acute kidney failure

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Related to acute kidney failure: chronic kidney failure

Acute Kidney Failure



Acute kidney failure occurs when illness, infection, or injury damages the kidneys. Temporarily, the kidneys cannot adequately remove fluids and wastes from the body or maintain the proper level of certain kidney-regulated chemicals in the bloodstream.


The kidneys are the body's natural filtration system. They perform the critical task of processing approximately 200 quarts of fluid in the bloodstream every 24 hours. Waste products like urea and toxins, along with excess fluids, are removed from the bloodstream in the form of urine. Kidney (or renal) failure occurs when kidney functioning becomes impaired. Fluids and toxins begin to accumulate in the bloodstream. As fluids build up in the bloodstream, the patient with acute kidney failure may become puffy and swollen (edematous) in the face, hands, and feet. Their blood pressure typically begins to rise, and they may experience fatigue and nausea.
Unlike chronic kidney failure, which is long term and irreversible, acute kidney failure is a temporary condition. With proper and timely treatment, it can typically be reversed. Often there is no permanent damage to the kidneys. Acute kidney failure appears most frequently as a complication of serious illness, like heart failure, liver failure, dehydration, severe burns, and excessive bleeding (hemorrhage). It may also be caused by an obstruction to the urinary tract or as a direct result of kidney disease, injury, or an adverse reaction to a medicine.

Causes and symptoms

Acute kidney failure can be caused by many different illnesses, injuries, and infections. These conditions fall into three main categories: prerenal, postrenal, and intrarenal conditions.
Prerenal conditions do not damage the kidney, but can cause diminished kidney function. They are the most common cause of acute renal failure, and include:
  • dehydration
  • hemorrhage
  • septicemia, or sepsis
  • heart failure
  • liver failure
  • burns
Postrenal conditions cause kidney failure by obstructing the urinary tract. These conditions include:
  • inflammation of the prostate gland in men (prostatitis)
  • enlargement of the prostate gland (benign prostatic hypertrophy)
  • bladder or pelvic tumors
  • kidney stones (calculi)

Key terms

Blood urea nitrogen (BUN) — A waste product that is formed in the liver and collects in the bloodstream; patients with kidney failure have high BUN levels.
Creatinine — A protein produced by muscle that healthy kidneys filter out.
Extracorporeal — Outside of, or unrelated to, the body.
Ischemia — A lack of blood supply to an organ or tissue.
Nephrotoxic — Toxic, or damaging, to the kidney.
Radiocontrast agents — Dyes administered to a patient for the purposes of a radiologic study.
Sepsis — A bacterial infection of the bloodstream.
Vasopressors — Medications that constrict the blood vessels.
Intrarenal conditions involve kidney disease or direct injury to the kidneys. These conditions include:
  • lack of blood supply to the kidneys (ischemia)
  • use of radiocontrast agents in patients with kidney problems
  • drug abuse or overdose
  • long-term use of nephrotoxic medications, like certain pain medicines
  • acute inflammation of the glomeruli, or filters, of the kidney (glomerulonephritis)
  • kidney infections (pyelitis or pyelonephritis).
Common symptoms of acute kidney failure include:
  • anemia. The kidneys are responsible for producing erythropoietin (EPO), a hormone that stimulates red blood cell production. If kidney disease causes shrinking of the kidney, red blood cell production is reduced, leading to anemia.
  • bad breath or bad taste in mouth. Urea in the saliva may cause an ammonia-like taste in the mouth.
  • bone and joint problems. The kidneys produce vitamin D, which helps the body absorb calcium and keeps bones strong. For patients with kidney failure, bones may become brittle. In children, normal growth may be stunted. Joint pain may also occur as a result of high phosphate levels in the blood. Retention of uric acid may cause gout.
  • edema. Puffiness or swelling in the arms, hands, feet, and around the eyes.
  • frequent urination.
  • foamy or bloody urine. Protein in the urine may cause it to foam significantly. Blood in the urine may indicate bleeding from diseased or obstructed kidneys, bladder, or ureters.
  • headaches. High blood pressure may trigger headaches.
  • hypertension, or high blood pressure. The retention of fluids and wastes causes blood volume to increase. This makes blood pressure rise.
  • increased fatigue. Toxic substances in the blood and the presence of anemia may cause the patient to feel exhausted.
  • itching. Phosphorus, normally eliminated in the urine, accumulates in the blood of patients with kidney failure. An increased phosphorus level may cause the skin to itch.
  • lower back pain. Patients suffering from certain kidney problems (like kidney stones and other obstructions) may have pain where the kidneys are located, in the small of the back below the ribs.
  • nausea. Urea in the gastric juices may cause upset stomach.


