Renal System

Sheryll Joy Lopez-Calayan,

R.N.
RENAL FAILURE
• loss of kidney function
• acute renal failure and chronic renal failure
• S/Sx  retention of wastes, the retention of fluids, and
the inability of the kidneys to regulate electrolytes
• Prerenal causes include intravascular volume depletion,
decreased cardiac output, and vascular failure secondary
to vasodilation or obstruction
• Intrarenal causes include tubular necrosis,
nephrotoxicity, and alterations in renal blood flow
• Postrenal causes include obstruction of urine flow
between the kidney and urethral meatus and bladder
neck obstruction
Acute renal failure (ARF)
– sudden loss of kidney function; caused
by renal cell damage from ischemia or
toxic substances
– abrupt and can be reversible
– Hypoperfusioncell death
decompensation in renal function
– prognosis  cause and the condition of
the client
– Near-normal or normal kidney function
may resume gradually
• Causes
– Infection
– Renal artery occlusion
– Obstruction
– Acute kidney disease
– Dehydration
– Diuretic therapy
– Ischemia from hypovolemia, heart failure,
septic shock, or blood loss
– Toxic substances such as medications,
particularly antibiotics
• Oliguric phase
– 8 to 15 days, longer the duration less chance of recovery
– Sudden drop in urine output; urine output less than 400 mL/day
– Urine specific gravity of 1.010 to 1.016
– Anorexia, nausea, and vomiting
– Hypertension
– Decreased skin turgor
– Pruritus
– Tingling of the extremities
– Drowsiness progressing to disorientation to coma
– Edema
– Dysrhythmias
– Signs of congestive heart failure (CHF) and pulmonary edema
– Signs of pericarditis
– Signs of acidosis
• Diuretic phase
– Urine output rises slowly then diuresis
occurs
– Excessive urine output indicates recovery
of damaged nephrons
– Hypotension
– Tachycardia
– Improvement in level of consciousness
(LOC)
• Recovery phase (convalescent)
– A slow process; complete recovery
may take 1 to 2 years
– Urine volume is normal
– Increase in strength
– Increase in LOC
– BUN is stable and normal
– Client can develop chronic renal failure
Chronic renal failure (CRF)
– progressive loss and ongoing deterioration in
kidney function that occurs slowly over a period of
time
– Has stages, is irreversible, and results in uremia
or end-stage renal disease
– affects all of the major body systems and requires
dialysis or kidney transplant to maintain life
– Hypervolemia can occur owing to the inability of
the kidneys to excrete sodium and water, or
hypovolemia can occur owing to the inability of
the kidneys to conserve sodium and water
• Causes
– May follow ARF
– Renal artery occlusion
– Chronic urinary obstruction
– Recurrent infections
– Hypertension
– Metabolic disorders
– Diabetes mellitus
– Autoimmune disorders
• Assessment
– Anorexia and nausea
– Headache
– Weakness and fatigue
– Hypertension
– Confusion and lethargy, followed by convulsions and coma
– Kussmaul respirations
– Diarrhea or constipation
– Muscle twitching and numbness of the extremities
– Decreased urine output
– Decreased urine specific gravity
– Proteinuria
– Anemia
– Azotemia
– Fluid overload and signs of heart failure
– Uremic frost: a layer of urea crystals from evaporated perspiration that appears on
the face, eyebrows, axilla, and groin in clients with advanced uremic syndrome
• Implementation
• Monitor vital signs
• Monitor urine and I & O (hourly in ARF)
• Monitor weight, noting that an increase of 0.5 to 1 pound daily indicates fluid
retention
• Monitor BUN, creatinine, and electrolyte values
• Monitor for acidosis and treat with sodium bicarbonate as prescribed
• Assess urinalysis for protein, hematuria, casts, and specific gravity
• Monitor LOC
• Assess for signs of infection, since the client may not demonstrate a temperature
or an increased white blood cell (WBC) count
• Assess for dysrhythmias, since a potassium level above 6 mEq/L will cause
peaked T waves and a widened QRS complex
• Monitor for fluid overload; assess lungs for rales and rhonchi
• Monitor for edema
• moderate protein intake (to decrease the workload
on the kidneys) and a high-carbohydrate, low-
potassium, and low-phosphorus
• Restrict sodium intake as prescribed, based on the
electrolyte level
• intake 400 mL to 1000 mL plus measured urinary
output
• Administer sodium polystyrene sulfonate (Kayexalate)
to lower the potassium level as prescribed
• X nephrotoxic medications, such as antibiotics,
which may be prescribed
• Prepare the client for dialysis if prescribed
Special problems in renal
failure
• Hypertension
– Failure of the kidneys to maintain
