The Client with Alterations in

Urinary Elimination

Sherry A. Burrell, RN, MSN

Rutgers University
Nursing III
Lecture Date: 10/24/05
 Anatomy: The Renal System
 Kidneys
 Ureters
 Enter at oblique angle
 Peristalsis
 Both prevent reflux

 Bladder
 Capacity 300–500 ml
 Urethra
 Excretion; outside of
body.
 In Males surrounded
by prostate
Functions of the Renal System
 Elimination of Metabolic Wastes
 Regulation of RBC Production
 Regulation of Vitamin D & Calcium
 Regulation of Blood Pressure
 Regulation of Electrolyte, Acid-Base &
Fluid Balances
Elimination of Waste Products
 Urea Nitrogen
 By-product of the protein metabolism.
 Measured clinically via serum BUN
 Some amounts normally found in blood; Not
a reliable indicator of renal function alone.
 Creatinine
A by-product of muscle metabolism.
 Normally, almost completely excreted
 A more reliable as an indicator of renal
function than BUN.
RBC Production
 Erythropoietin is a hormone that
prompts bone marrow to produce
RBC’s therefore more HgB to carry
oxygen to cells.
 Secreted in response to decreased
amount of oxygen delivered to
kidneys (i.e. anemia or hypoxia).
Vitamin D & Calcium Regulation
 Vitamin D from food sources must be
converted into it’s active form by the
kidneys.
 Active Vitamin D increases absorption
of calcium by the renal tubules and the
intestines.
 Required to maintain normal calcium
balances with the body.
 Blood Pressure & Fluid Regulation
 RAAS: Maintenance of blood volume &
altering peripheral vascular resistance.
 Specialized JGA cells in the kidneys respond
to decreased renal blood flow and pressures
by releasing renin…activating angio. I →
lungs → angio. II:
 Vasoconstriction
 Stimulates aldosterone release from the adrenal
cortex = Na & H2O retention (distal tubules).
 Net Result: ↑ BP & ↑ renal blood flow.
 Antidiuretic Hormone (ADH): release from
the posterior pituitary = H20 retention
(collecting ducts).
 Electrolyte Balances
 Potassium
 NL: 3.5 – 5.0 mEq /liter
 Sodium
 NL: 135-145 mEq / liter
 Calcium
 Total NL: 8.5 – 10.5 mg/dL
 Ionized Calcium NL: 4.5- 5.1 mg/dL
 Magnesium
 NL: 1.8 – 2.7 mg /dL
 Phosphorous
 NL: 2.5 -4.5 mg/dL
*See Thalen (pp. 748-749; table 30-2 & 3)
 Acid-Base Balance

 Kidneys regulate day-to-day acid-base

balances; not as rapid as lungs.
 Hydrogen: potent organic acidic
 Bicarbonate (HCO3-): principle buffer

CO2 + H20 ↔ H2CO3 ↔ H + HCO3

LUNGS Carbonic Kidneys
Acid
Anatomy & Physiology:
The Nephron
 Functional unit or
the “heart” of the
kidney
 One million
nephrons per kidney
 Each can perform all
individual functions
of the kidney
Components of the Nephron

See Thalen pp. 720-722

 A Closer Look: Urine Formation
 Excretion of waste products and retention
of essential electrolytes and water.
 Three processes involved:
 Glomerular Filtration
 Glomeruli filter blood as it follows through the
kidneys; creating filtrate.
 Glomerular blood flow and pressures

 Tubular Reabsorption
 The movement of substances from the filtrate
(renal tubules) into plasma (capillaries).
 Tubular Secretion
 The movement of substances from plasma into
renal tubules to be excreted.
 Factors Affecting Glomerular
Filtration
 Glomerular Blood Flow:
 Plasma Hydrostatic Pressure
 Pushing pressure: result of arterial blood
pressure; Favors filtration
 Plasma Oncotic / Osmotic Pressures
 Pulling pressure: result of plasma proteins
(i.e. albumin); Opposes filtration
 Pressure within the Bowman Capsule:
 Capsular Hydrostatic Pressures
 Pushing pressures from within the
capsule; Opposes filtration
 Glomerular Filtration
Plasma Forces Favoring Filtration:
Hydrostatic Plasma Oncotic Plasma Hydrostatic Pressure
Pressure Pressure Forces Opposing Filtration:
70 mmHg 32mmHg Plasma Oncotic Pressure
Capsule Hydrostatic Pressure

Total Capsule 38 mmHg

70 mmHg - 14 mmHg
Plasma Hydrostatic
- 32 mmHg
38 mmHg Pressure 24 mmHg
38 mmHg
14mmHg

NET FILTRATION PRESSURE

= 24 mmHg
(70 mmHg - 46mmHg (32mmHg + 14mmHG) = 24mmHg)
 General Renal Failure Symptoms
 Subjective  Objective
 Metallic taste in mouth
 Ammonia (urine) odor

