CASE STUDY: ACUTE RENAL FAILURE
Amicably, incidence of such acute renal failure is common complication of critical illness, which is associated with high mortality and has separate independent effect on the risk of death. Nonetheless, the urine output is far less specific, except when it is severely decreased or absent. Several criteria must be considered in selection of outcome measures, including clinical importance, responsiveness to the intervention, accuracy of measurement and completeness of ascertainment. It is important to recognize that fluid deficits can occur in the absence of obvious fluid loss because of vasodilation or alterations in capillary permeability (, 2004 ). Generally, most dialysis devices operate independently from the information infrastructure within institutions. Focusing on integration with the information infrastructure should facilitate many of the key steps necessary for improved care. The dialysis machine should contribute information to automated assessment of patients and thus should be interfaced to such systems. Hydration status will influence urine output and, to some degree, may even alter the volume of distribution for creatinine. Large dose diuretics may be used to force a urine output when it would otherwise fall into category consistent with diagnosis of acute renal failure (, 2004 ). The two possible causes in Mrs Kennedy’s case of acute renal failure are hypovolemia and antibiotic treatment.
Other possible contributing factors that may predispose her to renal failure are the high risk for surgical patients and diseases like diabetes, heart disease and hypertension ( and 2003) not indicated but could be undiagnosed. Then, dehydration can be also the cause for Mrs. Kennedy’s renal failure as it refer to the significant depletion of body water and to varying degrees, electrolytes and the diagnosis is based on history and physical examination and treatment is with oral or IV replacement of fluid and electrolytes with the common source of fluid loss is the vomiting of the patient as due to the failure as accompanied by electrolyte loss. There need consideration of fluid resuscitation requirements and maintenance requirement as the goal is to restore adequate circulating volume to restore BP and perfusion (, and , 2003 ). Dehydration occurs when fluid loss exceeds intake ( 2005). As two thirds of the body’s water is contained in the intracellular compartments (ICF), it is the first area to be depleted. The body compensates for this loss by the osmotic forces that shift water from the other third of the body, the extracellular compartments (ECF), back into the ICF. Interstitial tissues and the circulatory systems contain ECF and are therefore most affected (, , 2005).
Furthermore, it is true that, the kidneys regulate fluid absorption and excretion and maintain narrow range of electrolyte fluctuation. Normally, sodium and potassium are filtered and excreted in the urine and feces according to the body's needs. The common electrolyte imbalance within the case could be hyponatremia being associated with kidney disease, acute renal failure as caused by conditions such as water retention and renal failure that result in a low sodium level in the blood. There can be weakness and nausea within the patient (, , , , , , and , 2002 ). The goal of treatment is to restore electrolyte balance for proper hydration and use of total body fluid. Sodium deficiency must be corrected slowly because drastic change in sodium level can cause brain cell shrinkage and central pontine myelinolysis. There can possibly be serious drop in blood flow to the kidneys. The most common causes of low blood flow are severe blood loss, severe infection, sepsis as well as dehydration due to reduced blood flow. There has been intakes also of problem medicines include antibiotics such as gentamicin, certain kind of pain medicines (, , , , , , and , 2002 ).
There are indications as there implies less of urine output and vomiting and the feeling confused, restless as well as being irritable to such situation. The need to prevent complications by taking medicines to get rid of extra fluid and prevent electrolyte imbalances which can be dangerous. The patient is in oliguric stage and it means, below normal of her urine output and it can be a fact that the patient is in a serious condition and is in danger as the body cannot properly excrete waste materials and toxins in which it can really be harmful as there was intake of antibiotic during her hospitalization and this antibiotics can be dangerous if not properly expel from the body, they can instead destroy cells in the body and Mrs. Kennedy’s kidneys may have no ways to release certain toxins brought by certain medication, otherwise other parts of the body can suffer like her liver (, and , 2003 ). Thus, due to her damaged kidneys, there are less indications of water excretion inside her body so, the need to limit her fluid intake such as in dextrose way and or oral intake in order not to have excessive water in her body. Thus, the patient has chances to die if not prevented right away with proper medication and measures for survival, the one useful treatment is dialysis which is expensive as acute renal failure is evident, the fluid electrolytes were being altered (, , and , 2003 ).
The fact that Mrs. Kennedy is having dehydration as on the process of renal failure, her kidneys are not functioning well that is the reason why there has been excessive water in her body. Thus, supposedly as there is evidence of appendicitis, there is an immediate need for undergoing operation and if not, otherwise there can be the rupturing of her appendix which could complicate the situation of the patient. Moreover, one complication is peritonitis which is inflammation of the peritoneum that surrounds on her intestines or any abdominal organs as there can also be possibilities of acquiring complications during operation. Then, the oliguric stage will last if there can be such dialysis treatment to the patient. The physiology of dehydration are reviewed as normal response to dehydration like for instance, decreased effective arterial blood volume or effective circulating volume is described. Increase in extracellular fluids is the only volume change that is both common and easily discernible in renal disease, but the opposite condition, sodium depletion or clinical dehydration can be result of vomiting as the complications of acute renal disease as sodium and water depletion can be recognized by lack of elasticity within the organs (, , and , 2003 ).
There was use of nasograstic tube in the patient after an abdominal operation in order to have spaces in her intestines and created the pressure as probably she is having been applied with anesthesia meaning there was paralysis in other organ functions. Thus, probable suspicion could be she was not operated right away and possible that her appendix did rupture that subject her for peritonitis as there is spreading of such infection into the blood and in return the blood did spread to her body and hence, have reached the kidneys. The paradigm of sepsis physiology is changing (, and , 2000 ). The early focus on inflammation as the dominant process in the cascade of events leading to organ dysfunction has now evolved to describe complex interaction, relationship to endothelial dysfunction, and the factors that may initiate these changes have brought the coagulation system to the forefront of sepsis physiology. Imbalanced hemostatic mechanisms manifest as microvascular thrombosis and subclinical disseminated intravascular coagulation when combined with inflammation, likely contribute to multiple organ failure and death. Kidney biopsy may be performed in the setting of acute renal failure, to provide a definitive diagnosis and sometimes an idea of the prognosis, unless the cause is clear and appropriate screening investigations are reassuringly negative (, , , , , , and , 2002 ).