homeostasis of the blood pressure
– Monitor vital signs
– Maintain fluid and sodium restrictions as
prescribed
– Administer propranolol (Inderal), a beta-
adrenergic antagonist, as prescribed,
which decreases rennin release (rennin
causes vasoconstriction)
• Hypervolemia
– Monitor vital signs
– Monitor I & O and weight
– Monitor for edema
– Monitor electrolytes
– Monitor for hypertension
– Monitor for CHF and pulmonary edema
– Enforce fluid restriction
– Avoid the administration of IV fluids
– Administer diuretics as prescribed
– Instruct the client to avoid foods with sodium
• Hypovolemia
– Monitor vital signs
– Monitor I & O and weight
– Monitor electrolytes
– Monitor for hypotension
– Monitor for dehydration
– Provide replacement therapy based on the
electrolyte results
– Provide sodium supplements as prescribed,
depending on the electrolyte value
• Potassium retention
– Monitor vital signs and apical rate
– Monitor potassium level
– Monitor for dysrhythmias (peaked T waves
and widened QRS complex) indicating
hyperkalemia
– Provide a low-potassium diet
– Administer medications as prescribed to
lower the potassium level
– Prepare the client for dialysis
• Phosphorus retention
– Phosphorus rises and calcium drops, which leads
to stimulation of parathyroid hormone, causing bone
demineralization
– Treatment is aimed at lowering serum
phosphorus levels
– aluminum hydroxide - bind phosphorus in the
intestine and allow the phosphorus to be
eliminated
– meals and not with other medications, because
they bind medications in the intestinal tract
– stools softeners and laxatives - constipating
– Enforce phosphorus restriction in the diet
• Low calcium
– because of the high phosphorus level and
inability of the diseased kidney to activate vitamin
D
– The absence of vitamin D causes a poor
absorption of calcium from the intestinal tract
– Monitor calcium level
– Administer calcium supplements as prescribed
– Administer activated vitamin D as prescribed
• Metabolic acidosis
– The kidneys are unable to excrete
hydrogen ions or manufacture
bicarbonate, resulting in acidosis
– alkalyzers - sodium bicarbonate
– Note that clients with CRF adjust to
low bicarbonate levels and do not
become acutely ill
• Anemia
– diseased kidney  decreased secretion of
erythropoietin
– Monitor hemoglobin and hematocrit
– epoetin alfa (Epogen) - stimulate the
production of RBCs
– folic acid (vitamin B9) X ORAL nausea
and vomiting
– blood transfusions if prescribed,  decrease
the stimulus to produce RBCs
– Monitor bleeding
– soft toothbrush
– stool softeners
– X acetylsalicylic acid (aspirin) -excreted by
kidneys; prolong bleeding time
• GI bleeding
– Urea  ammonia by the intestinal
bacteria ammonia -mucosal irritant
that causes ulceration and bleeding
– hemoglobin and hematocrit levels
– Monitor stools for occult blood
• Infection and injury
– need to be monitored and avoided because
tissue breakdown causes increased
potassium levels
– X urinary catheters and provide strict asepsis
during insertion and catheter care
– avoid persons with infections
– Administer antibiotics as prescribed,
monitoring for nephrotoxic effects
• Pruritis
– Urate crystals are excreted through the skin to rid of
excess wastes
– This deposit of crystals is called uremic frost, and it
is seen in advanced stages of renal failure
– Monitor for skin breakdown, rash, and uremic frost
– Provide good skin care and oral hygiene
– Avoid the use of soaps
– Administer antipruritics as prescribed
• Muscle cramps
– Occur in the extremities and hands and
can be due to electrolyte imbalances
– Monitor electrolytes
– Administer electrolyte replacements as
prescribed
– Administer heat and massage as
prescribed
• Ocular irritation
– Calcium deposits in the conjunctiva
cause burning and watering of the
eyes
– Administer medications to control the
calcium and phosphate levels as
prescribed
– Administer lubricating eye drops
• Insomnia and fatigue
– The diseased kidneys cause a buildup
of wastes, causing fatigue in the
client
– Provide adequate rest periods
– Administer mild CNS depressants as
prescribed
• Neurological changes
– The buildup of active particles and fluids
causes changes in the brain cells and leads to
confusion and impairment in decision-
making ability
– Provide a safe and hazard-free environment
– Use side rails as needed
– Provide a calm and restful environment
– Provide comfort measures and backrubs
Psychosocial problems: Monitor the
client for psychological problems
such as depression, anxiety,
suicidal behavior, denial,
dependence/independence conflict,
and changes in body image
HEMODIALYSIS

