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Treatment Modalities and Best Practice The ultimate goals for treating ARF caused by sepsis are to eliminate the cause and to support the patient’s renal function. The primary focus in treatment of prerenal disease is restoring the blood flow with adequate pressure to the kidney. However, some of the treatments such as mechanical ventilation bring about further complications for the renal system, requiring greater need for the following supportive measure: maintaining fluid and electrolyte balance, removing nitrogenous wastes, sustaining nutrition, and providing emotional support and teaching to the patient and his family. Mechanical Ventilation Renal blood flow (RBF) is decreased as a result of permissive hypercapnea, hypoxemia and positive end-expiratory pressure (PEEP) associated with the use of mechanical ventilation. Decreased RBF caused by constriction in permissive hypercapnea results from both direct and indirect mechanisms. According to Broden (2009), the direct mechanism of hypercapnea is the stimulation of the sympathetic nervous system and release of norepinephrine, causing vasoconstriction and decrease in renal blood flow and GFR. The indirect mechanism is the effect of systemic vasodilatation and decrease vascular resistance, leading to further release of norepinephrine. The use of lung-protective mechanical ventilation with optimal combination of lower tidal volumes and PEEP is currently standard of practice for preventing acute lung injury. The use of PEEP has not been directly linked to impairment of renal function. Healthcare providers need to recognize the stress of mechanical ventilation on the renal system and conduct frequent ongoing thorough assessments to identify potential complications. Fluid replacement and vasoactive drugs Vasoactive medications are frequently used to increase the mean arterial pressure and blood flow to the kidneys once the autoregulation of the kidneys is lost. Norepinephrine has been shown to be the most advantageous in patients with acute kidney injury and failure caused by sepsis (Kosinski, 2009). The norepinephrine increases the mean arterial pressure which, in turn, controls renal function and urine output. Norepinephrine has been shown to decrease renal blood flow in hypovolemic patients; therefore, it is critical to treat hypovolemia with crystalloid solutions prior to administration. Dialysis Acute renal failure can be treated by intermittent dialysis, peritoneal dialysis, or continuous renal replacement therapy (CRRT). The treatment modality is determined based on the patient’s diagnosis and condition. Many patients who are hemodynamically unstable do nottolerate intermittent dialysis as they often become hypotensive during treatment. Repeated episodes of hypotension may cause further injury and ischemia to the nephrons. Likewise, peritoneal dialysis is contraindicated in unstable patients because the pulmonary function may be compromised by the large volume of fluid instilled into the peritoneal cavity. CRRT is tolerated best in unstable, critically ill patients because it removes volume and solutes slowly, avoiding the rapid changes associated with hemodialysis. The goals of CRRT are to maintain optimal fluid balance and to correct electrolyte and metabolic abnormalities. Frequent assessments are required for patients who are on CRRT. Vital signs need to be monitored for hypotension that may occur as a result of hypovolemia during therapy and for hypothermia that may occur as a result of the amount of blood that is in the tubing outside the body. Perfusion and hemodynamic status should be assessed by observing capillary refill, peripheral pulses, and skin temperature and color. The catheter site must be assessed for warmth, redness, edema, drainage, and tenderness. Accurate monitoring of the patient’s electrolyte levels, acid-base balance, and fluid balance are essential with CRRT. Hourly calculations must be performed to determine adjustments in fluid volumes. Caring for CRRT patients requires knowledge of the CRRT system for troubleshooting alarms when they occur. For instance, if the patient is not receiving anticoagulant therapy and/or replacement fluids, the risk of clotting of the hemofilter is increased. Nutrition Critically ill patients often experience catabolism due to stress, further contributing to increased risks of ARF. The BUN and creatinine levels are increased as the body breaks down muscle for protein; however, nutrition should be low in protein and sodium and high in fats and carbohydrates to prevent the protein burden on the patient’s kidneys (Campbell, 2003). Fluids are generally restricted to the amount of the patient’s urine output plus 500 to 700 ml. Parental nutrition is recommended if the gastrointestinal tract is not functional.
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Relationships among the Elderly: The Effects on One’s Health and Psychosocial Well Being
Advances in medicine are allowing many adults to live longer lives than previous generations. In fact, the elderly population is becoming one of the largest growing sectors of the present ...
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Nurse’s Legal Plight
A poem...!
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Looks Can Be Deceiving
I asked his family to step out for a moment so I could empty his JP drains. I emptied them into a basin and I noticed that they were very dark. I inspected them a little closer and I noticed it had a ...
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Culturally Competent Nursing in Homecare
Homecare nurses must be culturally aware in order to appropriately care for homecare patients. Culture plays a part in the care of all types of patients but it plays a more important role in homecare.
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The Importance of Supporting Mothers Who Breastfeed
There are many health benefits to breastfeeding children such as lower mortality rates, ideal nutritional values, and long term benefits such as healthy weights and higher intelligence later in life. ...
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Maximizing Pain Relief in Pediatric Patients
Pain management is a complex issue that has become increasingly significant in the nursing profession; so much so that the assessment of pain has become known as the fifth vital sign. This issue ...
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TO GOWN OR NOT TO GOWN?
The Center for Disease Control (CDC) states that standard precautions should be used for all patients and should be enough to prevent the spread of most MRSA cases. However, in acute-care settings ...
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Family Presence During CPR in the Emergency Department
A descriptive survey conducted in 2000 (Myers, et al 2000) investigated attitudes and beliefs of patients’ families and ER staff members about FWR. The survey reported that 98% of patients’ ...
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Keeping a Positive Outlook: My Clinical Experience as a Student Nurse
My experience in my senior year clinical preceptorship was without a doubt unique but I feel its uniqueness was in what I made of it, something every nursing student can do for themselves. If there ...
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Managing Diabetic Patients on Dialysis: The Nurse and Practitioners Role in Multidisciplinary Team Essentials
The chronic state of diabetes mellitus (DM) mainly type II, is an increasingly common cause of end stage renal disease (ESRD) in all countries, accounting for 51% of dialysis patients in the U.S. and ...
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A Solution for Solving the Nursing Shortage? Advantages and Disadvantages of Recruitment of Foreign-Trained Nurses
The Nursing shortage is not only an American dilemma but a phenomenon threatening the entire global community. Developed, as well as undeveloped, countries are experiencing an increasing number of ...
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Memories from a Haitian Cholera Treatment Center
In January and February of this year I worked in Haiti with United States NDMS DMAT and ImSurt teams providing medical and surgical care to the victims of the January 12th earthquake. What I ...
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