Acute Renal Failure Nursing Diagnosis and Nursing Care Plan

Acute renal failure (ARF), also known as acute kidney failure or acute renal injury (AKI), occurs when the kidneys lose their ability to filter waste products from the bloodstream.

As these harmful chemicals accumulate, the normal balance of the blood is disrupted. ARF usually progresses in less than a few days.

This condition is most common in chronically hospitalized patients, or critically ill patients.

ARF may be reversible; however, it may also lead to death if not diagnosed early and treated promptly.

Recovery from ARF may be difficult for those with more complex conditions, but not particularly if the patient is normally fit and healthy.

Signs and Symptoms for Acute Renal Failure

1. Oliguria – decreased urine output; however, urine output may remain normal in the early stages of ARF/AKI
2. Fluid retention  and edema, especially on the lower extremities
3. Shortness of breath
4. Fatigue
5. Nausea
6. Confusion
7. Weakness
8. Irregular heartbeat
9. Chest pain or pressure
10. Seizures or coma in severe cases

On other occasions, acute renal failure will have no signs and symptoms and would only be seen via other tests of a different purpose.

Causes and Risk Factors for Acute Renal Failure

There are three main causes of acute renal failure: condition that decreases blood flow to the kidneys, direct kidney damage, and blocked ureters.

Decreased blood flow to the kidneys. This condition may be due to blood or fluid loss, use of anti-hypertensives, use of blood thinners, use of non-steroidal anti inflammatory drugs (NSAIDs), and history of heart attack, heart disease, infection, or liver failure.

It may also be due to severe allergic reaction called anaphylaxis, severe burns, or severe dehydration.

Direct kidney damage. Many conditions can lead to direct injury to the kidney, which can result to ARF. These may include:

1. Blood clots in the kidney’s veins and arteries
2. Cholesterol deposits
3. Glomerulonephritis– inflammation of the glomeruli
4. Hemolytic uremic syndrome- caused by early destruction of red blood cells
5. Infection
6. Lupus – an immune system disorder causing glomerulonephritis
7. Medications, such as specific chemotherapy drugs, antibiotics and imaging contrasts
8. Scleroderma- a group of rare diseases affecting the skin and connective tissues
9. Thrombotic thrombocytopenic purpura – blood disorder
10. Toxins – such as alcohol, heavy metals and cocaine
11. Rhabdomyolysis– muscle tissue breakdown
12. Tumor lysis syndrome- releases toxins that can cause kidney damage

Conditions that cause blocked ureters. Cancers of the bladder, cervix, colon, and prostate can lead to blocked ureters. Also, blood clots in the urinary tract, an enlarged prostate, kidney stones, and bladder nerve damage may eventually lead to ARF.

The risk factors that may increase the chance of developing ARF include the following

• Hospitalization
• Age
• Peripheral Artery Disease
• Diabetes
• Hypertension
• Heart failure
• Liver Disease
• Cancer

Diagnosis for Acute Renal Failure

1. Urine output measurements
2. Urine test: urine sample analysis
3. Blood tests – to check for levels of urea and creatinine
4. Imaging tests such as CT scan
5. Kidney biopsy – to take a sample of kidney tissue for examination

Complications of for Acute Renal Failure

Acute renal failure can lead to different complications, such as:

1. Pleural effusion and pulmonary edema. Fluid may build up in the lungs, causing pulmonary swelling and difficulty of breathing.
2. Chest pain. ARF can eventually lead to the inflammation of the pericardium, which can cause chest pain or angina.
3. Body malaise and fatigue. ARF can result to fluid and electrolyte imbalance, which may lead to muscle weakness and fatigue.
4. Permanent kidney injury. If left untreated, ARF can progress into end stage renal disease which would require long-term dialysis treatment.
5. Death. The severe loss of kidney function may ultimately lead to death.

Treatment and Prevention for Acute Renal Failure

Hospitalization. Treatment usually involves being admitted to the hospital, but most people who have acute renal failure are already admitted.  The length of stay in hospital depends on how fast one recovers and in some cases recovery can be continued at home. Also, the treatment may depend on underlying conditions that led to ARF. Other than treating the injury, the healthcare team will also work hand in hand with the patients in order to prevent any complications from occurring.

Correction of blood and fluid imbalance. Intravenous fluid for inadequate blood volume can be given to an ARF patient as needed. On the other hand, diuretics can be prescribed in case of excess fluid that may lead to edema. Diuretics can help order to decrease swelling in the extremities.