Kidney failure is diagnosed by a doctor. A nephrologist, a doctor that specializes in the kidney, may be consulted to confirm the diagnosis and recommend treatment options. The patient that is suspected of having acute kidney failure will have blood and urine tests to determine the level of kidney function. A blood test will assess the levels of creatinine, blood urea nitrogen (BUN), uric acid, phosphate, sodium, and potassium. The kidney regulates these agents in the blood. Urine samples will also be collected, usually over a 24-hour period, to assess protein loss and/or creatinine clearance.
Determining the cause of kidney failure is critical to proper treatment. A full assessment of the kidneys is necessary to determine if the underlying disease is treatable and if the kidney failure is chronic or acute. X rays, magnetic resonance imaging (MRI), computed tomography scan (CT), ultrasound, renal biopsy, and/or arteriogram of the kidneys may be used to determine the cause of kidney failure and level of remaining kidney function. X rays and ultrasound of the bladder and/or ureters may also be needed.


Treatment for acute kidney failure varies. Treatment is directed to the underlying, primary medical condition that has triggered kidney failure. Prerenal conditions may be treated with replacement fluids given through a vein, diuretics, blood transfusion, or medications. Postrenal conditions and intrarenal conditions may require surgery and/or medication.
Frequently, patients in acute kidney failure require hemodialysis, hemofiltration, or peritoneal dialysis to filter fluids and wastes from the bloodstream until the primary medical condition can be controlled.


Hemodialysis involves circulating the patient's blood outside of the body through an extracorporeal circuit (ECC), or dialysis circuit. The ECC is made up of plastic blood tubing, a filter known as a dialyzer (or artificial kidney), and a dialysis machine that monitors and maintains blood flow and administers dialysate. Dialysate is a sterile chemical solution that is used to draw waste products out of the blood. The patient's blood leaves the body through the vein and travels through the ECC and the dialyzer, where fluid removal takes place.
During dialysis, waste products in the bloodstream are carried out of the body. At the same time, electrolytes and other chemicals are added to the blood. The purified, chemically-balanced blood is then returned to the body.
A dialysis "run" typically lasts three to four hours, depending on the type of dialyzer used and the physical condition of the patient. Dialysis is used several times a week until acute kidney failure is reversed.
Blood pressure changes associated with hemodialysis may pose a risk for patients with heart problems. Peritoneal dialysis may be the preferred treatment option in these cases.


Hemofiltration, also called continuous renal replacement therapy (CRRT), is a slow, continuous blood filtration therapy used to control acute kidney failure in critically ill patients. These patients are typically very sick and may have heart problems or circulatory problems. They cannot handle the rapid filtration rates of hemodialysis. They also frequently need antibiotics, nutrition, vasopressors, and other fluids given through a vein to treat their primary condition. Because hemofiltration is continuous, prescription fluids can be given to patients in kidney failure without the risk of fluid overload.
Like hemodialysis, hemofiltration uses an ECC. A hollow fiber hemofilter is used instead of a dialyzer to remove fluids and toxins. Instead of a dialysis machine, a blood pump makes the blood flow through the ECC. The volume of blood circulating through the ECC in hemofiltration is less than that in hemodialysis. Filtration rates are slower and gentler on the circulatory system. Hemofiltration treatment will generally be used until kidney failure is reversed.

Peritoneal dialysis

Peritoneal dialysis may be used if an acute kidney failure patient is stable and not in immediate crisis. In peritoneal dialysis (PD), the lining of the patient's abdomen, the peritoneum, acts as a blood filter. A flexible tube-like instrument (catheter) is surgically inserted into the patient's abdomen. During treatment, the catheter is used to fill the abdominal cavity with dialysate. Waste products and excess fluids move from the patient's bloodstream into the dialysate solution. After a certain time period, the waste-filled dialysate is drained from the abdomen, and replaced with clean dialysate. There are three type of peritoneal dialysis, which vary according to treatment time and administration method.
Peritoneal dialysis is often the best treatment option for infants and children. Their small size can make vein access difficult to maintain. It is not recommended for patients with abdominal adhesions or other abdominal defects (like a hernia) that might reduce the efficiency of the treatment. It is also not recommended for patients who suffer frequent bouts of an inflammation of the small pouches in the intestinal tract (diverticulitis).


Because many of the illnesses and underlying conditions that often trigger acute kidney failure are critical, the prognosis for these patients many times is not good. Studies have estimated overall death rates for acute kidney failure at 42-88%. Many people, however, die because of the primary disease that has caused the kidney failure. These figures may also be misleading because patients who experience kidney failure as a result of less serious illnesses (like kidney stones or dehydration) have an excellent chance of complete recovery. Early recognition and prompt, appropriate treatment are key to patient recovery.
Up to 10% of patients who experience acute kidney failure will suffer irreversible kidney damage. They will eventually go on to develop chronic kidney failure or end-stage renal disease. These patients will require long-term dialysis or kidney transplantation to replace their lost renal functioning.


Since acute kidney failure can be caused by many things, prevention is difficult. Medications that may impair kidney function should be given cautiously. Patients with pre-existing kidney conditions who are hospitalized for other illnesses or injuries should be carefully monitored for kidney failure complications. Treatments and procedures that may put them at risk for kidney failure (like diagnostic tests requiring radiocontrast agents or dyes) should be used with extreme caution.