• The diffusion of dissolved

particles from one fluid compartment
into another across a
semipermeable membrane
• The client’s blood flows through one
fluid compartment into another fluid
compartment
• Functions of hemodialysis
– Cleanses the blood of accumulated waste products
– Removes the by-products of protein metabolism,
such as urea, creatinine, and uric acid
– Removes excessive fluids
– Maintains or restores the body’s buffer system
– Maintains or restores electrolyte levels
• Principles of hemodialysis
– The semipermeable membrane is made of a thin, porous cellophane
– The pore size of the membrane allows small particles to pass through,
such as urea, creatinine, uric acid, and water molecules
– Proteins, bacteria, and blood cells are too large to pass through the
membrane
– The client’s blood flows into dialyzer; the movement of substances occurs
from the blood to the dialysate
– Diffusion: The movement of particles from an area of greater
concentration to one of a lesser concentration
– Osmosis: The movement of fluids across a semipermeable membrane from
an area of lesser concentration of particles to an area of greater
concentration of particles
– Ultrafiltration: The movement of fluid across a semipermeable membrane
as a result of an artificially created pressure gradient
Dialysate bath
• Composed of water and major
electrolytes
• The dialysate need not be sterile
because bacteria are too large to pass
through; however, the dialysate must
meet specific standards, and water
treatment systems are used to ensure
a safe water supply
• Implementation
– vital signs
– laboratory values before, during, and after dialysis
– Assess the client for fluid overload prior to the procedure
– Assess patency of the blood access device
– Weigh the client before and after the procedure to determine fluid loss
– Hold antihypertensives and other medications that can affect the BP
prior to the procedure, as prescribed
– Hold medications that could be dialyzed off, such as water-soluble
vitamins and certain antibiotics
– Monitor for shock and hypovolemia during the procedure
– Provide adequate nutrition (client may eat prior to the procedure)
COMPLICATIONS OF
HEMODIALYSIS
Disequilibrium syndrome
– A rapid change in the composition of
the extracellular fluid (ECF) occurs
during hemodialysis
– Solutes are removed from the blood
faster than from the cerebrospinal fluid
(CSF) and brain; fluid is pulled into the
brain, causing cerebral edema
• Assessment
– Nausea
– Vomiting
– Headache
– Hypertension
– Restlessness and agitation
– Confusion
– Seizures
• Implementation
– Reduce environmental stimuli
– Prepare to dialyze the client for a
shorter period at reduced blood
flow rates to prevent occurrence
Dialysis encephalopathy

• aluminum toxicity - aluminum in

the H2O sources used in the
dialysate, and the ingestion of
aluminum-containing antacids
(phosphate binders)
• Assessment
– Progressive neurological impairment
– Mental cloudiness
– Speech disturbances
– Dementia
– Muscle incoordination
– Bone pain
– Seizures
• Implementation
– Monitor for signs of disequilibrium
syndrome
– Notify the physician if signs of
disequilibrium syndrome occur
– Administer aluminum-chelating
agents as prescribed so that the
aluminum is freed up and dialyzed
from the body
ACCESS FOR HEMODIALYSIS