 Weakness to breath

 Irritability
 Oliguria / anuria
 Tachycardia
 Fatigue
 Dysrhythmias
 Nausea
 Anorexia
 Hypertension
 Rapid weight gain
 Pruritis
 Dry, scaly skin
 Peripheral edema
 Laboratory Studies
 Serum Analysis
 BUN (5-20mg/dl)
 Creatinine (0.6 -1.5 mg/dl)
 Osmolarity
 H&H
 Electrolytes (K+, Na+, Mg+, Ca++ & PO4-)
 Combination: Serum/Urine Analysis
 Creatinine Clearance (100-140 ml/min)
 Direct measure of glomerular filtration (GFR)
See Thalen pp. 738-742
 Laboratory Studies Cont.,
 Urine Analysis
 Spot / Random Urine Collections
 Urine Analysis (UA)
 Color, appearance & casts
 Specific gravity (1.010 -1.030)
 Protein

 WBC’s & RBC’s

 Urine Osmolarity
 Culture & Sensitivity (C&S)
 Twenty-Four Hour Urine Collections
 i.e. For creatinine or electrolytes
 Diagnostic Studies
 Kidney-Ureter-Bladder (KUB)
 Intravenous Pyelogram (IVP)
 Renal Ultrasound
 Renal Computed Tomography (CT)
 Magnetic Resonance Imaging (MRI)
 Renal Angiography
 Interventional radiology procedure
 Renal Biopsy
 Gold standard to diagnosis specific renal
disease.
 Renal Failure
 Is a severe impairment in or a total lack of
renal function, which leads to disturbances in
all body systems.
 Classification According To Onset:
 Acute Renal Failure (ARF)
 Developing within hours to days with little time to
adjust to the biochemical changes, but is
potentially reversible with treatment.
 Chronic Renal Failure (CRF)
 Insidious & progressive development over a
period of several years; allows for some
adjustment to biochemical changes.
 Irreversible; often necessitates some form of
dialysis or transplantation for long-term survival.
 Acute Renal Failure (ARF)
 Sudden loss of kidney function over a
period of hour or days.
 Characterized by:
 A rapid decrease in GFR
 Retention of metabolic waste
A progressive ↑ in BUN & Creatinine levels.
 Associated with:
 Classic finding of Oliguria (UO < 400ml/day);
but may have normal to increase UO.
 Fluid, electrolyte and acid-base imbalances
 Usually reversible with prompt treatment
Classification of ARF
 Acute renal failure is often classified
according to location of the initial insult:
 Prerenal
 Before the kidneys; ↓ Blood flow to kidneys
 Occurs in about 55-60% of all ARF cases

 Intrarenal
 Within the kidneys; actual damage to the
filtering structures of the kidneys.
 Occurs in about 35-40% of all ARF cases

 Postrenal
 After the kidneys; obstruction of urinary
excretion
 Occurs in about 5% of all ARF cases
 Prerenal ARF
 It occurs when renal blood flow is
decreased before reaching the kidney,
causing ischemia of nephrons.
 ↓ Renal Perfusion = ↓ GFR leading to Oliguria
 Most common type of ARF
 Common Causes:
 Hypotension (severe and abrupt)
 Hypovolemia
 Low Cardiac Output States
 Treatment to correct cause, if not corrected
it may lead to permanent renal damage.
 Intrarenal ARF
 It occurs when there is actual damage to
the renal tissue, resulting in malfunction of
the nephrons.
 Acute Tubular Necrosis (ATN)
 Damage to the renal tubules characterized by
varying degrees of cellular damage or death.
 Ischemic: Renal trauma, massive hemorrhage or
post-surgery
 Nephrotoxic: I.V. contrast dyes, heavy metals or
antibiotics (i.e. aminoglyclosides)
 Treatment: Immediate treatment to increase
renal blood flow and minimize damage. Not
always reversible; may lead to CRF.
 Postrenal ARF
 Occurs as a result of conditions that block
urine flow distal to kidneys, resulting in
urine to backing-up into the kidneys.
 Caused by a bilateral obstruction of the ureters
or a bladder outlet obstruction.
 Calculi (stones)
 Tumors or masses
 Blood clots
 Benign prostate hypertrophy (BPH)
 ↓ UO: Oliguria or Anuria (UO < 100ml/day).
 Treatment to correct cause, if not corrected
it may lead to permanent renal damage.
ARF: The Clinical Course

 Involves Four Distinct Phases:

 Onset (Initiation) Phase
 Oliguric Phase
 Diuresis Phase
 Recovery Phase
Onset Phase
 Time of insult until cell injury ending
with the development of oliguria.
↓ renal blood flow and pressures =↓
GFR
 Accumulation of metabolic waste
products; ↑ Serum creatinine and BUN.
 Onset is sudden; can last hours to days;
toxic causes longer duration
 Treatment during the onset phase may
alleviate irreversible cellular damage.
 Oliguric Phase
 Characterized by a decreased UO (less
than 400ml/day) that does not respond to
fluid challenges or diuretics.
 Also, call the “maintenance phase” because
total support of renal function is required.
 May last for several days to several weeks; 8-
15 days on average.
 Further impairment of GFR:
 Continued ↑ BUN and ↑ Creatinine (serum)
 Metabolic Acidosis: ↓HCO3-
 Electrolytes: ↑ K+, ↑ PO4-, ↑ Mg+, ↓ Na+ &
 Diuretic Phase
 Begins with the onset of polyuria
(2-4 liters / day) and ends when BUN &
creatinine levels cease to rise .
 Also called the “high-output” phase
 This phase lasts on average 1 to 3 weeks.
 Polyuria may not be as evident with hemodialysis
therapy (more pulled off).
 Marked ↑ in GFR, but little improvement of
tubular function (can’t properly clear wastes).
 Electrolyte imbalances & volume depletion
 Strict I&O, daily weights & electrolyte monitoring are
essential !!
 Recovery Phase
 Return to normal activity levels
 Majorimprovement within first 1-2
weeks of the recovery phase.
 UO and renal function: normal or near
normal usually within 1-2 years.
 Requires close renal function monitoring
 Increased vulnerability to additional renal
injury during this time.
 Remember some do not recover = CRF.
 Chronic Renal Failure
 A progressive and irreversible loss of
renal function over a period of months to
years
 The kidneys can loss up to 80% of all
nephrons with relatively few overt changes
in functioning of the body.
 Nephrons are destroyed and replace with
scar tissue; remaining nephrons become
hypertrophied and eventually fail to function.
 Resulting in alterations in all of body’s systems.
Precipitating / Risk Factors of CRF
 Increased Age
 > 60 years-old
 Race
 African-Americans,
Native Americans & Asian
Americans at greater risk
 Gender
 Men at slightly greater
risk than women
 Positive Family History
 i.e. Polycystic kidney
Disease
 Smoking
 Environmental Or
Occupational Factors
 Systemic Disorders
 Diabetes Mellitus*
 Hypertension*
 Chronic glomerulonephritis
or Pyelonephritis
 Frequent obstructions of
the urinary tract
 Sickle cell anemia
 Systemic lupus
erythematous
Stages of CRF
 Stage 1
 Reduced Renal Reserve
 Characterizedby a loss of 40-75% of
nephron function.
 Usuallyasymptomatic; remaining
function nephrons able to rid the body of
metabolic wastes.
Stages of CRF Cont.,
 Stage 2
 Renal Insufficiency
 Characterizedby a 75-90% loss of
nephron function.
 Clinical Manifestations:
↑ Serum Creatinine and ↑BUN
 Kidneys loose ability to concentrate
urine
 Client may report polyuria and nocturia.
 Anemia develops
Stages of CRF Cont.,
 Stage 3
 End-Stage Renal Disease (ESRD)
 Final Stage: Characterized by < 90%
loss of nephron function or < 10% of
functioning nephrons remain !!
 Clinical Manifestations:

↑ Serum Creatinine & ↑ BUN

 Electrolyte Imbalances
 Uremia Affecting All Body Systems
 Requireslife-long dialysis or renal
transplant to prolong life !!
 Renal Failure:
Clinical Manifestations Cont.,
 Retention of Nitrogenous Wastes
 Azotemia: ↑ BUN & ↑ Serum Creatinine
 Uremia: Signs & symptoms of azotemia
 Fluid Volume Excess
↓ UO leads to ↑ fluid retention
 JVD, bounding pulse & peripheral edema
 Hemodynamics: ↑ CVP & ↑ PAOP values
 Renal Failure:
Clinical Manifestations
 Metabolic Imbalances:
 Electrolyte Imbalances:
 Hyperkalemia

 Hyperphosphatemia

 Hypocalcemia

 Hypermagnesia

 Hyponatremia (Dilutional)
 Acid-Base Imbalances:
 Metabolic Acidosis (↓pH & ↓HCO3ˉ)
*See Thalen (pp. 748-749; table 30-2 & 3)
 Renal Failure:
Clinical Manifestations
 Affects of Renal Failure on the Body’s
Systems:
 Genitourinary:
 Oliguria

 Urine Findings:
+ Casts, RBC, WBC & Protein
 Specific gravity decreased & fixed at 1.010
 Urine Osmolarity < Serum Osmolarity

 Creatinine Clearance: Decreased

 Neurologic:

 Fatigue, confusion, lethargy, changes in

level of consciousness → seizures & coma.
 Renal Failure:
Clinical Manifestations Cont.,
 Affects of Renal Failure On The Body’s
Systems Cont.,:
 Cardiovascular:
 Dysrhythmias, HTN, Hyperlipidemia &
peripheral edema → HF & Uremic Pericarditis
 Respiratory:

 Kussmaul respirations, crackles &

pulmonary edema → Uremic Pleuritis
 Gastrointestinal:

 Anorexia,
N/V, stomatitis, metallic taste in
mouth and uremic fector → GI Bleeding
 Renal Failure:
Clinical Manifestations Cont.,
 Affects of Renal Failure On The Body’s
Systems Cont.,
 Integumentary:
 Pruritus,dry skin, brittle nails and hair,
ecchymosis, pallor or a yellowish-bronze
discoloration of the skin.
 When terminal uremic frost (rare today)
 Musculoskeletal:
 Muscle cramps and weakness → foot drop
 Long-Term→ Renal Osteodystrophy:
resulting in bone pain, deformities and
pathological fractures.
 Renal Failure:
Clinical Manifestations Cont.,
 Affects of Renal Failure On The Body’s
Systems Cont.,
 Hematologic:
 Anemia, decreased platelets → prolonged
clotting times & decreased leukocytes.
 Endocrine:
 Glucose Intolerance
 Reproductive:
 Decreased libido and infertility
Renal Failure: Complications
 Seizures
 Coma
 Heart Failure
 Pericardial & Pulmonary Effusions
 GI Ulcerations & Bleeding
 Renal Osteodystrophy
 Secondary Hyperparathyroidism
Renal Failure:
Conservative Management
 Fluid Imbalances
 Volume Excess
 Fluid Restriction
 24 hour UO + 500-600ml
 Daily weights & I&O’s are essential !!
 Also, treatment for hyponatremia
 Diuretics

 Loop: i.e. Furosemide (Lasix)

 Osmotic: i.e. Mannitol (Osmitrol)
 Both promotes diuresis and increases
renal blood flow.
 Renal Failure:
Conservative Management Cont.,
 Electrolyte Imbalances
 Hyperkalemia
 I.V. Glucose accompanied by regular insulin
 Forces K+ out of serum and into cells
 I.V. Sodium Bicarbonate
 Creates temporary alkalemia moving H+ out
of cells and allowing K+ to shift into cells.
 I.V. Calcium Gluconate
 Supportive: reduces myocardial irritability=
decreasing risk of dysrhythmias
 Polystyrene Sulfonate (Kayexalate)
 Cationexchanging resin; oral, rectal or down
NG tube; resin binds with K+ in bowel,
promoting elimination in stool.
 Renal Failure:
Conservative Management Cont.,
 Electrolyte Imbalances Cont.,
 Hyperphosphatemia

 Phosphate Binders:
 Bind to phosphate in bowel & promote excretion
in stool; Given with meals.
 i.e.
Renagel or Calcium Acetate (Phos-Lo).
 Avoid long-term use of aluminum &
magnesium based binders = toxicity !!
 Hypocalcemia
 Supplements of Ca++
 Synthetic Active Vitamin D i.e. calcitrol

(Rocaltrol)
Renal Failure:
Conservative Management Cont.,
 Acid-Base Imbalances (↓pH &
↓HCO3ˉ)
 Metabolic Acidosis
 I.V. Sodium Bicarbonate
 Hypertensive Management
 ACE Inhibitors
 Angiotensin II Receptor Blockers (ARB’s)

 Calcium Channel Blockers

 Anemia
 RBC transfusions
 Epogen: Stimulates RBC production
Renal Failure:
Conservative Management Cont.,
 Prevention of Complications /
Symptom Management:
 Antiseizure

 Antiulcer

 Antiemetics

 Antibiotics; ensure renal dosing

 Antipruritics
Renal Failure:
Conservative Management Cont.,
 Pharmacologic Considerations:
 Potentiation of Effects
 Prone To Drug Toxicity
 Renal Dosing for Nephrotoxic Agents
 Antibiotics (i.e. Gentamycin or Vancomycin)
 Avoid NSAIDs, Demerol & Morphine for
pain management.
 Use Dilaudid or Percocet instead.
Renal Failure
Conservative Management Cont.,
 Nutrition- Renal Diet
 Caloric requirements met with a high
carbohydrate diet.
 Blood glucose control
 Dietary Restrictions
 “Low” Protein (0.8 grams/kg/day)
 Potassium

 Sodium

 Phosphorus

 Total parental nutrition: Watch volume !!

 Dietician Consult helpful with management
 Nursing Diagnoses: Renal Failure
 Fluid volume excess related to inability of
kidneys to produce urine.
 Altered renal perfusion related to damaged
nephrons secondary to acute or chronic renal
failure.
 Nutrition Altered: less than body
requirements related to renal failure or
dietary restrictions.
 Skin Integrity, high-risk for impairment
related to poor cellular nutrition.
 Nursing Diagnoses:
Renal Failure Cont.,
 Infection, high-risk for impairment related to
lowered resistance
 Potential for infection related to suppressed
immune responses associated with azotemia.
 Anxiety, related to unknown outcomes of
disease processes of renal failure
 Potential for altered family processes related
to health crisis in family member.
 Knowledge deficit related to renal failure
and/or its treatments
 Renal Failure:
Nursing Interventions
 Monitoring
 Vital Signs
 Fluid Balances
 I&O’s, Daily Weights & Assess For Edema
 Laboratory Results
 CBC; WBC & Urinalysis / Culture & Sensitivity
 Electrolytes & Acid-Base Balances
 Be alert for signs/symptoms of imbalances !!

