.
      4. Urea osmotic diuresis —» flushing effect on tubules —> decreased reabsorption of sodium —» sodium depletion.
      5. Waste product retention —» depressed bone marrow function —» decreased circulating RBCs —» renal tissue hypoxia —» decreased erythropoietin production —» further depression of bone marrow—»anemia.
    2. Risk factors:
      1. Diabetic retinopathy.
      2. Chronic glomerulonephritis.
      3. Chronic urinary obstruction, ureteral stricture, calculi, neoplasms.
      4. Chronic pyelonephritis.
      5. Hypertensive nephrosclerosis.
      6. Congenital or acquired renal artery stenosis.
      7. Systemic lupus erythematosus.
    3. Assessment:
      1. Subjective data: excessive fatigue, weakness.
      2. Objective data:
        1. Skin: bronze colored, uremic frost.
        2. Ammonia breath.
        3. Symptoms gradual in onset.
    4. Analysis/nursing diagnosis:
      1. In addition to the following,
      2. Fatigue related to severe anemia.
      3. Risk for impaired skin integrity related to pruritus.
      4. Ineffective individual coping related to chronic illness.
      5. Body image disturbance related to need for dialysis.
      6. Noncompliance related to denial of illness.
    5. Nursing care plan/implementation:
      1. Goal: maintain fluid/electrolyte balance and nutrition.
        1. Diet: low sodium; foods high in: calcium, vitamin B complex, vitamins C and D, and iron (to reduce edema, replace deficits, and promote absorption of nutrients).
        2. Medications: given to control BP, regulate electrolytes, control fluid volume; supplemental vitamins if deficient; electrolyte modifier (aluminum hydroxide [AluCap, Amphojel]), calcium carbonate to bind phosphate.
        3. I&O; intake should be equivalent to previous daily output to prevent fluid retention.
      2. Goal: employ comfort measures that reduce distress and support physical function.
        1. Activity: bed rest; facilitate ventilation; turn, cough, deep breathe q2h; ROM - active and passive, to prevent thrombi.
        2. Hygiene: mouth care to prevent stomatitis and reduce discomfort from mouth ulcers; perineal care.
        3. Skin care: soothing lotions to reduce pruritus.
        4. Encourage communication of concerns.
      3. Goal: health teaching.
        1. Dietary restrictions: no added salt when cooking; change cooking water in vegetables during process to decrease potassium; read food labels to avoid Na+ and K+; protein restriction according to BUN/creatinine ratio (10:1).
        2. Importance of daily weight: same scale, time, clothing.
        3. Prepare for dialysis; transplantation.
    6. Evaluation/outcome criteria:
      1. Acceptance of chronic illness (no indication of indiscretions, destructive behavior, suicidal tendency).
      2. Compliance with dietary restriction - no signs of protein excess (e.g., nausea, vomiting) or fluid/sodium excess (e.g., edema, weight gain).