Acute Renal Failure Nursing Care Plan & Management


  • Is a sudden decline in renal function, usually marked by increased concentrations of blood urea nitrogen (BUN; azotemia) and creatinine; oliguria (less than 500 ml of urine in 24 hours); hyperkalemia; and sodium retention.
  • Acute renal failure are classified into following:
    • Prerenal failure – results from conditions that interrupt the renal blood supply; thereby reducing renal perfusion (hypovolemia, shock, hemorrhage, burns impaired cardiac output, diuretic therapy).
    • Postrenal failure – results from obstruction of urine flow.
    • Intrarenal failure – results from injury to the kidneys themselves (ischemia, toxins, immunologic processes, systemic and vascular disorders).
  • The disease progresses through three clinically distinct phase which is oliguric-anuric, diuretic, and recovery, distinguished primarily by changes in urine volume and BUN and creatinine levels.
  • Complication of ARF include dysrhythmias, increased susceptibility to infection, electrolyte abnormalities, GI bleeding due to stress ulcers, and multiple organ failure. Untreated ARF can also progress to chronic renal failure, end-stage renal disease, and death from uremia or related causes.
  1. Oliguric-anuric phase: urine volume less than 400 ml per 24 hours; increased in serum creatinine, urea, uric acid, organic acids, potassium, and magnesium; lasts 3 to 5 days in infants and children, 10 to 14 days in adolescents and adults.
  2. Diuretic phase: begins when urine output exceeds 500 ml per 24 hours, end when BUN and creatinine levels stop rising; length is availabe.
  3. Recovery phase: asymptomatic; last several months to 1 year; some scar tissue may remain.
  4. In prerenal disease: decreased tissue turgor, dryness of mucous membranes, weight loss, flat neck veins, hypotension, tachycardia.
  5. In postrenal disease: difficulty in voiding, changes in urine flow.
  6. In Intrarenal disease: presentation varies; usually have edema, may have fever, skin rash.
  7. Nausea, vomiting, diarrhea, and lethargy may also occur.
Diagnostic Evaluation:
  1. Urinalysis shows proteinuria, hematuria, casts. Urine chemistry distinguishes various forms of ARF(prerenal, postrenal, intrarenal).
  2. Serum creatinine and BUN levels are elevated; arterial blood gas (ABG) levels, serum electrolytes may be abnormal.
  3. Renal ultrasonography estimates renal size and rules out treatable obstructive uropathy.
Primary Nursing Diagnosis
  • Fluid volume deficit related to excessive urinary output,vomiting,hemorrhage
Other Diagnoses that may occur in Nursing Care Plans For Acute Renal Failure
  • Ineffective tissue perfusion (renal)
  • Excess fluid volume
  • Risk for infection
Therapeutic and Pharmacologic Interventions:
  1. Surgical relief of obstruction may be necessary.
  2. Correction of underlying fluid excesses or deficits.
  3. Correction and control of biochemical imbalances.
  4. Restoration and maintenance of blood pressure through I.V. fluids and vasopressors.
  5. Maintenance of adequate nutrition: Low protein diet with supplemental amino acids and vitamins.
  6. Initiation of hemodialysis, peritoneal dialysis, or continuous renal replacement therapy for patients with progressive azotemia and other life-threatening complications.
Nursing Interventions:
  1. Monitor 24-hour urine volume to follow clinical course of the disease.
  2. Monitor BUN, creatinine, and electrolyte.
  3. Monitor ABG levels as necessary to evaluate acid-base balance.
  4. Weigh the patient to provide an index of fluid balance.
  5. Measure blood pressure at various times during the day with patients in supine, sitting, and standing positions.
  6. Adjust fluid intake to avoid volume overload and dehydration.
  7. Watch for cardiac dysrhythmias and heart failure from hyperkalemia, electrolyte imbalance, or fluid overload. Have resuscitation equipment available in case of cardiac arrest.
  8. Watch for urinary tract infection, and remove bladder catheter as soon as possible.
  9. Employ intensive pulmonary hygiene because incidence of pulmonary edema and infection is high.
  10. Provide meticulous wound care.
  11. Offer high-carbohydrate feedings because carbohydrates have a greater protein-sparing power and provide additional calories.
  12. Institute seizure precautions. Provide padded side rails and have airway and suction equipment at the bedside.
  13. Encourage and assist the patient to turn and move because drowsiness and lethargy may reduce activity.
  14. Explain that the patient may experience residual defects in kidney function for a long time after acute illness.
  15. Encourage the patient to report routine urinalysis and follow-up examinations.
  16. Recommend resuming activity gradually because muscle weakness will be present from excessive catabolism.
Documentation Guidelines
  • Physical findings:Urinary output and description of urine, fluid balance, vital signs, findings related to original disease process or insult,presence of pain or pruritus,mental status,GI status, and skin integrity
  • Condition of peritoneal or vascular access sites
  • Nutrition: Response to dietary or fluid restrictions, tolerance to food, maintenance of body weight
  • Complications:Cardiovascular,integumentary infection
Discharge and Home Healthcare Guidelines