Stark, June. "Dialysis Choices: Turning the Tide in Acute Renal Failure." Nursing 27, no. 2 (February 1997): 41-8.


National Kidney Foundation. 30 East 33rd St., New York, NY 10016. (800) 622-9010.

acute renal failure

An abrupt decline in renal function, marked by a rise in serum creatinine or azotemia, triggered by various processes—e.g., sepsis, shock, trauma, kidney stones, drug toxicity (aspirin, lithium, substances of abuse), toxins, iodinated radiocontrast.

Clinical findings
• Cardiovascular
Congestive heart failure, myocardial infarction, arrhythmias, cardiac arrest occur in up to 35% of patients with ARF. The elderly with low cardiac reserve are at risk of fluid overload secondary to oliguric ARF.

• Pulmonary
Lung disease occurs in over half of patients with ARF and may be linked to shared pulmonary and renal syndromes—e.g., Goodpasture syndrome, Wegener granulomatosis, polyarteritis nodosa, cryoglobulinemia, sarcoidosis. Hypoxia is common during hemodialysis and attributed to white cell sequestration by the lungs and alveolar hypoventilation.

• GI tract
Nausea, vomiting, anorexia; GI bleeding occurs in ± one third of patients with ARF and causes nearly 10% of deaths in patients with ARF. Other GI complaints include pancreatitis, jaundice linked to hepatic congestion, blood transfusions, and sepsis.

• Infections
Occur in up to 33% of patients with ARF; most occur in the lungs and urinary tract, and have mortality rates of up to 72%.
• Neurologic signs of uraemia occur in one-third of ARF patients, and have the expected findings of lethargy, somnolence, reversal of the sleep-wake cycle, and cognitive or memory deficits.

• Prerenal—adaptive response to volume depletion and hypotension.
• Renal/intrinsic—response to cytotoxicity, ischaemia, or inflammation with structural and functional damage to the renal parenchyma.
• Postrenal—obstruction to the passage of urine.

Acute renal failure by type
Crescentic GN—renal vasculitis, anti-GBM disease, immune complex diseases.
Acute tubular injury—ischaemic, toxic, crystals, myoglobinuria
Acute tubulointerstitial nephritis.
Thrombotic microangiopathy—haemolytic-uraemic syndrome, accelerated hypertension, scleroderma.

acute kidney failure

Acute renal failure, see there.


(fal'yer) [Fr. faillir, fr L. fallere, to deceive]
Inability to function, esp. loss of what was once present, as in failing eyesight or hearing.

acute kidney failure

Acute renal failure.

acute liver failure

The development of severe liver damage with encephalopathy and jaundice within eight weeks of the onset of liver disease. Coagulopathy, electrolyte imbalance, and cerebral edema are common. Death is likely without liver transplantation. Synonym: fulminant hepatic failure; fulminant hepatitis


The most common causes of acute liver failure are viral hepatitis, acetaminophen overdose (and other drug reactions), trauma, ischemia, acute fatty liver of pregnancy, and autoimmune disorders.


Early symptoms are often nonspecific and mFay include nausea, vomiting, dizziness, lightheadedness, or drowsiness. As liver injury becomes more obvious, bile permeates the skin, producing jaundice. Alterations in mental status (lethargy or coma) and bleeding caused by coagulopathy may develop.


The diagnosis is suggested by jaundice and altered mental status in addition to elevations in liver function tests and prolongation of the protime and international normalized ratio (INR).

Patient care

Affected patients should be hospitalized, usually in intensive care under very close monitoring. General patient care concerns apply. Airway support and mechanical ventilation are often needed. Fluids and/or pressors, such as dopamine, may be needed to maintain blood pressure and cardiac output. Nutritional support with a low salt, protein-restricted diet, and most calories supplied by carbohydrates, blood product infusions (fresh frozen plasma and platelets), and lactulose are usually administered. Potassium supplements help to reverse the affects of high aldosterone levels; potassium-sparing diuretics increase urine volume. Ascitic fluid is removed by paracentesis or shunt placement to relieve abdominal discomfort and aid respiratory effort. Portal hypertension requires shunt placement to divert blood flow, and variceal bleeding is treated with vasoconstrictor drugs, balloon tamponade, vitamin K administration, and perhaps surgery (to ligate bleeding portal vein collateral vessels).

Medications that are normally metabolized by the liver and medications that may injure the liver further should be avoided. Patients who have overdosed on acetaminophen may benefit from the administration of acetylcysteine if it can be administered within 12 hr of a single ingestion.

Liver transplantation is the definitive treatment for acute liver failure. Early transplant evaluation should be carried out for every patient for whom there is a donated organ available. Without transplantation, the mortality from acute liver injury may reach 80%.

The patient’s level of consciousness should be assessed frequently, with ongoing orientation to time and place. Girth should be measured daily. Signs of anemia, infection, alkalosis, and GI bleeding should be documented and reported immediately. A quiet atmosphere is provided. Physical restraints are applied as minimally as possible, with chemical restraint prohibited. If the patient is comatose, the eyes are protected from corneal injury using artificial tears and/or eye patches.

