Nursing Care of Patients With Kidney Disorders

Chapter 28:
Nursing Care of Patients with Kidney Disorders

Learning Outcomes:
1. Describe the pathophysiology of common kidney disorders,
relating pathophysiology to normal functions and manifestations of
the disorder.
a. Suggested Activity: Use anatomical models to help students
visualize the interrelationships of urinary tract organs and
how damage in one area can affect another area.
b. Suggested Activity: Review clinical patient medical records,
health histories, and assessments for indications of kidney
disorder. Help students relate those manifestations to the
specific disorder.
2. Discuss risk factors for kidney disorders and nursing measures to
reduce these risks.
a. Suggested Activity: Have students develop a “life plan” for
the maintenance of healthy kidney function.
b. Suggested Activity: Help students identify clinical patients
with kidney disorders. Have students develop a teaching plan
for patients that will help the patient manage risk factors for
kidney disorders.
c. Suggested Activity: Discuss the difference between activities
designed to improve kidney health and those designed to
reduce progression to ESRD.
3. Explain diagnostic studies used to identify disorders of the kidneys
and their effects.
©2015 by Pearson Education, Inc.

LeMone/Burke/Bauldoff/Gubrud, Instructor’s Resource Manual for Medical-Surgical Nursing, 6th Edition
Ch. 28: Nursing Care of Patients with Kidney Disorders
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a. Suggested Activity: Present results for common kidney
function laboratory tests. Help students identify results that
are considered normal and abnormal. Have students identify
when normal results might indicate kidney disorder and when
abnormal results might indicate improving kidney function.
b. Suggested Activity: Have students discuss the implication of
aging on normal laboratory and diagnostic tests of kidney
function.
c. Suggested Activity: Have students review clinical patient
charts, and help them relate test results to patient clinical
findings.
4. Discuss the effects and nursing implications for medications and
treatments used for patients with kidney disorders.
a. Suggested Activity: Have students investigate methods for
individualizing standard “textbook” interventions to the care
of the specific patient with kidney disorder.
5. Compare and contrast renal replacement therapies, including
dialysis and kidney transplant, to manage acute and chronic renal
failure.
a. Suggested Activity: Arrange for a registered nurse who
works on a dialysis unit to speak to the class.
b. Suggested Activity: Arrange for a hemodialysis patient to
speak to the class.
c. Suggested Activity: Have students plan a 1-month traveling
vacation for a patient who is on hemodialysis and for a
patient who is on peritoneal dialysis. Compare and contrast
issues for each patient.
d. Suggested Activity: Arrange for clinical students to visit a
dialysis unit.

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e. Suggested Activity: Have students develop an assessment
documentation flow sheet for patients undergoing routine
hemodialysis.
I. Age-Related Changes in Kidney Function
A. Reduced kidney mass due to lost glomeruli in the renal cortex
B. Decline in glomerular filtration rate (GFR)
C. Complications
1. Increased risk for dehydration, fluid and electrolyte imbalances, reduced clearance of
drugs
2. Medications impacted by decreased GFR: cardiac drugs, antibiotics, histamine H2
antagonists: cimetidine, antidiabetic agents
II. The Patient with Polycystic Kidney Disease

A. Forms: autosomal dominant (ADPKD) and autosomal recessive
B. Pathophysiology
1. Cysts arise from tubular epithelial cells
2. Kidneys enlarge as cysts enlarge
3. People often develop cysts in other parts of the body
4. Complications: liver cysts, diverticular disease of the colon, cardiac valve
abnormalities, subarachnoid or cerebral hemorrhage
C. Manifestations
1. Flank pain, microscopic or gross hematuria, proteinuria, polyuria and nocturia,
UTIs, renal calculi, hypertension, enlarged kidneys, symptoms of renal insufficiency
and chronic renal failure
D. Interprofessional care
1. Diagnosis
a) Renal ultrasonography
b) Computed tomography (CT) scan or MRI of the kidney
c) Genetic testing for ADPKD type 1 and type 2
2. Treatments