 Signs and Symptoms of Infection

 Renal Failure:
Nursing Interventions Cont.,
 Maintain
 Diet Restrictions / Supplements
 Fluids Restrictions
 Bedrest / Semi-Fowler’s
 Quiet Environment
 Prevent Infection
 Avoid unnecessary use of Foley catheters
 Aseptic technique with invasive line care
 Pulmonary Care
 Skin & Mouth Care
 Renal Failure:
Nursing Interventions Cont.,
 Other Considerations
 Handle client with care
 Bleeding Precautions
 Administer medications as ordered
 Provide support to client & significant others
 Renal Failure:
Nursing Education
 Explain:
 Renal Failure (and its etiology)
 Dietary Restrictions / Supplements

 Fluid Restriction

 Medications (side effects too)

 Signs & Symptoms:

 Worsening renal function; signs and
symptoms of infection & hyperkalemia
 When to Notify Physician:
 i.e. Rapid weight gains (>2 lbs /day) or
recurrent nausea / vomiting
Renal Failure:
Nursing Education Cont.,
 Demonstrate how to check daily
weights and to assess for edema.
 Stress the Importance of:
 Keeping follow-up appointments
 Importance of good hygiene
 Maintaining an activity-rest balance
 Maintaining a normal weight
 Smoking Cessation
 Avoiding OTC medications i.e. NSAIDs
Renal Failure:
Nursing Education Cont.,
 Demonstrate how to check daily
weights.
 Stress the Importance of:
 Keeping follow-up appointments
 Importance of good hygiene
 Maintaining an activity-rest balance
 Smoking cessation
 Maintaining a normal weight
The Client with Alterations in
Urinary Elimination

Sherry A. Burrell, RN, MSN

Rutgers University
Nursing III
Lecture Dates: 10/28/05
Renal Dialysis
 Process of movement of fluid and
particles from one fluid compartment to
another across a semipermeable
membrane.
 Removes excess fluid and metabolic waste
products from the body when the kidneys
are unable to do so.
 Can be done in-home, in-hospital or in-
center
 The need for dialysis maybe acute or
chronic in nature.
 Renal Dialysis Cont.,
 In 2001, 287,494 Americans with ESRD
received dialysis. (ASN.org, 2005)
 Dialysis therapies are expensive;
Medicare covers 80% of cost of dialysis.
 In 1997, the total cost of treatment for
ESRD in the U.S. was 15 billion dollars.
 Types of Dialysis Therapies:
 Hemodialysis
 Continuous renal replacement therapies
(CRRT)
 Peritoneal dialysis (various forms)
General Principles of Dialysis
 Diffusion
 Toxins and waste products are moved
from an area higher concentration in the
client’s blood to an area of lower
concentration the dialysate solution.
 Osmosis
 Excess water is moved from a higher
concentration in the client’s blood to a
lower concentration in the dialysate
solution.
General Principles of Dialysis Cont.,
 Ultrafiltration
 Removal of excess water by creating a
pressure gradient between the positive
hydrostatic pressure of the client’s blood
and the negative hydrostatic pressure
(suctioning force) applied to the dialysate
solution.
 More efficient water removal than osmosis
Indications For Acute Dialysis
 Hyperkalemia
 Fluid Overload
 Impending pulmonary edema
 Pericarditis
 Drug overdose or poisoning
 Acidosis
 Severe mental confusion
Indications For Chronic Dialysis
 End-Stage Renal Disease (ESRD)
 Hyperkalemia

 Nausea / Vomiting
 Anorexia

 Mental confusion
 Increasing lethargy
 Fluid overload despite medical therapies
 Pericardial
friction rub indicates an urgent
need for dialysis
Mnemonic “AEIOU”

 Acid-base Imbalances
 Electrolyte Disturbances
 Intoxication
 Overload, Fluid
 Uremic Symptoms
Hemodialysis
 Most common method of dialysis
 Maybe used for short-term therapy
(days to weeks) in acutely ill or life-
long therapy as in ESRD.
 Life-Long Therapy
 3 times a week for 3-4 hours each session
 Prevents death, but does not cure renal

disease
 Dialysis machine removes “dirty”
blood, cleanses it and then returns it
to the body.
 Hemodialysis: Requirements
 Vascular Access
 Dialysis Machine
 Dialyzer
 Tube-like apparatus
containing a semi-
permeable membrane.
 Dialysate Solution
 A solution containing
all important electrolytes
in ideal cellular
concentrations.
 Can be adjusted based

on client needs.
 The Process of Hemodialysis
 Blood is removed from the arterial end and
pumped through the dialysis machine
(extracorporeal circuit) to the dialyzer at 200-
400 ml/min (rapid flow).
 Heparin added to blood to prevent clotting with in the
dialysis machine.
 The dialyzer receives arterial blood flow along
one side of the semipermeable membrane, with
the dialysis solution flowing along the other
side, usually in the opposite (countercurrent)
direction.
 Osmosis, Diffusion & Ultrafiltration Occur
 The filtered blood then is returned through
venous access to the client.
Vascular Access
 Short-Term Devices
 Venous Catheters
 Arteriovenous (A-V) Shunts
 Long-Term Devices
 Arteriovenous (A-V) Fistulas
 Arteriovenous (A-V) Grafts
 Venous Catheters
 Preferred method for temporary access
 Often used for acute dialysis
 Often double lumen, cuffed subclavian
catheters
 i.e. Hickman or Quinton
 Complications:
 Infection