The prognosis for the illness should be discussed in a sensitive but forthright fashion and emotional support provided to family members. Agency social workers, the hospital chaplain, and other support personnel should be involved in the patient’s care as appropriate to individual needs.

acute renal failure

Abbreviation: ARF
A sudden, significant decrease in the filtration capabilities of the kidneys and, within hours or days, an increase in the levels of creatinine and other waste products in the systemic circulation. ARF occurs in approximately 5% of all patients admitted to hospitals. It often results from accidents, e.g., severe burns and trauma, that cause large losses in body fluid. A number of drugs can cause ARF. Hospital procedures can also cause ARF, and ARF affects more than 25% of surgical patients who require cardiopulmonary bypass and almost 30% of patients in ICU. When ARF is the result of a decrease in blood volume without kidney damage, the condition can often be quickly and completely reversed. When the kidneys have been injured, however, they must heal if the ARF is to resolve. Synonym: acute kidney failure; acute kidney injurydialysis; table;


Prerenal: Most ARF is caused by low perfusion of the kidneys due to problems that do not at first directly damage the kidneys: hypovolemia (such as burns, cirrhosis with portal hypertension and ascites, dehydration, diarrhea, excess diuresis hemorrhage, vomiting); low cardiac output (such as arrhythmias, cardiac tamponade, massive pulmonary embolus, mechanical ventilation, myocardial diseases, pulmonary hypertension); systemic vasodilation (such as anaphylaxis, anesthesia, antihypertensives, sepsis); or bilateral renal vascular blockage (such as emboli, stenosis, thrombi).

Intrarenal: A less common ARF is caused from direct damage to the kidneys. Ninety percent of these cases are caused either by ischemia (from prolonged prerenal ARF or from diseases of blood vessel walls, glomerulonephritis, hyperviscosity syndromes, malignant hypertension, thrombotic microangiopathies, or vasculitis) or by nephrotoxins.

Postrenal: The least common ARF (less than 5% of cases) is caused by urinary obstruction that leads to increased back-pressure in the kidney tubules, which, in turn, decreases the glomerular filtration rate (GFR). Urinary obstruction most often occurs at the bladder neck due to anticholinergic drug therapy, neurogenic bladder, or prostatic disease.


Acute renal failure caused by urinary outlet obstruction (postrenal failure) often completely resolves when urinary flow is restored, i.e., after a urinary catheter is placed or a prostatectomy performed. Renal failure caused by prerenal conditions, i.e., from reduced blood flow to the kidneys (as in dehydration or shock), sometimes improves with fluid and pressor support but may require other therapies, including dialysis. The resolution of ARF caused by intrarenal diseases (as in acute tubular necrosis) and kidney toxins depends on the underlying cause and the duration of the exposure. For example, immunosuppressant drugs may reverse ARF due to glomerulonephritis or renal vasculitis whereas forced diuresis is the treatment for those whose disease is caused by rhabdomyolysis.

Patient care

Patients with ARF may stop making urine, have a sudden rise in BUN and creatinine levels, and develop metabolic acidosis and electrolyte imbalances, esp. hyperkalemia. Other complications may follow as uremia develops, e.g., altered mental status, anorexia, arrhythmias, and fluid overload. The specific cause is identified and removed if possible. The nurse instructs the patient about dietary and fluid restrictions and implements these restrictions, promotes infection prevention, and advises the patient about activity restrictions due to metabolic alterations.

Neurological status is assessed, and safety measures are instituted. Intake and output and daily weights (measures of fluid status) are monitored. Daily blood tests determine acid-base and electrolyte balance. Hyperkalemia is treated with dialysis, intravenous hypertonic glucose solutions, insulin infusion, sodium bicarbonate, or potassium exchange resins administered orally or by enema, depending on its severity. The nurse should assess the patient for edema in the legs and feet, hands and sacrum, and around the eyes. It is also usual to record urine color and clarity. The patient is assessed for gastrointestinal (GI) and cutaneous bleeding and anemia; blood components are replaced, or erythropoietin therapy is administered as prescribed. Blood pressure, pulse, respiratory rate, and heart and lung sounds are regularly assessed for evidence of pericarditis or fluid overload. Cardiac monitoring is used to detect changes in cardiac conduction related to hyperkalemia. Anorexia, nausea, and vomiting result from uremia and lead to poor nutrition with loss of body muscle and mass. Nutritional support is critical to combat malnutrition, infection, and to limit electrolyte imbalances. Protein calorie malnutrition is prevalent in ARF. Renal failure diet requires careful management of total calories, protein, electrolytes, minerals, vitamins, and fluid volume. It should provide enough calories (30–35 kcal/kg) through fats and carbohydrates to limit muscle breakdown. At the same time, protein intake should be restricted to about 1.2 to 1.3 g/kg to minimize azotemia. Sodium intake should be limited to 2 to 4 g a day to limit water retention and hypertension. Potassium intake is restricted because, in renal failure, potassium is not excreted by the kidneys, and hyperkalemia may produce muscle weakness and cardiac rhythm disturbances. Oral intake of phosphorus must also be limited as prescribed; alternately, phosphorus-binding medications are taken with meals to prevent hyperphosphatemia. Oral calcium supplements are often used for this purpose. Vitamins B, C, and folate supplements are often given. Fluids are usually limited to the amount of the patient's urine output plus 500 to 700 ml for metabolic needs. Oral hygiene and misting provide relief for dry mucous membranes and help to prevent inflammation and infection. All stools are tested to monitor for GI bleeding. Aseptic technique is used in caring for this patient, who is extremely susceptible to infection. Other therapies include incentive spirometry, coughing, passive range-of-motion exercises, antiembolism stockings or pneumatic leg dressings, and ambulation. Acute renal failure often results in a protracted illness. Many patients with ARF requiring intensive care will die. As a result, the patient and family require continuous emotional support, and education about the treatment regimen (including dialysis if it is employed), nutritional restrictions, and the use of medications. Because some patients will eventually need to have arteriovenous fistula constructed for dialysis, intravenous access should be limited to the dorsal aspects of the hands whenever possible.