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a) Largely supportive, fluid intake of 2000–2500 mL per day
b) Control hypertension using multidrug regimen
c) Angiotensin-converting enzyme (ACE) inhibitors and angiotensin receptor blockers
(ARBs)
d) Dialysis or renal transplantation
E. Nursing care
1. Diagnosis, outcomes, and interventions
a) Excess fluid volume
b) Grieving
c) Readiness for enhanced knowledge
d) Risk of ineffective coping
F. Continuity of care
1. Teach about the disease, its genetic nature, and usual course
2. Discuss measures to maintain optimal renal function
3. Teach how to prevent UTI and early manifestations of UTI
4. Avoid drugs that are toxic to kidneys
5. Discuss benefits of genetic counseling
III. The Patient with a Glomerular Disorder

A. May be either primary or secondary to a multisystem disease or hereditary
condition
B. Pathophysiology
1. Affects both the structure and function of the glomerulus, disrupting glomerular
filtration
2. Acute postinfectious glomerulonephritis
a) Inflammation of the glomerular capillary membrane
b) Etiologies: infection of the pharynx or skin with group A beta-hemolytic streptococcus
c) Manifestations: hematuria, cola-colored urine; proteinuria; salt and water retention;
edema, periorbital and facial, dependent; hypertension; azotemia; fatigue, anorexia,
nausea, and vomiting; headache
3. Antiglomerular basement membrane glomerulonephritis
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a) Autoantibodies to antigens in the glomerular basement membrane and manifestations
of severe glomerular injury
b) Goodpasture’s syndrome
c) Manifestations: weakness, nausea and vomiting, possible abdominal or flank pain,
hematuria, proteinuria, edema, moderate hypertension, oliguria, pulmonary
hemorrhage, cough, shortness of breath, and hemoptysis
4. Nephrotic syndrome
a) A group of clinical findings as opposed to a specific disorder
b) Manifestations: massive proteinuria, hypoalbuminemia, hyperlipidemia, and edema
c) Etiologies: minimal change disease (MCD), membranous glomerulonephropathy,
focal sclerosis, and membranoproliferative glomerulonephritis
d) Complications: thromboemboli
5. Chronic glomerulonephritis
a) Typically the result of progressive glomerular disorders such as anti-GBM
glomerulonephritis, lupus nephritis, or diabetic nephropathy
b) Symptoms develop insidiously, and the disease is often not recognized until signs of
renal failure develop
6. Diabetic nephropathy
a) Leading cause of chronic kidney disease in North America
b) Manifestations: microproteinuria, overt proteinuria, nephropathy, glomerulosclerosis
and thickening of the glomerular basement membrane
7. Lupus nephritis
a) Manifestations: microscopic hematuria to massive proteinuria
C. Interprofessional care
1. Diagnosis
a) Urinalysis
b) Blood urea nitrogen (BUN)
c) Serum creatinine
d) Urine creatinine levels
e) eGFR (estimated GFR)
f) Creatinine clearance