• Subclavian and femoral catheter

– A subclavian (subclavian vein) or femoral
(femoral vein) catheter may be inserted
for short-term or temporary use in
ARF
– May be used until a fistula or graft
matures or develops, or when the client
has fistula or graft access failure because
of infection or clotting
• Implementation
– Assess insertion site for hematoma,
bleeding, dislodging, and infection
– Do not use these catheters for any
reason other than dialysis
– Maintain an occlusive dressing
• Subclavian vein catheter
– Is usually filled with heparin and
capped to maintain patency between
dialysis treatments
– The catheter should not be uncapped
– The catheter may be left in place for up
to 6 weeks if complications do not occur
• Femoral vein catheter
– The client should not sit up more than
45 degrees or lean forward, or the
catheter may kink and occlude
– Assess extremity for circulation,
temperature, and pulses
– Prevent pulling or disconnecting of the
catheter when giving care
– Use an IV control pump with microdrip
tubing if a heparin infusion is prescribed
External arteriovenous shunt
(AV shunt)
– surgical insertion of two Silastic cannulas into
an artery and a vein in the forearm or leg, to
form an external blood path
– U shape; blood flows artery  shunt  vein
– A tube leading to the membrane compartment
of the dialyzer is connected to the arterial
cannula
– Blood fills the membrane compartment and
flows back to the client by way of a tube
connected to the venous cannula
– When dialysis is complete, the cannulas are
clamped and reattached to form their U
shape
• Advantages
– Can be used immediately following creation
– No venipuncture is necessary for dialysis
• Disadvantages
– External danger of disconnecting or dislodging
– Risk of hemorrhage, infection, or clotting
– Skin erosion around the catheter site can occur
• Implementation
– Avoid wetting the shunt
– A dressing is completely wrapped around the shunt
and kept dry and intact
– Cannula clamps need to be available at the client’s
bedside
– Do not take a blood pressure, draw blood, place an IV,
or administer injections in the shunt extremity
– patent if it is warm to touch
– Auscultate and palpate for a bruit, although a bruit
may not be heard and is not always felt with the shunt
– Notify the physician immediately if signs of clotting,
hemorrhage, or infection occur
• Signs of clotting
– Fold back the dressing
– Fibrin-white flecks noted in the tubing
– The separation of serum and cells
– The absence of a previously heard bruit
– Coolness of the tubing or extremity
– Client complaints of a tingling sensation
Internal arteriovenous fistula
(AV fistula)
– chronic dialysis clients
– Created surgically by anastomosis of an artery in the arm
to a vein; this creates an opening or fistula between a
large artery and a large vein
– The flow of arterial blood into the venous system causes the
veins to become engorged (matured or developed)
– Maturity takes about 1 to 2 weeks and is required before
the fistula can be used, so that the engorged vein can be
punctured with a large-bore needle for the dialysis
procedure
– Subclavian or femoral catheters, peritoneal dialysis, or an
external AV shunt can be used for dialysis while the fistula is
maturing or developing
• Advantages
– Since the fistula is internal- less danger of clotting and bleeding
– used indefinitely
– Decreased incidence of infection
– No external dressing is required
– freedom of movement
• Disadvantages
– Cannot be used immediately after insertion
– Needle insertions are required for dialysis
– Infiltration of the needles during dialysis can occur and cause hematomas
– An aneurysm can form in the fistula
– Arterial steal syndrome can develop (too much blood is diverted to the
vein, and arterial perfusion to the hand is compromised)
– CHF can occur from the increased blood flow in the venous system
Internal arteriovenous graft
(AV graft)
– chronic dialysis clients who do not have
adequate blood vessels for the creation of a
fistula
– Gore-Tex or a bovine (cow) carotid artery is
used to create an artificial vein for blood flow
– The procedure involves the anastomosis of the
graft of the artery, a tunneling under the skin, and
anastomosis to a vein
– The graft can be used 2 weeks after insertion
– Complications of the graft include clotting,
aneurysms, and infection
• Advantages
– Since the graft is internal, there is less danger of clotting and bleeding
– The graft can be used indefinitely
– Decreased incidence of infection
– No external dressing is required
– Allows freedom of movement
• Disadvantages
– Cannot be used immediately after insertion
– Needle insertions are required for dialysis
– Infiltration of the needles during dialysis can occur and cause hematomas
– An aneurysm can form in the graft
– Arterial steal syndrome can develop (too much blood is diverted to the vein,
and arterial perfusion to the hand is compromised)
– CHF can occur from the increased blood flow in the venous system
• Implementation for AV fistula and AV graft
– Do not measure a blood pressure, draw blood, place an IV, or
administer injections in the fistula or graft extremity
– Monitor for clotting
• Complaints of tingling or discomfort in the extremity
• Inability to palpate a thrill or auscultate a bruit over the fistula or graft
– Monitor for arterial steal syndrome
• Palpate pulses below the fistula or graft, and monitor for hand swelling as an