If ARF is not reversed but progresses to chronic (end-stage) renal failure, follow-up care with a nephrologist is arranged, and evaluation and teaching are provided for maintenance dialysis and/or possible kidney transplant. Referral is made for vocational or other counseling as needed.

WhereWhat's ResponsibleExamples
PrerenalInadequate blood flow to the kidneySevere dehydration; prolonged hypotension; renal ischemia or emboli; septic or cardiogenic shock
RenalInjury to kidney glomeruli or tubulesGlomerulonephritis; toxic injury to the kidneys, e.g., by drugs or poisons
PostrenalObstruction to urinary outflowProstatic hyperplasia; bladder outlet obstruction

acute respiratory failure

Any impairment in oxygenation or ventilation in which the arterial oxygen tension falls below 60 mm Hg, and/or the carbon dioxide tension rises above 50 mm Hg, and the pH drops below 7.35.


In most cases the patient will need supplemental oxygen therapy. Intubation and mechanical ventilation may be needed if the patient cannot oxygenate and ventilate adequately, i.e., if carbon dioxide retention occurs. Treatment depends on the underlying cause of the respiratory failure, e.g., bronchodilators for asthma, antibiotics for pneumonia, diuretics or vasodilators for congestive heart failure.

Patient care

Patients with acute respiratory failure are usually admitted to an acute care unit. The patient is positioned for optimal gas exchange, as well as for comfort. Supplemental oxygen is provided, but patients with chronic obstructive lung disease who retain carbon dioxide are closely monitored for adverse effects. A normothermic state is maintained to reduce the patient's oxygen demand. The patient is monitored closely for signs of respiratory arrest; lung sounds are auscultated and any deterioration in oxygen saturation immediately reported. The patient is also watched for adverse drug effects and treatment complications such as oxygen toxicity and acute respiratory distress syndrome. Vital signs are assessed frequently, and fever, tachycardia, tachypnea or bradypnea, and hypotension are reported. The electrocardiogram is monitored for arrhythmias. Serum electrolyte levels and fluid balance are monitored and steps are taken to correct and prevent imbalances. If mechanical ventilation or noninvasive support is needed, ventilator settings and inspired oxygen concentrations are adjusted based on arterial blood gas results. See: ventilation To maintain a patent airway, the trachea is suctioned after oxygenation as necessary, and humidification is provided to help loosen and liquefy secretions. Secretions are collected as needed for culture and sensitivity testing. Sterile technique during suctioning and change of ventilator tubing helps to prevent infection. Use of the minimal leak technique for endotracheal tube cuff inflation helps prevent tracheal erosion. Positioning the nasoendotracheal tube midline within the nostril, avoiding excessive tube movement, and providing adequate support for ventilator tubing all help to prevent nasal and endotracheal tissue necrosis. Periodically loosening the securing tapes and supports prevents skin irritation and breakdown. The patient is assessed for complications of mechanical ventilation, including reduced cardiac output, pneumothorax or other barotrauma, increased pulmonary vascular resistance, diminished urine output, increased intracranial pressure, and gastrointestinal bleeding.

All tests, procedures, and treatments should be explained to the patient and family to improve understanding and help reduce anxiety. Rationales for such measures should be presented, and concerns elicited and answered. If the patient is intubated (or has had a tracheostomy), the patient should be told why speech is not possible and should be taught how to use alternative methods to communicate needs, wishes, and concerns to health care staff and family members.

adult failure to thrive

A progressive functional deterioration of a physical and cognitive nature. The individual's ability to live with multisystem diseases, cope with ensuing problems, and care for himself are markedly diminished.

failure of artificial pacemaker

A defect in a pacemaker device caused by either a failure to sense the patient's intrinsic beat or a failure to pace. Failure to pace can be caused by a worn-out battery, fracture or displacement of the electrode, or pulse generator defect.

backward heart failure

Heart failure in which blood congests the lungs, and often the right ventricle, liver, and lower extremities.

cardiac failure

Heart failure.

chronic respiratory failure

Chronic inability of the respiratory system to maintain the function of oxygenating blood and remove carbon dioxide from the lungs. Many diseases can cause chronic pulmonary insufficiency, including asthmatic airway obstruction, emphysema, chronic bronchitis, and cystic fibrosis; and chronic pulmonary interstitial tissue diseases such as sarcoidosis, pneumoconiosis, idiopathic pulmonary fibrosis, disseminated carcinoma, radiation injury, and leukemia.