 Inadequate Flow
 Thrombosis
 Arteriovenous (A-V) Shunts
 Temporary access; rarely used today.
 External shunt created by connecting a
peripheral artery and vein with a U-
shaped silicone tubing.
 Complications:
 External Occlusion
 Infection

 Skin erosion
 Dislodgement

 Thrombosis
 Arteriovenous (A-V) Fistulas
 Preferred method for chronic dialysis
 Decreased rate of infection, inexpensive and
tend to last longer.
 Client’s vessels (peripheral artery & vein)
anastomosed end-to-end, end-to-side,
or side-to-side.
 Requires 4-6 weeks to mature
 Complications
 Vascular Steal Syndrome
 Hand pale and cold
 Extremely Painful

 Thrombosis
 Arteriovenous (A-V) Grafts
 Used in chronic renal failure when
vessels inadequate to create a fistula.
 Ready to use in about 2 weeks
 Gore-Tex graft implanted to connect a
peripheral artery and vein.
 Complications
 Vascular steal syndrome
 Infection

 Thrombosis
 Hemodialysis:
Nursing Considerations
 Strict aseptic technique during dialysis
 Universal precautions
 Continuous monitoring of vital signs
 Watch for hypotension from rapid fluid shifts!!
 Monitor Laboratory Results
 i.e. CBC, BUN, Creatinine & PTT levels
 Observe for signs & symptoms of
 Bleeding
 Infection

 Monitor Fluid balance

 Daily weights and I & O’s
Hemodialysis:
Nursing Considerations Cont.,
 Chronic Access Devices
 Assessment
 Auscultate for bruit & palpate for thrill
 Neurovascular Checks

 Monitor for s/sx of infection

 No blood pressure or venipuncture to the

extremity with A-V access.

 Education
 Care of device
 No constrictive clothing, avoid sleeping on arm

with access
 Signs and symptoms of infection
 Hemodialysis:
Pharmacologic Considerations
 Some medications are removed during
hemodialysis.
 Caution with medication administration prior
to dialysis
 Daily Medications usually administered after
dialysis or at night
 Medication doses often need to be adjusted
with the initiation of dialysis
 Protein bound medications or some drug
metabolites are not removed
 Tend to remain in system longer; prone to
toxicity.
Complications of Hemodialysis
 Hypotension
 Dysrhythmias
 Chest Pain
 Muscle Cramping
 Exsanguination
 Air embolism
 Sleep Disorders
 Hyperlipidemia (esp. triglycerides)
Complications of Hemodialysis
Cont.,
 Dialysis Disequilibrium Syndrome
 Acute disorder occurring during or
shortly after hemodialysis
procedure.
 Results from the faster removal of urea
from plasma than brain &
cerebrospinal fluid causing water from
plasma to be shifted into the brain=
cerebral edema.
 S/Sx: HA, N/V, muscle cramps,

restlessness, decreased level of

consciousness and seizures
Complications of Hemodialysis
Cont.,
 Dialysis Encephalopathy
 Occurs in clients on chronic
hemodialysis
 Results from aluminum toxicity
 i.e.aluminum containing antacids or
dialysate bath
 S/Sx: dementia, muscle

uncoordination, speech disturbances,

personality changes and later seizures
 Continuous Renal Replacement
Therapies (CRRT)
 Completed only on critical care units
 Indicated for the acute treatment of drug
overdose, fluid overload and acute or chronic
renal failure client’s who are too
hemodynamically unstable for traditional
hemodialysis.
 Procedure is similar to hemodialysis:
 Requires vascular access to circulation
 A hollow fiber filter (semipermeable
membrane); hemofilter often used.
 Extracorporeal circuit
 One Type of CRRT is Continuous
Arteriovenous Hemofiltration (CAVH)
 Continuous Arteriovenous
Hemofiltration (CAVH)
 Arterial blood pressure used to circulate
blood through the extracorporeal circuit.
 Requires a MAP < 70 mm Hg
 Rate of fluid removal much slower than
hemodialysis; about 5 - 20 ml / minute
 Therapy lasts 12 hours or longer
 Gentle fluid removal by convection
 Convection:
 No concentration gradient, filters fluid only, but
solutes are removed because they are pulled or
“dragged” along with the fluid.
 Can clear more drugs, wastes and fluid than
traditional hemodialysis.
CAVH: Procedural Considerations
 Blood removed via arterial access
 Arterial
blood pressure used to propel blood
through the extracorporeal circuit
 Heparin added to arterial flow once leaves
the body to prevent clotting
 Blood
filtered through semipermeable
membrane (hemofilter); Convection Occurs.
 Filtered blood returned to the body via
venous access.
 Fluidand solutes wastes are collected in a
drainage bag; measure & discard
Continuous Arteriovenous
Hemofiltration (CAVH) Cont.,
 Nursing Considerations
 Continuous monitoring of vital signs
 Monitor Laboratory Results
 i.e. CBC, BUN, Creatinine & PTT
 Observe for signs & symptoms of
 Bleeding
 Infection