indication of ischemia
• Note temperature and capillary refill of the extremity
– Monitor for infection
– Monitor lung and heart sounds for signs of CHF
– Notify the physician immediately if signs of clotting, infection, or
arterial steal syndrome occur
PERITONEAL DIALYSIS
• The peritoneum is the dialyzing membrane
(semipermeable membrane) and substitutes for
kidney function during kidney failure
• Works on the principles of diffusion and osmosis,
and the dialysis occurs via the transfer of fluid and
solute from the bloodstream through the peritoneum
• large and porous, allowing solutes and fluid to move
via an osmotic gradient from an area of higher
concentration in the body at an area of lower
concentration in the dialyzing fluid
• The peritoneal cavity is rich in capillaries; therefore,
it provides a ready access to blood supply
• Contraindications to peritoneal
dialysis
– Peritonitis
– Recent abdominal surgery
– Abdominal adhesions
– Impending renal transplant
• Dialysate-sterile
• The higher the glucose concentration, the
greater the amount of fluid removed during
an exchange
• Heparin- prevent clotting of the catheter
• Antibiotics: Prophylactic - prevent peritonitis
• Insulin: - diabetes mellitus
ACCESS FOR PERITONEAL
DIALYSIS
• siliconized rubber catheter
• 3 to 5 cm below the umbilicus - avascular and has
less fascial resistance
• The catheters are tunneled under the skin to stabilize
the catheter and reduce the risk of infection
• 1 to 2 weeks - ingrowth of fibroblasts and blood
vessels into the cuffs of the catheter, which fix the
catheter in place and provide an extra barrier against
dialysate leakage and bacterial invasion
• Types of peritoneal dialysis
• Continuous ambulatory peritoneal dialysis
(CAPD)
– continuous process
– X machine
– Promotes client independence
– self-dialysis 24 hours a day, 7 days a week
– four dialysis cycles are administered in 24 hours,
including an 8-hour dwell time overnight
– 1 ½ - 2 L dialysate
– After dwell, fluid drains by gravity flow
• Automated peritoneal dialysis (APD)
– Similar to CAPD in that it is a
continuous dialysis process
– Requires a peritoneal cycling
machine
– Can be done as intermittent peritoneal
dialysis (IPD), continuous cycling
peritoneal dialysis (CCPD), or nightly
peritoneal dialysis (NPD)
Peritoneal dialysis infusion
– One infusion (inflow), dwell,and outflow
=one exchange
– open system - risk of infection
– Inflow: 1 to 2 liters of dialysate 10 to 20
minutes
– Dwell time: The amount of time in the cavity;
prescribed by the physician
– Outflow: Fluid drains out of body by gravity
into the drainage bag
• Implementation before treatment
– Monitor vital signs
– Obtain weight
– Have the client void, if possible
– Assess electrolyte and glucose
levels
• Implementation during treatment
– Monitor for signs of infection
– Monitor for respiratory distress, pain, or discomfort
– Monitor for signs of pulmonary edema
– Monitor for hypotension and hypertension
– Monitor for malaise, nausea, vomiting
– Assess the catheter site dressing for wetness or bleeding
– Do not allow dwell time to extend  hyperglycemia
– Turn the client from side to side or have the client sit upright if the flow is
slow to start
– Monitor outflow, which should be a continuous stream after the clamp is
opened
– Monitor outflow for color and clarity
– Monitor I & O accurately
– If outflow is less than inflow, the difference is equal to the amount
absorbed or retained by the client during dialysis and should be counted as
intake
COMPLICATIONS OF
PERITONEAL DIALYSIS
• Peritonitis
– Maintain meticulous sterile technique when hooking up
or clamping off bags, and when caring for the catheter
insertion site
– Follow institutional procedure for hooking up or clamping
off bags, which may include scrubbing the connection
sites with an antiseptic solution
– Monitor temperature closely
– Monitor for fever, cloudy outflow, and rebound
abdominal tenderness
– If peritonitis is suspected, obtain a culture of the
outflow to determine the infective organism
– Administer antibiotics as prescribed
• Abdominal pain
– Pain during inflow is common during the first few
exchanges, is caused by peritoneal irritation, and
usually disappears after a week or two of dialysis
treatments
– The cold temperature of the dialysate aggravates
the discomfort, and the dialysate should be warmed
before use, only with a special dialysate warmer
pad
– Place a heating pad on the abdomen during the
inflow to relive discomfort
• Insufficient outflow
– May be caused by catheter migration out of the
peritoneal area; if this occurs, the catheter must be
repositioned by the physician
– Insufficient outflow can also be caused by a full colon
– Maintain the drainage bag below the client’s abdomen
– Change the client’s outflow position by turning or
ambulating
– Check for kinks in the tubing
– Encourage a high-fiber diet
– Administer stool softeners as prescribed
• Leakage around the catheter site
– 1 to 2 weeks - ingrowth of
fibroblasts and blood vessels - extra
barrier against dialysate leakage and
bacterial invasion
– 2 weeks for the client to tolerate a full
2-liter exchange without leaking
around the catheter site
• Characteristics of outflow
– initial exchanges, the outflow bloody
clear and colorless
– brown - bowel perforation
– outflow is same color as urine-
bladder perforation
– Cloudy - peritonitis
UREMIC SYNDROME