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g) Serum electrolytes
h) Antistreptolysin O (ASO) titer and other tests to detect antigenic proteins or antibodies
i) Renal ultrasound
j) Kidney scan
k) Biopsy
2. Medications
a) No drugs can cure disorder
b) Nephrotoxic antibiotics, aggressive immunosuppressive therapy, glucocorticoid,
corticosteroids, ACE inhibitors or angiotensin-receptor blockers (ARBs),
antihypertensives
3. Treatments
a) Restricted activity, restricted sodium and protein intake
b) Plasma exchange therapy
c) Dialysis
D. Nursing care
1. Health promotion
a) Discuss importance of treating streptococcal infections
b) Discuss the importance of completing the full course of antibiotic therapy
c) Teach patients with diabetes mellitus and SLE about potential renal effects
d) Discuss measures to reduce the risk of associated nephritis
2. Assessment
a) Health history: complaints of facial or peripheral edema or weight gain, fatigue,
nausea and vomiting, headache, general malaise, abdominal or flank pain; cough or
shortness of breath; changes in amount, color, or character of urine (e.g., frothy
urine); history of skin or pharyngeal streptococcal infection, diabetes, SLE, or kidney
disease; current medications
b) Physical examination: general appearance; vital signs; weight; presence of
periorbital, facial, or peripheral edema; inspect skin for lesions, infection; inspect
throat, obtain culture as indicated; obtain urine specimen for color, character, odor
a) Excess fluid volume
(1) Monitor vital signs at least every 4 hours
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(2) Record intake and output every 4 to 8 hours, or more frequently as indicated
(3) Weigh daily, using consistent technique
(4) Monitor serum electrolytes, hemoglobin and hematocrit, BUN, creatinine, and
eGFR
(5) Maintain fluid restriction as ordered
(6) Arrange dietary consultation regarding sodium or protein restricted diets
(7) Monitor for desired and adverse effects of prescribed medications
(8) Provide frequent position changes and good skin care
b) Fatigue
(1) Document energy level
(2) Schedule activities and procedures to provide adequate rest and energy
conservation
(3) Assist with ADLs as needed
(4) Discuss the relationship between fatigue and the disease process
(5) Reduce energy demands with frequent, small meals and short periods of activity;
limit the number of visitors and visit length
c) Risk for infection
(1) Monitor vital signs, temperature, and mental status every 4 hours
(2) Assess frequently for signs of infection
(3) Monitor CBC, focusing on the WBC and differential
(4) Perform effective hand hygiene
(5) Avoid or minimize invasive procedures
(6) If catheterization is required, use sterile intermittent straight catheterization or
maintain a closed drainage system for an indwelling catheter
(7) Prevent urine reflux from the drainage system to the bladder or the bladder to the
kidneys by ensuring a patent, gravity flow system
(8) Provide a nutritionally sound diet with complete proteins
(9) Teach measures to prevent infection
d) Ineffective role performance
(1) Encourage self-care and active participation in decision making
(2) Provide time for verbalization of thoughts and feelings
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(3) Support coping skills, helping the patient identify personal strengths
(4) When possible, enlist the support of family, other patients, and friends
(5) Discuss the effect of the disease and treatments on roles and relationships, helping
identify potential changes in roles, relationships, and lifestyle
(6) Evaluate the need for additional support and social services for the patient and
family
E. Continuity of care
1. Information about the disease and the prognosis
2. Prescribed treatment, including activity and diet restrictions; the use and potential
effects, both beneficial and adverse, of all medications
3. Risks, manifestations, prevention, and management of complications such as edema
and infection
4. Signs, symptoms, and implications of improving or declining renal function
5. Measures to prevent further kidney damage, such as nephrotoxic drugs to avoid
6. Community resources, such as home care providers and support groups
IV. The Patient with a Vascular Kidney Disorder

A. Hypertension: sustained elevation of systemic blood pressure
1. Malignant hypertension: diastolic pressure is in excess of 120 mmHg and may be as
high as 150 to 170 mmHg
2. Secondary hypertension: manifestation of an underlying disease
B. Renal artery stenosis (RAS)
1. Causes: atherosclerosis, coronary heart disease or peripheral vascular disease,
fibromuscular dysplasia
2. Diagnosis
a) Doppler ultrasonography
b) Magnetic resonance angiography (MRA) and computed tomography (CT)
angiography
3. Treatment
a) ACE inhibitors or angiotensin-receptor blockers (ARBs) along with other
antihypertensive drugs
b) Stains, low-dose aspirin

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c) Percutaneous transluminal angioplasty
4. Nursing care
a) Achieve target blood pressures
b) Monitor renal function
c) Implement measures to preserve remaining renal function
d) Teach the patient and family about the prescribed treatment
C. Renal artery occlusion
1. Risk factors: severe abdominal trauma, vessel trauma from surgery or angiography,
aortic or renal artery aneurysms, and severe aortic or renal artery atherosclerosis
2. Manifestations: may be asymptomatic; sudden, severe localized flank pain; nausea
and vomiting; fever; hypertension; hematuria; and oliguria
3. Diagnosis
a) Leukocytosis (elevated WBC) and elevated renal enzyme levels
4. Treatment: surgery to restore blood flow to affected kidney, anticoagulant therapy,
intrarenal fibrinolysis, hypertension control, and supportive treatment
D. Renal vein occlusion
1. Predisposing factors: nephritic syndrome, pregnancy, oral contraceptive use, certain
malignancies
2. Manifestations: gradual or acute deterioration of renal function
3. Diagnosis: visualizing the thrombus through renal venography
4. Treatment: fibrinolytic drugs, anticoagulant therapy
V. The Patient with Kidney Trauma