 Monitor Fluid balance

 Daily weights and I & O’s
 Assessextremity distal to arterial &
venous access
 Neurovascular checks
CRRT Complications:
 Fluid & Electrolyte Imbalances
 Hypotension
 Infection
 Bleeding
 Access Dislodgement
 Heparin
Peritoneal Dialysis
 Indications for peritoneal dialysis:
 Acute or Chronic Renal failure
 Young Children & Older Adults

 Severe Cardiovascular Disease

 Diabetes Mellitus

 Client with bleeding disorders and can not

tolerate systemic use of heparin.
 Principles of Peritoneal Dialysis
 Osmosis, Diffusion & Ultrafiltration
 Ultrafiltration: pressure gradient established
by high dextrose content of dialysate
solution.
Peritoneal Dialysis Cont.,
 Contraindications
 Recent abdominal surgery
 Previous abdominal surgery
resulting in scaring and adhesions
 Significant pulmonary disease
 Peritonitis

 Client
that requires rapid fluid
removal.
Peritoneal Dialysis Cont.,
 The peritoneum, a serous membrane
that covers the abdominal organs
functions as the semipermeable
membrane to the capillaries below.
 A catheter is inserted into the abdomen for
access. (i.e. Tenckhoff catheter)
 Exchanges: Dialysate instilled (over 5-10
min) at body temperature into the peritoneal
cavity; left in (dwell time) usually is between
1- 8 hours. Fluid later drained over 10-30
min by gravity
 Peritoneal Dialysis Cont.,
 Peritoneal drainage should be clear or
straw-colored.
 Fluidmaybe blood-tinged or pink the first
treatment after new catheter insertion
 Turn client side-to-side to facilitate drainage

 Dialysate composition, amount of

dialysate used & dwell time as per MD.
Main Types of Peritoneal Dialysis
 Continuous Ambulatory Peritoneal
Dialysis (CAPD)
 Continuous Cycling Peritoneal
Dialysis (CCPD)
 Continuous Ambulatory
Peritoneal Dialysis (CAPD)
 Completed in the home; As per MD’s orders
 Exchanges preformed 4-5 times a day, 7 days a
week; dwell time from 4-8 hours.
 Advantages
 More consistent, less electrolyte imbalances
 Frees client physically & mentally from dialysis
centers
 Disadvantages
 More opportunity for infection
 Must be able to complete exchanges at more
frequent intervals; less freedom for work and
social engagements outside the home.
 Continuous Cycling Peritoneal
Dialysis (CCPD)
 Completed in the home; As per MD’s orders
 Peritoneal automated cycler machine 4-5 exchanges
completed during sleep, with one prolonged dwell
time during the day.
 Advantages:
 Free from exchanges during the day allowing work
and social activities outside the home.
 Reduced risk of infection in comparison to CAPD
 Frees client from attending dialysis centers
 Disadvantages:
 Prolonged daytime dwell time
 Requires a peritoneal cycler machine
 Less night-time mobility
Peritoneal Dialysis
 Nursing Considerations
 Teaching Self-Care
 Stress the importance of proper hand
washing
 Explain and Demonstrate

 Basic aseptic technique

 PD procedure

 Tenckhoff catheter exit site care

 Daily Weights

A home health care consult is

necessary!!
Complications: Peritoneal Dialysis
 Peritonitis
 Bleeding

 Abdominal Wall Hernias

 Hyperlipidemia (esp. triglycerides)

 Anorexia

 Low-Back Pain

 Catheter Malfunction
 Leakage

 Occlusion
Dialysis: Dietary Considerations
 “High” Protein Diet (1.0-1.5 g/kg/day)
 Dietary Restrictions
 Sodium, Potassium & Phosphate
 Likely to continue; may be less severe
 Use of phosphate binders likely to continue
 Fluid Restrictions
 24 Hour UO + 500-600 ml
 Dietary Supplements
 Calcium

 Active Vitamin D i.e. calcitrol (Rocaltrol)

Long-Term Dialysis:
Psychosocial Considerations
 Client’s and their significant others
constantly vulnerable to medical, social
and emotional crisis.
 In-center and in-hospital dialysis schedule
according to the convenience of others.
 May affect work, schooling or leisure activities
 In-home dialysis may increase a client’s
dependence.
 Sick Role
 Often leads to caregiver strain

 Family roles and responsibilities change

 Creating tension, feelings of guilt or
inadequacy
Long-Term Dialysis:
Psychosocial Considerations Cont.,
 Financial
burdens of treatment, medications
and transportation
 Changes in sexual function
 i.e. decreasing libido and impotence
 Body image disturbances
 Fear,
depression and anger are common and
permissible
 Suicide rates increased in dialysis clients
 Some act-out depression with non-compliance
 Fear is common related to medications, infection
and contracting HBV and/or HIV
Kidney Transplantation
 The treatment of choice of ESRD
 The average cost of maintaining a successful
kidney transplant is 1/3 the cost of dialysis.
 Medicare will cover 80% of the cost of
transplant surgery
 As of October 1, 2005 there are 63,301
individuals wait-listed to receive a kidney
transplant (www.unos.org).
 Lack of donors is a major problem!!