• The accumulation of nitrogenous

waste products in the blood because
of the inability of the kidneys to
filter out these waste products
• It may occur as a result of acute or
chronic renal failure
• Assessment
– Oliguria
– (+) protein, red blood cells, and casts in
the urine
– A urine specific gravity of 1.010
– Elevated levels of urea, uric acid,
potassium, and magnesium in the urine
– Alterations in LOC
– Electrolyte imbalancesStomatitis
– Nausea or vomiting
• Implementation
– Monitor vital signs
– Monitor electrolyte values
– Monitor I & O
– Provide a diet low in protein unless the client
is on peritoneal dialysis
– Limit sodium, nitrogen, potassium, and
phosphate intake as prescribed
CYSTITIS/URINARY TRACT
INFECTIONS (UTI)
• Inflammation of the bladder from infection or
obstruction of the urethra
• The most common causative organisms are
Escherichia coli, Enterobacter,
Pseudomonas, and Serratia
• More common in women - shorter urethra
& close to the rectum
• Sexually active and pregnant women are
most vulnerable to cystitis
• Assessment
– Frequency and urgency
– Burning on urination
– Voiding in small amounts
– Inability to void
– Incomplete emptying of the bladder
– Lower abdominal discomfort or back discomfort
– Cloudy, dark, foul-smelling
– Hematuria
– Bladder spasms
– Malaise, chills, fever
– Nausea and vomiting
• Implementation
– culture and sensitivity antibiotics
– force fluids up to 3000 mL a day, especially if the client is
taking a sulfonamide,  crystals in concentrated urine.
– Maintain an acid urine pH (5.5) - acid ash diet;
– Note that if the client is prescribed an aminoglycoside, a
sulfonamide, or nitrofurantoin (Macrodantin), the actions
of these medications are diminished by acidic urine
UROSEPSIS
• A gram-negative bacteremia originating in
the urinary tract
• Escherichia coli
• Cause: indwelling urinary catheter or an
untreated UTI in a client who is medically
compromised
• bacterium to develop resistant strains
• Urosepsis can lead to septic shock if not
treated aggressively
• Assessment: Fever is the most common and
earliest manifestation
• Implementation
– Obtain a urine specimen for urine culture and
sensitivity
– IV antibiotics - until afebrile for 3 to 5 days
– oral antibiotics after the 3- to 5-day afebrile
period
URETHRITIS
• inflammation of the urethra commonly
associated with sexually transmitted
diseases (STD), and may be seen with cystitis
• In men, it is most often caused by gonorrhea
or chlamydial infection
• In women, it is most often caused by feminine
hygiene sprays, perfumed toilet paper or
sanitary napkins, spermicidal jellies, UTIs,
or changes in the vaginal mucosal lining
• Assessment
• Males
– Frequency
– Urgency
– Nocturia
– Difficulty voiding
– Discharge from the penis
• Females
– Frequency
– Urgency
– Nocturia
– Painful urination
– Difficulty voiding
– Lower abdominal discomfort
• Implementation
• Encourage fluids
• sitz baths
• If stricture =dilation + instillation of an antiseptic
solution
• Instruct the client to avoid intercourse until the
symptoms subside or treatment of the STD is
complete
• Instruct the female client to avoid the use of
perfumed toilet paper or sanitary napkins and
feminine hygiene sprays- AVOID CAUSES
URETERITIS AND
PYELONEPHRITIS
• Ureteritis
• An inflammation of the renal pelvis and the
parenchyma, commonly caused by bacterial
invasion
• Acute pyelonephritis  bacterial
contamination of the urethra or following an
invasive procedure of the urinary tract
• Chronic pyelonephritis chronic
obstruction with reflux or chronic disorders
• Escherichia coli
• Assessment
– Fever and chills
– Nausea
– Flank pain on the affected side
– Costovertebral angle (CVA) tenderness
– Headache
– Muscular pain
– Dysuria
– Frequency and urgency
– Cloudy, bloody, or foul-smelling urine
– Increased white blood cells in the urine
Chronic pyelonephritis

• A slow, progressive - recurrent acute

attacks
• Causes contraction of the kidney and
dysfunctioning of the nephrons, which
are replaced by scar tissue
• Can lead to renal failure
• Assessment
– Frequently diagnosed incidentally when a
client is being evaluted for hypertension
– Poor urine-concentrating ability
– Pyuria
– Azotemia
– Proteinuria
– Anemia
– Acidosis
• Implementation
– Monitor vital signs
– Monitor I & O
– Monitor weight
– Encourage fluids up to 3000 mL a day
– Encourage adequate rest
– Instruct the client in a high-calorie, lowprotein diet
– Provide warm moist compresses to the flank area
– Encourage the client to take warm baths
– Monitor for signs of renal failure
GLOMERULONEPHRITIS
• caused by an immunological reaction
• proliferative and inflammatory changes
within the glomerular structure
• Destruction, inflammation, and sclerosis of
the glomeruli of both kidneys occur
• The inflammation of the glomeruli results from
an antigen-antibody reaction produced from
an infection elsewhere in the body
• Loss of kidney function develops
• Causes
– Immunological or autoimmune diseases
– Previous/ history of Streptococcal infection, group A beta-hemolytic
– History of pharyngitis or tonsillitis 2 to 3 weeks prior to symptoms
• Types
• Acute: Occurs 2 to 3 weeks after a streptococcal infection
• Chronic: Can occur after the acute phase or slowly over time
• Complications
– Heart failure
– Hypertensive encephalopathy
– Pulmonary edema
– Renal failure
• Assessment
– Gross hematuria
– Dark, smoky, cola-colored or red-brown urine
– Proteinuria - excessive foam in the urine
– high specific gravity
– Low urinary pH
– Oliguria or anuria
– Headache
– Chills and fevers
– Fatigue and weakness
– Anorexia, nausea, and vomiting
– Pallor
– Edema in the face, periorbital area, feet, or generalized
– Shortness of breath, ascites, pleural effusion, and CHF
– Abdominal or flank pain
– Hypertension
– Reduced visual acuity
– Increased BUN and creatinine levels
– Increased antistreptolysin O titer (used to diagnose disorders caused by streptococcal infections)
• Infections
– Monitor vital signs
– Monitor I & O and urine closely
– Monitor daily weight
– Monitor for edema
– Monitor for fluid overload, ascites, pulmonary edema, and CHF
– Restrict fluid intake as prescribed
– Provide a high-calorie and low-protein diet
– Restrict sodium intake as prescribed if edema is present
– Provide bed rest and limited activity
– Instruct the client to obtain treatment for infections,
specifically sore throats and upper respiratory infections
– report signs of bloody urine, headache, or edema
NEPHROTIC SYNDROME
• A set of clinical manifestations arising from protein wasting
secondary to diffuse glomerular damage
• Assessment
– Proteinuria
– Hypoalbuminemia
– Edema
– Hyperlipidemia
– Waxy pallor to the skin
– Anemia
– Anorexia
– Malaise
– Irritability
– Amenorrhea or abnormal menses
– Hematuria may be present
– Hypertension
• Implementation
– Monitor vital signs
– Monitor I & O
– Bed rest if severe edema is present
– Normal to low-protein diet as prescribed, with adequate
carbohydrate and calorie intake
– Monitor daily weights
– Provide a mild sodium restriction as prescribed
– Monitor potassium level; potassium may be restricted from the diet if
the potassium rises
– Administer diuretics as prescribed
– Administer corticosteroids and cytotoxic medications as prescribed
– Administer plasma volume expanders, such as albumin, plasma,
and dextran, to raise the osmotic pressure
– Administer anticoagulants as prescribed for those clients who develop
renal vein thrombosis
HYDRONEPHROSIS