A. Pathophysiology and manifestations
1. Causes: blunt force
2. Manifestations: hematuria, flank or abdominal pain, oliguria or anuria, localized
swelling, tenderness, or ecchymoses in the flank region, Turner’s sign, signs of shock
B. Interprofessional care
1. Diagnosis
a) Hemoglobin and hematocrit levels
b) Urinalysis
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c) AST levels
d) Renal ultrasonography
e) CT scan with contrast
2. Treatments
a) Bed rest and observation
b) Surgery to stop bleeding: partial nephrectomy, or total nephrectomy
C. Nursing care
1. Obtain urine specimen for analysis
2. Monitor level of consciousness, vital signs, skin color and temperature, and urine
output for possible signs of shock
VI. The Patient with a Renal Tumor

A. Pathophysiology
1. May be benign or malignant, primary or metastatic
2. 92% are renal cell carcinomas
3. Metastases tend to occur in the lungs, bone, lymph nodes, liver, and brain
4. Paraneoplastic syndromes
B. Manifestations
1. Microscopic or gross hematuria, flank pain, palpable abdominal mass, fever, fatigue,
weight loss, anemia or polycythemia
C. Interprofessional care
1. Diagnosis
a) Renal ultrasonography
b) CT scan of the abdomen and pelvis
c) Chest x-ray, bone scan, MRI, and liver function studies
2. Treatments
a) Stage I or II: radical nephrectomy
b) Antiangiogenesis agents, interferon α and interleukin 2, targeted therapy with
monoclonal antibodies
D. Nursing care
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a) Acute pain
(1) Assess frequently for adequate pain relief
(2) Assess the incision for inflammation or swelling and drainage catheters and tubes
for patency
(3) Assess for abdominal distention, tenderness, and bowel sounds
(4) Use adjunctive pain relief measures such as positioning, diversional activities,
management of environmental stimuli, guided imagery, and relaxation techniques
b) Ineffective breathing pattern
(1) Position to promote respiratory excursion, using semi-Fowler’s position and side-
lying positions as allowed and tolerated
(2) Change position frequently; ambulate as soon as possible
(3) Encourage frequent (every 1 to 2 hours) deep breathing, spirometer use, and
coughing
c) Risk for impaired urinary elimination
(1) Monitor vital signs, CVP, and urine output every 1 to 2 hours initially, then every
4 hours
(2) Frequently assess the amount and nature of drainage on surgical dressings and
from drainage tubes, stents, and catheters; measure and record output from each
drain or catheter separately
(3) Maintain fluid intake with intravenous fluids until oral intake is resumed
(4) Use strict aseptic technique in caring for all urinary catheters, tubes, stents, drains,
and incisions
(5) Following catheter removal, assess frequently for urinary retention
(6) Monitor laboratory results, including urinalysis, BUN, serum creatinine, and
serum electrolytes; report abnormal findings to the physician
d) Grieving
(1) Work to develop a trusting relationship with the patient and family
(2) Listen actively, encouraging the patient and family to express fears and concerns
(3) Assist the patient and family to identify strengths, past experiences, and support
systems
(4) Demonstrate respect for cultural, spiritual, and religious values and beliefs;
encourage use of these resources to cope with losses
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(5) Encourage discussion of the potential impact of loss on the patient and the family
structure and function
(6) Refer to cancer support groups, social services, or counseling as appropriate
E. Continuity of care
1. Maintain a fluid intake of 2000 to 2500 mL per day, increasing the amount during hot
weather or strenuous exercise
2. Urinate when the urge is perceived, and before and after sexual intercourse
3. Properly clean the perineal area
4. Watch for manifestations of UTI and understand the importance of early and
appropriate evaluation and intervention
5. If the patient is an older adult male, he should watch for manifestations of prostatic
hypertrophy, a major cause of urinary tract obstruction. Stress the importance of
routine screening examinations
6. Avoid contact sports such as football or hockey; use measures to prevent motor
vehicle accidents and falls, which could damage the kidney
VII. Kidney Failure