 Two main types of human donors

 Living (related or non-related)
 Cadaver
 Kidney Transplantation Cont.,
 Regulatory Agencies:
 United Network for Organ Sharing (UNOS)
 Regional Support Agencies:
 Giftof Life Program
 Coalition on Donation (Southern NJ)

 Legislation:
 Uniform Anatomical Gift Act (1968)
 End Stage Renal Disease Act (1972)

 The National Organ Transplant Act (1984)

 Organ Donation Leave Act (1999)

Preoperative Considerations
 Informed Consent
 Dialyzed within 24 hours of procedure to
ensure best metabolic state as possible.
 Donor Compatibility
 ABO (blood type) & cross-match antigens and
HLA (human leukocyte antigens).
 Lower urinary tract studies to ensure
proper functioning prior to transplant.
 Screening for infection; must be
infection free to proceed.
Preoperative Considerations Cont.,
 Psychosocial Considerations:
 Some welcome transplant as freedom
 Some anxious about the procedure,
possible rejection or the need to
return to dialysis or dietary
restrictions.
Intraoperative Considerations
 The donor kidney is placed in the iliac
fossa, anterior to iliac crest.
 The native kidney is usually left in
for hormones unless cancer or prone
to chronic infection.
Postoperative Considerations
 Standard Postoperative Care
 Monitor
 Vital Signs
 Daily Weight and I&O’s

 Strict aspesis with invasive lines and catheters

 Provide Pain Control

 Prevent Infection
 Early Ambulation
 Pulmonary Toileting

 Incisional Care

 Administermedications as ordered
 Advance diet with return of bowel sounds;
encourage protein for healing
Postoperative Considerations Cont.,
 Immunosuppressive Therapy
 Thesurvival of the kidney depends on
blocking the body’s immune response.
 Neoral (cyclosporine)
 Prograf (tracrolimus)

 CellCept (mycophenolate)

 Rapamune (Sirolimus)

 Doses gradually decreased over a period

over several weeks, but will need to be on
immunosuppressants for life !!
 Complications: nephrotoxicity, decreased
platelets and leukocytes and malignancies.
Postoperative Considerations Cont.,
 Immunosuppressive Therapy Cont.,
 Corticosteroids
 i.e. Oral: Prednisone / I.V. Solu-Medrol
 Doses gradually decreased, but require a life-

long maintenance dose !!

 Many Long-Term Adverse Effects:

 Glucose Intolerance; Monitor Closely !!

 Weight Gain
 GI Ulcerations
 Osteoporosis
 Increased Susceptibility to Infections

 Dietary Considerations:
 Glucose Intolerance: No concentrated sweets
 Weight Gain: Reduced caloric intake
 Kidney Transplantation:
Complications
 Cardiovascular Disease
 Most common overall cause of mortality; occurs most
often in the later stages of transplantation
 3-5x more likely to have CV disease than normal
population.
 Infection
 Common cause of mortality within the first year of
transplantation.
 Sources: urine, lung, operative site, catheters or
drains.
 S/Sx: shaking chills, fever, tachycardia, tachypnea,
changes in WBC’s counts
 Kidney Transplantation:
Complications Cont.,
 Graft Rejection
 Three Types
 Hyperacute:
 Occurs within 24 hours of transplantation;
usually within minutes.
 This type of rejection is rare due to advances
in compatibility screening.
 Acute:

 Usually occurs in 6 weeks to 3 months, but

can occur for up to 2 years after transplant.
 Chronic:

 Occurs slowly over months to years; often

occurs more than 1 year of transplantation.
 Kidney Transplantation:
Complications Cont.,
 Graft Rejection Cont.,
 Acute Rejection:
 Signs/Symptoms:

 Lethargy, fever, edema, weight gain,

oliguria, HTN, tenderness & swelling of the
graft site.
 An elevation in serum creatinine > 20%
 Management:

 Increased
doses of Corticosteroids and other
immunosuppressant agents
Kidney Transplantation:
Complications Cont.,
 Graft Rejection Cont.,
 Chronic Rejection:
 Signs/Symptoms (mimic CRF):
 Fatigue

 Gradual increase in serum BUN and

creatinine
 Electrolyte imbalances.

 Management:

 Conservative therapies until dialysis

required or a another transplant can
be performed.
Kidney Transplantation:
Nursing Considerations Cont.,
 Promoting Organ Donation:
 Stress to client the importance of sharing
wishes to be an organ donor with
significant others.
 Provide information to the client and/or
significant others; clarify any
misconceptions.
 Provide support and understanding the
client and / or significant other during the
decision making process.
 Lead by example; become an organ
donor.