Correction of electrolyte imbalance. If the kidneys do not filter potassium appropriately, the doctor may prescribe mineral supplements to prevent hyperkalemia, ultimately preventing irregular heart rhythms and muscle weakness. Calcium supplement infusion may be recommended in an ARF patient with calcium imbalance.

Dialysis. An ARF patient may benefit from dialysis to prevent further toxin build up while the kidneys are healing. It may also help remove excess potassium in the blood. In dialysis, a machine serves as the artificial kidney and filters the blood of excess wastes then returns it to the body.

Acute Renal Failure Nursing Diagnosis

Nursing Care Plan for Acute Renal Failure 1

Nursing Diagnosis: Ineffective Renal Tissue Perfusion related glomerular malfunction to secondary to acute renal failure as evidenced by increase in lab results (BUN, creatinine, uric acid, eGFR levels), oliguria, peripheral edema, hypertension, muscle twitching and cramping, fatigue, and weakness

Desired Outcome: The patient will actively participate in the treatment plan and will be able to demonstrate behaviors that will help prevent complications.

Acute Renal Failure Nursing Interventions	Rationale
Assess and monitor vital signs.	To establish baseline data. To monitor the patient’s blood pressure levels as hypertension can worsen kidney damage. Fever may indicate disease progression or the presence of an infection.
Perform the necessary renal function blood tests as ordered. Monitor electrolytes, particularly potassium levels.	To monitor renal function. The kidneys may not be able to filter potassium in the blood in a patient with ARF. This may result to hyperkalemia or high serum potassium levels.
Monitor blood glucose levels, especially if the patient is diabetic.	To reduce the stress on the kidneys.
Weigh the patient daily. Commence strict Input and Output monitoring. Note the characteristics of the urine.	To assess the fluid volume status of the patient. To check for signs of worsening renal function and perfusion.
Administer medications as prescribed. Correct hyperkalemia and/or fluid retention using diuretics.	ARF or AKI is reversible. It can be  treated by managing the underlying causes and signs and symptoms, such as hyperkalemia and fluid retention.
Encourage the patient to have a low potassium, low phosphorus, and low salt diet. Start a food chart.	The kidneys may not be able to filter potassium in the blood in a patient with ARF. A low potassium diet can give the kidneys rest and prevent further deterioration of renal perfusion and function. On the other hand, too much phosphorus can weaken the bones, so a low phosphorus intake is advised. Too much salt may lead to fluid retention. Food charting can help monitor dietary protein and caloric intake.
Refer to the dietitian.	To enable to patient to have specialized advice on renal diet while incorporating his/her food preferences.
Encourage the patient to exercise. Refer to the physiotherapy team.	To reduce peripheral edema and to manage obesity, hypertension, fatigue, and weakness. To enable to patient to have specialized advice on exercise.
Prepare the patient for dialysis if indicated.	An ARF patient may benefit from dialysis to prevent further toxin build up while the kidneys are healing. It may also help remove excess potassium in the blood.

Nursing Care Plan for Acute Renal Failure 2

Nursing Diagnosis: Excess Fluid Volume related to decreased renal function secondary to ARF, as evidenced by blood pressure level of 190/100, leg edema, shortness of breath, chest pain, and weight gain

Desired Outcome: The patient will demonstrate a normal fluid balance with vital signs within normal range, normal BMI, and absence of edema, shortness of breath, and chest pain.

Acute Renal Failure Nursing Interventions	Rationales
Assess the patient’s activities of daily living, as well as actual and perceived limitations to physical activity. Ask for any form of exercise that he/she used to do or wants to try. Ensure that the exercise is safe to perform during the patient’s current stage of disease.	To create a baseline of activity levels and mental status related to fatigue and activity intolerance.
Encourage progressive activity through self-care and exercise as tolerated. Explain the need to reduce sedentary activities such as watching television and using social media in long periods. Alternate periods of physical activity with rest and sleep.	To gradually increase the patient’s tolerance to physical activity.
Teach deep breathing exercises and relaxation techniques.   Provide adequate ventilation in the room.	To allow the patient to relax while at rest and to facilitate effective stress management. To allow enough oxygenation in the room.
Encourage the next of kin, relative, or caregiver of the patient to participate in his/her care, such as monitoring hydration and diet, and activities of daily living where the patient requires a helping hand.	ARF may cause fatigue and exhaustion of the patient, so it is best to have the partner or a caregiver beside him/her at all times and ensure her safety and assist him/ her to perform activities of daily living.