A. Kidneys are unable to remove accumulated metabolites from the blood, leading
to altered fluid, electrolyte, and acid–base balance
B. Cause may be primary or secondary
C. Onset may be acute or chronic
VIII. The Patient with Acute Kidney Injury (AKI)
A. AKI: rapid decline in renal function with azotemia and fluid and electrolyte
imbalances
B. Causes: ischemia, sepsis, nephrotoxins
C. Risk factors
1. Major trauma or surgery, infection and sepsis, hemorrhage, severe heart failure,
severe liver disease, urinary tract obstruction, drugs and radiologic contrast media,
aging process
D. Pathophysiology
1. Prerenal AKI: results from conditions that affect renal blood flow and perfusion
a) Causes: hypovolemia, low cardiac output, altered vascular resistance
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2. Postrenal AKI: results from obstructive causes of acute renal failure
a) Causes: ureteral and urethral obstruction
3. Intrinsic AKI: acute damage to the renal parenchyma and nephrons
a) Causes: glomerular/microvascular injury, acute tubular necrosis, interstitial nephritis
(1) Acute tubular necrosis (ATN): destruction of tubular epithelial cells
(2) Nephrotoxins associated with ATN: radiologic contrast agents, the
aminoglycoside antibiotics, amphotericin B, NSAIDs, some chemotherapy drugs,
heavy metals such as mercury and gold, and some common chemicals such as
ethylene glycol
(3) Rhabdomyolysis: caused by release of excess myoglobin from injured skeletal
muscles
(4) Hemolysis: red blood cell destruction
E. Course and manifestations
1. Initial phase: may last hours to days, and may be seen as a continuum from prerenal
azotemia to intrinsic AKI
2. Maintenance phase: characterized by a significant fall in GFR and tubular necrosis
a) Manifestations: anemia, impaired immune function, edema and hypertension,
confusion, disorientation, agitation or lethargy, hyperreflexia, possible seizures or
coma due to azotemia, electrolyte and acid–base imbalances, anorexia, nausea,
vomiting, decreased or absent bowel sounds, and uremic syndrome if AKI is
prolonged
3. Recovery phase: characterized by a process of tubule cell repair and regeneration and
gradual return of the GFR to normal or pre-AKI levels
F. Complications
1. Uremia, hypervolemia, hyperkalemia, metabolic acidosis, infections, bleeding, cardiac
complications, and malnutrition
G. Interprofessional care
1. Staging: used to guide treatment decisions for AKI
a) RIFLE: risk, injury, failure, loss, end-stage kidney disease
b) AKIN: Stage 1–3
2. Diagnosis
a) Urinalysis