Patient care

The focus of patient care is to relieve respiratory symptoms, manage hypoxia, conserve energy, and avoid respiratory irritants and infections. The nurse, respiratory therapist, primary care physician, and pulmonologist carry out the prescribed treatment regimen and teach the patient and family to manage care at home.

Patients may require supplemental oxygen. The patient is taught how to use the equipment and the importance of maintaining an appropriate flow rate. Low flow rates (1–2 L/min) are often best for patients with chronic obstructive lung disease. Drug therapy can include inhaled bronchodilators (if bronchospasm is reversible), oral or inhaled corticosteroids, oral or inhaled sympathomimetics, inhaled mucolytic therapy, and prompt use of oral antibiotics in the presence of respiratory infection. The patient and family are taught the order and spacing for administering these drugs, as well as how to use a metered-dose inhaler (with spacer if necessary). They are taught the desired effects, serious adverse reactions to report, and minor adverse effects and how to deal with them. Patients are taught care of inhalers and other respiratory equipment and are advised to rinse the mouth after using these devices to help limit bad tastes, dryness, and Candida infections.

Unless otherwise restricted, the patient will benefit from increased fluid intake (to 3 L/day) to help liquefy secretions and aid in their expectoration. Deep-breathing and coughing techniques are taught to promote ventilation and remove secretions. The patient also may be taught postural drainage and chest physiotherapy to help mobilize secretions and clear airways. Such therapy is to be carried out at least 1 hr before or after meals. Incentive spirometry may help to promote optimal lung expansion. A high-calorie, high-protein diet, offered as small, frequent meals, helps the patient maintain needed nutrition, while conserving energy and reducing fatigue.

Daily activity is encouraged, alternating with rest to prevent fatigue. Patients may benefit from a planned respiratory rehabilitation program to teach breathing techniques, provide conditioning, and help increase exercise tolerance. Diversional activities also should be provided, based on the patient's interests.

The patient is assessed for changes in baseline respiratory function; restlessness, changes in breath sounds, and tachypnea may signal an exacerbation. Any changes in sputum quality or quantity are noted. The patient is taught to be aware of these changes.

Patients need help in adjusting to lifestyle changes necessitated by this chronic illness. Patients and their families are encouraged to ask questions and voice concerns; answers are provided when possible, and support is given throughout. The patient and family should be included in all care planning and related decisions. The patient also is taught to avoid air pollutants such as automobile exhaust fumes and aerosol sprays, as well as crowds and people with respiratory infections. Patients should obtain influenza immunization annually and pneumonia immunization every 6 years. The patient also may benefit from avoiding exposure to cold air and covering the nose and mouth with a scarf or mask when outdoors in cold, windy weather. Patients who smoke tobacco are advised to abstain, using nicotine replacement therapy, hypnotism, support groups, or other methods.

circulatory failure

Failure of the cardiovascular system to provide body tissues with enough blood for proper functioning. It may be caused by cardiac failure or peripheral circulatory failure, as occurs in shock, in which there is general peripheral vasodilation with pooling of blood in the expanded vascular space, resulting in decreased venous return.

failure of compensation

The inability of the heart muscle or other diseased organs to meet the body's needs. In cardiac failure, this results in pulmonary congestion, difficult breathing, and sometimes hypotension or lower extremity swelling. Causes of cardiac compensatory failure may occur in patients with ischemic heart disease, valvular heart disease, or cardiomyopathies.

congestive heart failure

Abbreviation: CHF
Heart failure.

extubation failure

Respiratory failure after discontinuation of mechanical ventilation, accompanied by the need to reintubate the patient.

forward heart failure

Heart failure in which forward flow of blood to the tissues is inadequate because the left ventricle is unable to pump blood with enough force to the systemic circulation (such as a result of cardiomyopathy, muscular stunning, or infarction) or because outflow from the left ventricle is obstructed as in aortic stenosis).

fulminant hepatic failure

Acute liver failure.

heart failure

Inability of the heart to circulate blood effectively enough to meet the body's metabolic needs. Heart failure may affect the left ventricle, right ventricle, or both. It may result from impaired ejection of blood from the heart during systole or from impaired relaxation of the heart during diastole. In the U.S., about 400,000 people are diagnosed with heart failure each year, and about 10% to 20% of affected persons die of the disease annually. Heart failure is one of the most common causes of hospitalization and rehospitalization in the U.S. The prognosis for patients with heart failure depends on the ejection fraction, that is, the proportion of blood in the ventricle that is propelled from the heart during each contraction. In healthy patients, the ejection fraction equals about 55% to 78%. Synonym: cardiac failure; congestive heart failure See: ejection fraction; pulmonary edema


Heart failure is easily diagnosed in a patient with typical symptoms and signs, esp. when these findings are accompanied by a chest x-ray that shows an enlarged heart and pulmonary edema. In patients with an uncertain presentation, elevated levels of B-type natriuretic peptide (BNP) may aid in the diagnosis.