Nursing Care Plan for Acute Renal Failure 3

Nursing Diagnosis: Activity Intolerance related to the disease process of ARF as evidenced by shortness of breath, chest pain, fatigue, muscle weakness,, overwhelming lack of energy, swollen feet, unsteady gait, and verbalization of tiredness

Desired Outcome: The patient will demonstrate alternate periods of desired activities and rest/sleep.

Acute Renal Failure Nursing Interventions	Rationales
Assess the patient’s activities of daily living, as well as actual and perceived limitations to physical activity. Ask for any form of exercise that he/she used to do or wants to try. Ensure that the exercise is safe to perform during the patient’s current stage of disease.	To create a baseline of activity levels and mental status related to fatigue and activity intolerance.
Encourage progressive activity through self-care and exercise as tolerated. Explain the need to reduce sedentary activities such as watching television and using social media in long periods. Alternate periods of physical activity with rest and sleep.	To gradually increase the patient’s tolerance to physical activity.
Teach deep breathing exercises and relaxation techniques.   Provide adequate ventilation in the room.	To allow the patient to relax while at rest and to facilitate effective stress management. To allow enough oxygenation in the room.
Encourage the next of kin, relative, or caregiver of the patient to participate in his/her care, such as monitoring hydration and diet, and activities of daily living where the patient requires a helping hand.	ARF may cause fatigue and exhaustion of the patient, so it is best to have the partner or a caregiver beside him/her at all times and ensure her safety and assist him/ her to perform activities of daily living.

Nursing Care Plan for Acute Renal Failure 4

Risk for Decreased Cardiac Output

Nursing Diagnosis: Risk for Decreased Cardiac Output related to fluid overload, and electrolyte imbalance secondary to acute renal failure.

Desired Outcomes:

• The patient will be able to maintain his or her cardiac output within normal levels.
• The patient’s peripheral pulses will be maintained strong and equal to the adequate capillary refill time.

Acute Renal Failure Nursing Interventions	Rationale
1. Check the patient’s vital signs, especially the blood pressure, heart rate, and presence of fluid volume excess.	It is important to assess the blood pressure, heart rate, and fluid volume excess because this is common in patients with renal failure. An increase in the blood pressure, heart rate, and fluid excess may lead to cardiac failure. Checking the vital signs helps in measuring the status of circulation and perfusion of a person. Sudden changes in a patient’s vital signs may signify unresolved or worsening of the patient’s condition.
2. Perform an electrocardiogram (ECG) or telemetry and assess for changes in rhythm.	Electrocardiogram (ECG) is a test used to check the patient’s heart rhythm and heart electrical activity. Sensors are attached to the patient’s skin to detect the electrical signals produced by the person’s heart each time it beats.  Changes in the patient’s electromechanical function may be seen in response to progressing renal failure and the presence of toxins and electrolyte imbalance.
3. Check the patient’s heart sounds.	The patient’s heart sounds should be checked for the presence of murmurs. A heart murmur may happen in between regular heartbeats and sounds such as rasping and whooshing. Pericardial friction rub should also be assessed because it may indicate uremic pericarditis which requires prompt intervention and acute dialysis.
4. Check the patient’s skin color, temperature, mucous membranes, and nail beds, and note the patient’s capillary time.	The patient’s skin color such as pallor and cyanosis should be assessed because this may indicate anemia, pulmonary congestion, or cardiac failure. The patient’s skin helps in assessing tissue perfusion. A cold, clammy, and pale skin indicates decreased cardiac output.
5. Assess for the presence of GI bleeding using the guaiac testing all stools for blood.	Renal failure may cause gastrointestinal bleeding however its pathogenesis remains uncertain. Other patients may experience gastrointestinal bleeding because of uremia on the gastrointestinal mucosa. The platelet adhesiveness may be affected by uremia which may cause gastrointestinal bleeding that can be seen in patients experiencing renal failure.
6. Evaluate for the presence of muscle cramps, numbness of the fingers, muscle twitching, and hyperreflexia, and check the patient’s laboratory studies.	The patient’s laboratory studies should be monitored such as the level of potassium, calcium, and magnesium. Changes in the potassium level should be monitored especially the presence of hypokalemia or low potassium level. Hypokalemia is a neuromuscular indicator that may affect the patient’s cardiac contractility and function. A decrease in the level of calcium enhances the toxic effects of potassium and the elevated magnesium level can cause CNS depressive effects.
7. Advise the patient to decrease oral fluids if indicated.	The patient’s cardiac output depends on the circulating volume that affects the fluid excess and deficit and the myocardial muscle function.
8. Provide the patient with supplemental oxygen as indicated.	To reduce the cardiac workload and cellular hypoxia, supplemental oxygen should be provided to the patient. Adequate oxygen is needed to help meet the metabolic demand of the patient’s body.
9. Instruct the patient to use and practice stress management, deep breathing exercise, and relaxation techniques.	Stress management, deep breathing exercises, and relaxation techniques should be instructed to the patient because the patient may experience stress because of the condition. If a patient is experiencing stress persistent cortisol levels may happen and may cause cardiac issues. Chronic stress may also cause an increase in the patient’s heart rate, respiratory rate, and blood sugar levels.
10. Provide medication or intravenous fluids as indicated and as prescribed by the physician.	To have adequate blood volume the patient may need medications and additional fluid support as prescribed by the physician.