The rationale for nursing care involves appropriate interventions for the renal failure as there is the need for monitoring fluid intake and output as closely as possible; insertion of urinary catheter is useful for monitoring urine output as well as relieving possible bladder outlet obstruction, such as with an enlarged prostate. In the absence of fluid overload, administering intravenous fluids is typically the first step to improve renal function (, and , 2000 ). Aside, fluid administration may be monitored with the use of central venous catheter to avoid over or under replacement of fluid. There can require medical treatment with sodium bicarbonate administration and antihyperkalemic measures, unless dialysis is required (, and , 2003 ). Depending on cause, proportion of patients will never regain full renal function, thus having end stage renal failure requiring lifelong dialysis or kidney transplant. Electrolytes help to regulate myocardial and neurological function, fluid balance and any electrolyte imbalances can develop by the following mechanisms: excessive ingestion or diminished elimination of an electrolyte or diminished ingestion or excessive elimination of an electrolyte as caused by renal failure.
As, there is oliguric phrase that can last for one to two weeks up to six weeks. Consistently rising blood urea nitrogen, serum creatinine levels and irregular serum electrolyte levels would have led to this diagnosis. It is important to note that comparisons and observations of diagnostic results and vital signs ( 2005). During the oliguric stage, there is less urine release from the patient with such symptoms implying the urine output as there can be obstruction as well as renal artery occlusion that is with gradual diminution of urine output indicating urethral structure as there is also nausea, vomiting and of course dehydration, urinary electrolytes that can give an indication of activity of the renal tubules. Mrs. K is in the oliguric stage, meaning that the GFR has decreased and therefore so has her output. One theory behind the oliguric stage is that this occurs because of the occlusive effects of the tubule lumen from inflammation and cell debris that have accumulated within ( and , 2004). For the management there has to be accurate control of fluid and most importantly, the accurate measurement of urine output is essential to prevent volume overload or depletion and being oliguric there can be provided with volume of fluid equal to the output on the previous day, plus at the very least an extra 500 mL if pyrexia is present but, the situation may change rapidly and the clinical assessment, measurement of body weight and certain monitoring are required (, and , 2004 ).
The effects of systemic sepsis that reduces blood pressure compromised Mrs. Kennedy’s unstable haemodynamic state ( 2003) then, toxins from sepsis destroy cells in endothelial walls within the vasculature enabling fluid to leak from capillaries, thereby reducing plasma volume (, , 2005). So, now that Mrs. Kennedy’s case has progressed to diuretic stage as there compensate with oliguric as the patient releases urine in excessive mode as ddiuretics do not alter the outcome of acute renal failure as it can be that high dose diuretics may convert oliguric renal failure to non-oliguric failure , which is worthwhile if dialysis is not readily available as the role of diuretics requires further evaluation. In addition, the loop diuretics are able as it was after establishing adequate circulating volume, to promote diuresis in some forms of oliguric acute renal failure but, there have shown that administration of loop diuretics may actually be associated with increased mortality and delayed recovery of renal function. Interventions to stimulate the recovery process of the damaged kidney with growth factors, although theoretically sound, have thus far not led to successful results. The ample need for daily measurement of her electrolytes, potassium and sodium restriction, nutritional support as such sodium intake should be restricted (, and , 2004 ).
There need specific treatment of underlying intrinsic renal disease where appropriate and apply process of dialysis as once oliguric, the fluid intake required for feeding generally means that dialysis will be necessary. In achieving certain education with regards to future renal care, there is a great requirement for data accumulation with possibility of delaying progression of kidney disease through the utilization of such multiple drug and behavior intervention therapies along with integrated renal care optimization of patient empowerment and enabling encouragement aspects respectively. The nursing care is to preserve organ function, balance and maintain homeostasis, stimulate immune competence and prevent malnutrition. Effective communication between the nurse, Mrs. K and her family will help to support, reassure and educate and care is based on multi-disciplinary approach. The nurse role is crucial to the patient’s well-being and recovery. If Mrs. K has a catheter, it may remain until she reaches the diuretic stage. This will enable accurate recording and monitoring of the copious amounts of urine that Mrs. K is likely to pass. The urine is initially hypotonic due to an increase in GFR, with little improvement in tubular function. Improvement in the kidneys ability to concentrate urine will begin in this stage as the nephron tubules begin to clear themselves of the inflammation and debris that has accumulated during healing (, 2005).
Furthermore, education for Mrs. Kennedy will serve to cover her present situation and prepare her for the future. It is important for the nurse to explain all procedures such as tests and medications and to understand that many patients may be embarrassed. Early recognition by the nurse who can identify patient at risk will not only reduce mortality, but would also reduce the chances of that person returning for treatment for chronic renal failure in later life. Therefore, it is important to maintain adequate nutrition, the need for infection prevention avoiding the incidence of sepsis as she was susceptible to infection as well as strict sepsis control is essential., avoidance of intravenous lines and respirators is recommended (, and , 2004 ).
On day two post operatively you notice Mrs. K appears to be confused and irritable. Her blood pressure is elevated and there has been a decrease in her urine output. Bowel sounds have returned and the nasogastric is draining minimal amounts so it can now be removed. You contact the doctor, who orders a set of blood tests to be taken. Blood results are consistent with acute renal failure.
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