Difficulty breathing is the predominant symptom of heart failure. In patients with mild impairments of ejection fraction (45% to 50%), breathing is normal at rest but labored after climbing a flight of stairs or lifting lightweight objects. Patients with advanced heart failure (ejection fraction 20%) may have such difficulty breathing that getting out of bed or taking a few steps is very tiring.

Difficulty breathing while lying flat (orthopnea) or awakening at night with shortness of breath (paroxysmal nocturnal dyspnea) are also hallmarks of heart failure, as are exertional fatigue and lower extremity swelling (edema).


Heart failure may result from myocardial infarction, myocardial ischemia, arrhythmias, heart valve lesions, congenital malformation of the heart or great vessels, constrictive pericarditis, cardiomyopathies, or conditions that affect the heart indirectly, including renal failure, fluid overload, thyrotoxicosis, severe anemia, and sepsis. Of the many causes of heart failure, ischemia and infarction are the most common.


Diuretics (including furosemide and bumetanide), neurohormonal agents (such as angiotensin-converting enzyme inhibitors or angiotension receptor blockers), beta blockers (such as carvedilol or bisoprolol) are often combined in the acute and chronic treatment of heart failure. Other drugs that have been shown to be effective are nitrates with hydralazine, and aldosterone (a potassium-sparing diuretic). All of these medications must be monitored closely for side effects. In patients with heart failure caused by valvular heart disease, valve replacement surgery may be effective. Cardiac transplantation can be used in advanced heart failure when donor organs are available.

Patient care

In the patient who presents for medical attention in heart failure, signs and symptoms are assessed, and vital signs, cardiac rhythm, and neurological status are closely monitored. A 12-lead ECG is examined for evidence of acute coronary syndromes and cardiac monitoring is instituted. Hemodynamic monitoring is initiated based on the severity of patient symptoms. The chest is auscultated for abnormal heart sounds and for lung crackles or gurgles. Daily weights are obtained to detect fluid retention, and the extremities are inspected for evidence of peripheral edema. If the patient is confined to a bed, the sacral area of the spine is assessed for edema. Fluid intake and output are monitored esp. if the patient is receiving diuretics. Blood urea nitrogen and serum creatinine, potassium, sodium, chloride, and bicarbonate levels are monitored frequently. The complete blood count, liver function tests, thyroid function tests, and kidney functions should be evaluated to determine whether any comorbid conditions such as anemia, nephrotic syndrome, cirrhosis, or hyperthyroidism are contributing to or worsening heart failure. Echocardiography helps measure ejection fraction, a key component in distinguishing between systolic heart failure and diastolic dysfunction. It is also used to estimate ventricular dysfunction, measure intracardiac pressures and wall motion, assess ventricular relaxation and compliance, and demonstrate abnormal chamber sizes, valve deformities, pericardial effusions, and ventricular thrombi. Multiple gated acquisition (MUGA) scans may be used as an alternative. Cardiac catheterization, recommended for patients with angina or large ischemic areas, can exclude coronary artery disease as a cause of HF. Cardiopulmonary exercise testing, employing computers and gas analyzers to determine maximal oxygen consumption, evaluates ventricular performance during exercise. Acceptable total oxygen uptake is 20 ml/kg/m or higher. A result of less than 12 indicates severe HF. Continuous ECG monitoring is provided during acute and advanced disease stages to identify and manage dysrhythmias promptly. The patient's blood pressure and pulse are assessed while the patient is supine, sitting, and standing to detect orthostasis, esp. during diuretic therapy. The legs are assessed for symmetrical pitting edema, a common finding. The patient is placed in high Fowler's position and on prescribed bedrest, and high concentration oxygen is administered as prescribed to ease the patient's breathing. Prescribed medications, such as carvedilol, candesartan, digoxin, furosemide, lisinopril, spironolactone, and potassium, are administered and evaluated for desired responses and any adverse reactions. All patient activities are organized to maximize rest periods. To prevent deep venous thrombosis due to vascular congestion, the caregiver assists with range-of-motion exercises and applies antiembolism stockings or uses heparins or warfarin. Any deterioration in the patient's condition is documented and reported immediately. To help curb fluid overload, the patient should avoid foods high in sodium content, such as canned and commercially prepared foods and dairy products, restricting dietary sodium to 2 to 3 grams a day and fluid intake to 2 liters a day. The importance of regular medical checkups is emphasized, and the patient is advised to notify the health care practitioner if the pulse rate is unusually irregular, falls below 60, or increases above 120, or if the patient experiences palpitations, dizziness, blurred vision, shortness of breath, persistent dry cough, increased fatigue, paroxysmal nocturnal dyspnea, swollen ankles, decreased urine output, or a weight gain of 3 to 5 lb (1.4 to 2.3 kg) in 1 week. Patients and their families and other care givers must understand the action of each of the medications prescribed, along with their possible adverse reactions and actions to be taken if a dose is missed. The importance of renewing prescriptions in a timely manner so that doses are available when needed should be stressed.