Nursing Care Plan for Acute Renal Failure 5

Risk for Imbalanced Nutrition: Less Than Body Requirements

Nursing Diagnosis: Risk for Imbalanced Nutrition: Less Than Body Requirements related to dietary restrictions to reduce nitrogenous waste, increased metabolic needs, anorexia, nausea, and vomiting secondary to acute renal failure.

Desired Outcomes:

• The patient will be able to maintain and gain weight as indicated in his or her situation.
• The patient will be free from having edema.
• The patient will express and demonstrate an adequate nutritional intake.

Acute Renal Failure Nursing Interventions	Rationale
1. Check and document the patient’s daily dietary intake.	Assessing the patient’s dietary intake aids in identifying the deficiencies and dietary needs. The patient’s general physical condition, uremic symptoms such as nausea and vomiting, and multiple dietary restrictions affect the patient’s food intake.
2. Provide and offer the patient small and frequent feedings.	Small frequent feedings will help the patient to minimize anorexia and nausea which are associated with the uremic state and will help to diminish peristalsis.
3. Provide the patient and the significant others a list of foods and liquids that are permitted for the patient and encourage them to include menu choices.	This will help the patient with a measure of control within dietary restrictions. To enhance the patient’s appetite, the nurse may offer food from home to enhance the patient’s appetite.
4. Provide frequent mouth care and rinse with diluted acetic acid solution and give hard candy, gums, and breath mints between patient’s meals.	Mouth care is important because the patient’s mucous membrane may be dry and cracked. Mouth care will help in providing a fresh mouth taste for the patient that will help increase the appetite.
5. Check and note the patient’s weight regularly.	To assess the weight loss and the patient’s nutritional status the nurse should weigh the patient daily. Weighing the patient daily will help in evaluating the patient’s progress after the interventions.
6. Check the patient’s laboratory tests which include BUN, albumin, transferrin, sodium, and potassium.	This test is an indicator of the patient’s nutritional needs, restrictions, and the effectiveness of therapy.
7. Refer the patient to a dietitian support team.	This will determine individual calorie and nutrient needs within the restrictions.  The dietitian will help in identifying effective routes and products such as oral supplements, and enteral and parenteral nutrition.
8. Give the patient a high-calorie, and a low to moderate protein diet and include complex carbohydrates and fat sources to meet the patient’s caloric needs and essential amino acids.	The needed amount of exogenous protein is lower than normal unless the patient is on dialysis. Foods that are rich in carbohydrates will help to meet the energy needs and will limit tissue catabolism and prevent ketoacid formation from protein and fat oxidation. The essential amino acids will help improve nitrogen balance, and nutritional status and will stimulate the repair of tubular epithelial cells.
9. Maintain the patient’s electrolyte balance by monitoring the levels strictly.	Electrolyte imbalances may be caused by medications and a decrease in GFR that will also cause renal injury. If the patient experiences electrolyte imbalance the body’s functions which include blood clotting, muscle contractions, acid balance, and fluid regulation will be impaired.
10. Advise and instruct the patient to restrict potassium, sodium, and phosphorus intake as indicated.	These electrolytes should be restricted to prevent renal damage, especially if dialysis is not part of the patient’s treatment or during the recovery phase of acute renal failure.
11. Give the patient medications as indicated including, iron preparations, vitamin D, C, and B complex, and emetics.	A patient with acute renal failure may experience iron deficiency because of protein restrictions and the impairment of GI functions. Vitamin D is needed to facilitate the absorption of calcium from the patient’s GI tract. Vitamin C and vitamin B complex help in cell growth and actions. Antiemetic medications will help relieve nausea and vomiting and will enhance oral intake.
12. Explain the nutritional recommendation of the nutritionist and dietitian to the patient and advise him or her to follow the recommended diet and thickness of fluids.	The nurse should explain to the patient about the new food choices and the recommended type of diet and fluids that will support the patient’s nutritional needs and promote the patient’s compliance to treatment.