• Distention of the renal pelvis and

calices, caused by an obstruction of
normal urine flow
• The urine becomes trapped proximal
to the obstruction
• The causes include calculus, tumors,
scar tissue, and kinks in the ureter
• Assessment
– Hypertension
– Headache
– Flank pain
– Electrolyte imbalances
• Implementation
– Monitor vital signs frequently
– Monitor for fluid and electrolyte imbalances,
including dehydration after the obstruction is
relieved
– Monitor for diuresis, which can lead to fluid
depletion
– Monitor daily weights
– Monitor urine for specific gravity, albumin, and
glucose
– Administer fluid replacement as prescribed
POLYCYSTIC KIDNEY DISEASE

• A cystic formation and hypertrophy of

the kidneys,  cystic rupture, infection,
the formation of scar tissue, and
damaged nephrons
• There is no known way to arrest the
progress of the destructive cysts
• The ultimate result of this disease is renal
failure
• Types
– Infantile polycystic disease: An
inherited autosomal recessive trait that
results in the death of the infant within a
few months after birth
– Adult polycystic disease: An autosomal
dominant trait that results in end-stage
renal disease
• Assessment
– Flank, lumbar, or abdominal pain
– Fever and chills
– UTIs
– Hematuria, proteinuria, pyuria
– Calculi
– Hypertension
– Palpable abdominal masses and enlarged kidneys
• Implementation
– Hematuria-indicates cyst rupture
– Increase sodium and water intake because sodium
loss rather than retention occurs
– Provide bed rest if ruptured cysts and bleeding occur
– Prepare the client for percutaneous cyst puncture for
relief of obstruction, or for draining an abscess
– Prepare the client for dialysis or renal transplantation
– Encourage the client to seek generic counseling
UROLITHIASIS AND
NEPHROLITIHIASIS
• Calculi or stones - most frequent site is the kidneys
• calculi pain, obstruction, and tissue trauma, with secondary
hemorrhage and infection
• Kidneys, ureters, and bladder (KUB) film, intravenous pyelogram
(IVP), computed tomography (CT) scan, and renal ultrasonography
will determining treatment
• stone analysis - type of stone  treatment
• Urolithiasis - urinary stones; urinary calculi - ureters
• Nephrolithiasis - kidney stones; renal parenchyma
• When a calculus occludes the ureter and blocks the flow of urine,
the ureter dilates, producing a condition known as hydroureter
• If the obstruction is not removed, urinary stasis results in
infection, impairment of renal function on the side of the blockage,
and resultant hydronephrosis and irreversible kidney damage
• Causes
– Family history of stone formation
– Diet high in calcium, vitamin D, milk, protein, oxalate,
purines, or alkali
– A high intake of purine-rich food
– Obstruction and urinary stasis
– Dehydration
– Use of diuretics, which can cause volume depletion
– UTIs and prolonged urinary catherization
– Immoblization
– Hypercalcemia and hyperparathyroidism
– Elevated uric acid, such as in gout
• Assessment
– Renal colic - lumbar region and radiates around the side and
down toward the testicle in men, and to the bladder in the
women
– Ureteral colic -radiates toward the genitalia and the thigh
– Sharp, severe pain of sudden onset
– Dull, aching kidney
– Nausea and vomiting, pallor, and diaphoresis during acute pain
– Urinary frequency with alternating retention
– Signs of a UTI
– Low-grade fever
– RBCs, WBCs, and bacteria in the urinalysis
– Hematuria
• Implementation
– Monitor I & O
– Assess for fever, chills, and infection
– Monitor for nausea, vomiting, and diarrhea
– Force fluids up to 3000 mL/day, unless contraindicated, to facilitate the
passage of the stone and prevent infection
– Strain all urine for the presence of stones
– Send stones to the laboratory for analysis
– Provide warm baths and heat to the flank area
– analgesics - relieve pain
– IV fluids - increase the flow of urine and facilitate the passage of the stone
– relaxation techniques - relieving pain
– diet specific to the stone composition
– pH depending on the type of stone
– Turn and reposition immobilized clients
• Stone composition
• Calcium phosphate stones
– Caused by supersaturation of urine with calcium
and phosphate
- acid ash foods- calcium stones -alkaline chemistry
– decrease intake of foods high in calcium and
phosphate to reduce urinary calcium content, and
to avoid excess vitamin D intake to prevent
stones from forming
• Calcium oxalate stones
– Caused by supersaturation of urine with calcium