All patients with ARF need an understanding of renal function,signs and symptoms of renal failure ,and how to monitor their own renal function. Patients who have recovered viable renal function still need to be monitored by a nephrologist for at least a year. Teach the patient that she or he may be more susceptible to infection than previously. Advise daily weight checks. Emphasize rest to prevent overexertion. Teach the patient or significant others about all medications, including dosage, potential side effects, and drug interactions. Explain that the patient should tell the healthcare professional about the medications if the patient needs treatment such as dental work or if a new medication is added. Explain that ongoing medical assessment is required to check renal function. Explain all dietary and fluid restrictions. Note if the restrictions are life-long or temporary.

Patients who have not recovered viable renal function need to understand that their condition may persist and even become chronic. If chronic renal failure is suspected, further outpatient treatment and monitoring are needed. Discuss with significant others the lifestyle changes that may be required with chronic renal failure.


Marilyn Sawyer Sommers, RN, PhD, FAAN , Susan A. Johnson, RN, PhD, Theresa A. Beery, PhD, RN , DISEASES AND DISORDERS A Nursing Therapeutics Manual, 2007 3rd ed


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Nursing Care Plan

Nursing Diagnosis: Excess fluid volume

May be relate to

  • Compromised regulatory mechanism (renal failure)

Possibly evidenced by

  • Intake greater than output, oliguria; changes in urine specific gravity
  • Venous distension; blood pressure (BP)/central venous pressure (CVP) changes
  • Generalized tissue edema, weight gain
  • Changes in mental status, restlessness
  • Decreased Hb/hematocrit (Hct), altered electrolytes; pulmonary congestion on x-ray
Desired Outcomes
  • Display appropriate urinary output with specific gravity/laboratory studies near normal; stable weight, vital signs within patient’s normal range; and absence of edema.
Nursing Interventions
  • Accurately record intake and output (I&O) noting to include “hidden” fluids such as IV antibiotic additives, liquid medications, frozen treats, ice chips. Religiously measure gastrointestinal losses and estimate insensible losses (sweating), including wound drainage, nasogastric outputs, and diarrhea.
    • Rationale: Decrease in output (to less than 400 ml per 24 hours) may indicate acute failure, especially in high-risk patients. Accurate monitoring of I&O is necessary for determining renal function and fluid replacement needs and reducing risk of fluid overload. Do note that hypervolemia usually occurs in anuric phase of ARF and may mask the symptoms.
  • Monitor urine specific gravity.
    • Rationale: Measures the kidney’s ability to concentrate urine. In intrarenal failure, specific gravity is usually equal to or less than 1.010, indicating loss of ability to concentrate the urine.
  • Weigh daily at same time of day, on same scale, with same equipment and clothing.
    • Rationale: Daily body weight is best monitor of fluid status. A weight gain of more than 0.5 kg/day suggests fluid retention.
  • Assess skin, face, dependent areas for edema. Evaluate degree of edema (on scale of +1–+4).
    • Rationale: Edema occurs primarily in dependent tissues of the body, (hands, feet, lumbosacral area). Patient can gain up to 10 lb (4.5 kg) of fluid before pitting edema is detected. Periorbital edema may be a presenting sign of this fluid shift because these fragile tissues are easily distended by even minimal fluid accumulation.
  • Monitor heart rate (HR), BP, and JVD/CVP.
    • Rationale: Tachycardia and hypertension can occur because of: (1) failure of the kidneys to excrete urine, (2) excess fluid resuscitation during efforts to treat hypovolemia and/or hypotension or convert oliguric phase of renal failure, (3) changes in the renin-angiotensin system. Invasive monitoring may be needed for assessing intravascular volume, especially in patients with poor cardiac function.
  • Auscultate lung and heart sounds.
    • Rationale: Fluid overload may lead to pulmonary edema and HF evidenced by development of adventitious breath sounds, extra heart sounds.
  • Assess level of consciousness. Investigate changes in mentation, presence of restlessness.
    • Rationale: May reflect fluid shifts, accumulation of toxins, acidosis, electrolyte imbalances, or developing hypoxia.
  • Scatter desired beverages throughout the 24-hour period and give various offering (hot, cold, frozen).
    • Rationale: Helps avoid periods without fluids, minimizes boredom of limited choices, and reduces sense of deprivation and thirst.
  • Correct any reversible cause of ARF: replace blood loss, maximize cardiac output, discontinue nephrotoxic drug, relieve obstruction via surgery.
    • Rationale: Kidneys may be able to return to normal functioning, preventing or limiting residual effects.
  • Use appropriate safety measures (raising side rails and restraints.
    • Rationale: Patient with CNS involvement may be dizzy and/or confused.