Nursing Care Plan for Acute Renal Failure 6

Deficient Knowledge

Nursing Diagnosis: Deficient Knowledge related to lack of recall, misinterpretation of information, and unfamiliarity with information resources secondary to the new diagnosis of acute renal failure as evidenced by patient questions for information, and development of preventable complications.

Desired Outcomes:

• The patient will verbalize and express understanding about acute renal failure, prognosis, and possible complications.
• The patient will be able to identify signs and symptoms of the condition.
• The patient will be able to correlate symptoms of acute renal failure with causative factors.
• The patient will be able to comply and verbalize understanding about the therapeutic needs.
• The patient will initiate necessary lifestyle changes and will participate in the treatment regimen.

Acute Renal Failure Nursing Interventions	Rationale
1. Assess the disease process, prognosis, and the precipitating factors of acute renal failure if known, and ask the patient about his or her expectations.	This will help the nurse to evaluate the patient’s knowledge about acute renal failure. Assessing the patient’s knowledge will help the nurse in planning individualized teaching for the patient.
2. Describe the level of renal function of the patient after the acute episode is over.	The nurse should discuss with the patient the defects in the patient’s kidney function that may happen and explain that they may or may not be permanent.
3. Explain and discuss renal dialysis or transplantation with the patient and the significant others if these are likely options for the future.	The nurse should discuss with the patient and the significant others about the possible interventions for the condition. Dialysis may be done on patients with acute renal failure to remove toxins from the patient’s blood and remove the excess fluids from the body while the kidneys heal. During dialysis, a dialysis machine pumps blood out of the patient’s body through an artificial kidney also known as a dialyzer that filters out waste from the kidneys.
4. Check the patient’s dietary plans and restrictions and include a fact sheet listing foods that should be restricted.	The patient’s nutrition should be adequate to promote tissue healing and following the restrictions may prevent complications.
5. Instruct the patient to check the characteristics, amount, and frequency of his or her urine output.	If the patient experiences changes in the characteristics, amount, and frequency of urine this may indicate an alteration in the renal function.
6. Instruct the patient and the significant others about the need for regular weight monitoring.	To monitor the patient’s fluid and dietary needs the nurse should note the changes in the patient’s weight.
7. Maintain emotional support to the patient as well as the family.	This will help in reassuring the patient and the significant others about the procedure that the patient may undergo.
8. Review and remind the patient about the fluid restrictions if necessary.	A patient with acute renal failure may need to restrict or increase his or her fluid intake depending on the case and stage of acute renal function.
9. Explain to the patient about activity restriction and gradual resumption of desired daily activities and encourage to use energy saving, relaxation, and diversional techniques.	A patient experiencing severe acute renal failure may feel weak for a long period during a lengthy recovery phase which requires measures that will help conserve the patient’s energy.
10. Determine the patient’s activities of daily living and personal responsibilities. Check for available resources and the support systems that are available for the patient.	Determining the patient’s responsibilities and activities of daily living will help the patient manage his or her lifestyle changes and meet his or her personal needs.
11. Explain the importance and stress necessity of follow-up care and laboratory studies.	The patient’s renal function may be slowly returned after an acute failure which usually lasts up to 12 months. Deficits may happen that require changes in therapy to avoid recurrence.

More Nursing Diagnosis for Acute Renal Failure

• Impaired Urinary Elimination

Nursing References

Ackley, B. J., Ladwig, G. B., Makic, M. B., Martinez-Kratz, M. R., & Zanotti, M. (2020). Nursing diagnoses handbook: An evidence-based guide to planning care. St. Louis, MO: Elsevier.  Buy on Amazon

Gulanick, M., & Myers, J. L. (2022). Nursing care plans: Diagnoses, interventions, & outcomes. St. Louis, MO: Elsevier. Buy on Amazon

Ignatavicius, D. D., Workman, M. L., Rebar, C. R., & Heimgartner, N. M. (2020). Medical-surgical nursing: Concepts for interprofessional collaborative care. St. Louis, MO: Elsevier.  Buy on Amazon

Silvestri, L. A. (2020). Saunders comprehensive review for the NCLEX-RN examination. St. Louis, MO: Elsevier.  Buy on Amazon

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