and oxalate
– acid ash - calcium stones - alkaline chemistry
– decreasing intake of foods high in calcium
– avoiding oxalate food sources to reduce urinary
oxalate content and the formation of stones
– Oxalate-rich food sources include tea, almonds,
cashews, chocolate, cocoa, beans, spinach,
and rhubarb
• Struvite stones
– triple phosphate stones - magnesium and
ammonium phosphate
– urea splitting by bacteria
– Struvite stones - alkaline urine
– acid ash foods
– limit high-phosphate foods - dairy products,
red and organ meats, and whole grains, to
reduce urinary phosphate content
• Uric acid stones
– excess dietary purine or gout
– Uric acid stones - acidic urine
– alkaline ash foods and decreased intake of
purine sources, such as Organ meats,
graves, red wines, and sardines, to
reduce urinary purine content
– Allopurinol (Zyloprim) may be prescribed to
lower uric acid levels
• Cystine stones
– cystine crystal formation
– Cystine stones - acidic urine
– alkaline ash foods
– low intake of methionine, an essential amino
acid that forms cystine, avoid meat, milk,
cheese, and eggs
– encouraging fluid intake up to 3 liters a day
unless contraindicated, to help dilute the urine
and prevent cystine crystals from forming
SURGICAL MANAGEMENT OF
KIDNEY STONES
• Cystoscopy
• May be done for stones located in the bladder or lower ureter
• There is no incision
• One or two ureteral catheters are inserted past the stone
• The stone may be manipulated and dislodged by the
procedure
• The catheters may mechanically guide the stones downward as
they are removed
• Catheters are left in place for 24 hours to drain the urine
trapped proximal to the stone and to dilate the ureter
• A continuous chemical irrigation may be prescribed to dissolve
the stone
• Extracorporeal shock wave lithotripsy (ESWL)
• Noninvasive mechanical procedure for breaking up stones that are located
in the kidney or upper ureter so that they can pass spontaneously or be
removed by other methods
• Fluoroscopy is used to visualize the stone
• There is no incision or drains
• Ultrasonic waves are delivered through a bath of warm water to the
areas of the stone to disintegrate it
• Stones are passed in the urine within a few days
• Preprocedure: NPO for 8 hours prior to procedure
• Postprocedure
– Monitor vital signs
– Monitor I & O
– Monitor for bleeding
– Monitor for pain and signs of urinary obstruction
– Instruct the client to increase fluid intake to wash out the stone
fragments
– Inform the client that ambulation is important
Percutaneous lithotripsy
• bladder, ureter, or kidney
• invasive procedure
• An ultrasonic wave is aimed at the stone to break it
into fragments
• May be performed via cytoscopy or nephroscopy
• No incision - cystoscopy; small flank incision - nephroscopy
• indwelling catheter
• A nephrostomy tube - administer chemical irrigations to break
up the stone; 1 to 5 days
• drink 3000 to 4000 mL of fluid per day following the procedure
• monitor for complications of infection, hemorrhage, and
extravasation of fluid into the retroperitoneal cavity
• Ureterolithotomy
– open surgical procedure, performed if lithotripsy is
not effective
– location of the stone is in the ureter
– Incision into the ureter is made through a lower
abdominal or flank incision to remove the stone
– The client may have a Penrose drain, a ureteral
stent catheter, and an indwelling bladder
catheter
• Pyelolithotomy
– flank incision into the kidney is made to
remove stones from the renal pelvis
– A large flank incision is required
– The client will have a Penrose drain and
an indwelling catheter
• Nephrolithotomy
– Incision into the kidney is made to
remove stones from the renal pelvis
– A large flank incision is required
– The client may have a nephrostomy
tube and an indwelling catheter
Partial or total nephrectomy

• Performed if there is extensive

kidney damage, renal infection, or
severe obstruction, and to prevent
stone recurrence
• Postoperative implementation
– Care=incision location and the type of drainage
tubes present
– Monitor incision, - Penrose drain is in place, because
it will drain large amounts of urine
– Protect the skin from urinary drainage
– ostomy pouch over the Penrose drain
– nephrostomy tube, - drainage bag for a free flow of
urine
– urethral catheters - do not irrigate
– indwelling Foley catheter for drainage
– Encourage fluid intake to ensure a urine output of
2500 to 3000 mL or more per day
– Monitor I & O closely