Patient activity as tolerated is encouraged with tasks divided into small segments to avoid shortness of breath.

Annual influenza vaccines and a pneumococcal vaccine (repeated every 5 years) help patients minimize the risk of systemic infections. Smokers are encouraged to quit. Frequent rehospitalizations are the rule rather than the exception in heart failure. Effective treatment may depend on a multidisciplinary approach that includes active participation by the patient, the primary care provider and nurse educator, case managers, pharmacists, dietitians, and social workers, among others. Evidence-based clinical pathways for managing heart failure are available from the American Heart Association and other agencies.

high output heart failure

Heart failure that occurs in spite of high cardiac output, for example, in severe anemia, thyrotoxicosis, arteriovenous fistulae, or other diseases.

intestinal failure

An inability to meet the nutritional requirements of the body for growth, development, and homeostasis that results from either a poorly functioning or a surgically-resected intestine. People with intestinal failure require parenteral or enteral nutritional support.

kidney failure

Renal failure.

left ventricular heart failure

Failure of the heart to maintain left ventricular output.

liver failure

The inability of the liver to function due to liver disease or demands beyond the capabilities of the liver.
See: acute liver failure

low output heart failure

Heart failure in which cardiac output low (as in most kinds of heart disease).

metabolic failure

Rapid failure of physical and mental functions ending in death.

multiple systems organ failure

Multiple organ dysfunction syndrome.

multisystem organ failure

Multiple organ dysfunction syndrome.

organ failure

Inability of one or more of the body's organ systems to perform the tasks of preserving health or homeostasis. The failure may be acute or chronic. Examples include blindness, chronic kidney disease, cirrhosis, dementia, fulminant hepatic failure, hearing loss, heart failure, hypothyroidism, menopause, respiratory failure, and shock.

ovarian failure

Cessation of normal ovarian function, the ability to produce fertilizable eggs when stimulated by gonadotropins.

pump failure

A colloquial term for cardiac failure.
See: cardiac failure

renal failure

Inability of the kidneys to function adequately. It may be partial, temporary, chronic, acute, or complete. Synonym: kidney failure See: end-stage renal disease

respiratory failure

See: acute respiratory failure; chronic respiratory failure

right ventricular heart failure

Failure of the heart to maintain right ventricular output.

failure to thrive

Abbreviation: FTT
A condition in which infants and children not only fail to gain weight but also may lose it, or in which older persons lose the physiological or psychosocial reserves needed to care for themselves. The causes include almost any chronic and debilitating condition.
References in periodicals archive ?
Her outburst came as twins Aaron and Todd, aged two, yesterday underwent dialysis at London's St Thomas's Hospital after suffering acute kidney failure.
Renal Diagnostics' Renostat system for the early detection of acute kidney failure is designed for non-invasive use in the 5 million patients who receive care each year in hospital Intensive Care Units.
The ICU teams administering therapy to a patient with acute kidney failure are critical to that patient's potential health and well-being," said Joe Turk, President of NxStage.
Her outburst came as twins Aaron and Todd, aged two, yesterday had dialysis at London's St Thomas's Hospital after suffering acute kidney failure.
president and CEO of FlowMedica, a medical device company focused on the prevention and treatment of acute kidney failure in the setting of cardiovascular disease and surgery.
AN autopsy has revealed the death of an Irishman after he took liquid ecstasy in Ibiza was due to acute kidney failure.
causes an estimated 73,480 illnesses, leading to an estimated 2,168 hospitalizations and 61 deaths and creating an important cause of acute kidney failure in children.
Mr Al-Mutari also suffered acute kidney failure and spent 62 days in hospital after the beatings, the High Court in London was told.
In addition to congestive heart failure patients who develop cardiorenal syndrome, the Delta system might also be used to provide therapy to patients who develop acute kidney failure while in the intensive care unit, or during or after surgery.
The Benephit system is being studied in patients who could benefit from minimally invasive cardiovascular procedures and diagnostic tests, such as stent placement, angioplasty or angiography, but could be at risk for acute kidney failure because their kidneys are unable to withstand the harmful effects of the dye (radiocontrast media) used during the procedure.
These patients are at high risk of developing acute kidney failure due to their inability to process the contrast agents used during coronary interventional or diagnostic procedures - a condition known as radiocontrast nephropathy (RCN).
NxStage is a medical device company, headquartered in Lawrence, Massachusetts, USA, that develops, manufactures and markets innovative products for the treatment of ESRD and acute kidney failure.

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