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b) Serum creatinine, BUN, BUN/creatinine ratio, and eGFR
c) Serum electrolytes
d) Arterial blood gases
e) CBC
f) Renal ultrasonography
g) CT scan or MRI
h) Kidney biopsy
3. Medications
a) To restore renal perfusion: dopamine, norepinephrine, fenoldopram, atrial natriuretic
peptide (ANP)
b) To control arterial pressures: ACE inhibitors, ARBs, or other antihypertensive
medications
c) Loop diuretics, osmotic diuretics, electrolytes and electrolyte modifiers
d) To prevent GI hemorrhage: antacids, histamine H2-receptor antagonists, or a proton-
pump inhibitor
4. Fluid management
a) Fluid intake is restricted once vascular after volume and renal perfusion restored
5. Nutrition
a) Adequate nutrients and calories needed (between 25 and 45 calories/kg/day) to
prevent catabolism
6. Renal replacement therapy
a) Dialysis: removes excess fluid and metabolic waste products in acute kidney injury
and renal failure
(1) Hemodialysis: blood passes through a semipermeable membrane filter outside the
body
(2) Peritoneal dialysis: uses the peritoneum surrounding the abdominal cavity as the
dialyzing membrane
(a) Poses less risk for unstable patient, increased risk for developing peritonitis
(3) Intermittent hemodialysis: most commonly used for the patient with AKI in the
U.S.
(a) Ultrafiltration, convection
(b) 3–4 hours per day, 3–4 times per week
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(c) Complications: hypotension, bleeding related to altered platelet function,
infection (local or systemic) related to WBC damage and immune system
suppression
b) Continuous renal replacement therapy: allows more gradual fluid and solute removal
(1) Continuous venovenous hemofiltration (CVVH)
(2) Continuous venovenous hemodialysis (CVVHD)
(3) Continuous venovenous hemodiafiltration (CVVHDF)
c) Vascular access: gained by inserting a double-lumen catheter into the subclavian,
jugular, or femoral vein
(1) Long term: arteriovenous fistula (AVF) is created
(2) Arteriovenous graft
(3) Complications: infection and clotting or thrombosis, aneurysms, systemic
complications (septicemia and embolization), depression, low-self esteem
H. Nursing care
1. Health promotion
a) Maintain fluid volume and cardiac output
b) Reduce the risk of exposure to nephrotoxins
c) Monitor critically ill for early signs of hypovolemia or infection
2. Assessment
a) Health history: complaints of anorexia, nausea, weight gain, or edema; recent
exposure to a nephrotoxin such as an aminoglycoside antibiotic or radiologic
procedure using an injected contrast medium; previous transfusion reaction; chronic
diseases such as diabetes, heart failure, or kidney disease
b) Physical examination: vital signs including temperature; urine output (amount, color,
clarity, specific gravity, presence of blood cells or protein); weight; skin color,
peripheral pulses; presence of edema (periorbital or dependent); lung sounds, heart
sounds, and bowel tones
a) Altered fluid and electrolyte balance
(1) Maintain hourly intake and output records
(2) Weigh daily or more frequently, as ordered
(3) Assess vital signs at least every 4 hours

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(4) If not contraindicated, place in semi-Fowler’s position
(5) Report abnormal serum electrolyte values and manifestations of electrolyte
imbalance. The patient with AKI is at particular risk for the following electrolyte
imbalances:
(a) Hyperkalemia due to impaired potassium excretion
(b) Hyponatremia due to water retention
(c) Hyperphosphatemia due to decreased phosphate excretion
(6) Restrict fluids as ordered; provide frequent mouth care and encourage using hard
candies to decrease thirst
(7) Administer medications with meals
(8) Turn frequently and provide good skin care
b) Imbalanced nutrition: less than body requirements
(1) Monitor and record food intake, including the amount and type of food consumed
(2) Weigh daily
(3) Arrange for dietary consultation to plan meals within prescribed limitations that
consider the patient’s food preferences
(4) Engage the patient in planning daily menus
(5) Allow family members to prepare meals within dietary restrictions; encourage
family members to eat with the patient
(6) Provide frequent, small meals or between-meal snacks
(7) Administer antiemetics as ordered and provide mouth care prior to meals
(8) Administer parenteral nutrition as ordered if the patient is unable to eat or tolerate
enteral nutrition
c) Readiness for enhanced knowledge
(1) Assess anxiety level and ability to comprehend instruction
(2) Assess knowledge and understanding
(3) Teach about diagnostic tests and therapeutic procedures
(4) Discuss dietary and fluid restrictions
(5) If the patient is discharged prior to the recovery phase of AKI, teach the signs and
symptoms of complications
(6) Teach how to monitor weight, blood pressure, and pulse

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(7) Instruct to avoid nephrotoxic drugs and chemicals for up to 1 year following an
episode of AKI
I. Continuity of care
1. Avoiding exposure to nephrotoxins, particularly those in over-the-counter products
2. Preventing infection and other major stressors that can slow healing
3. Monitoring weight, blood pressure, and pulse
4. Manifestations of relapse
5. Continuing dietary restrictions
6. Knowing when to contact the physician
IX. The Patient with Chronic Kidney Disease (CKD)

A. CKD: kidney damage with resulting dysfunction (GFR less than 60 mL/min) that
persists for three or more months
B. Incidence and risk factors
1. Incidence increasing in people 65 and older
2. Highest incidence in African Americans
3. Higher incidence in people of Hispanic origin than non-Hispanics
4. Diabetes mellitus is the leading cause of CKD
5. Risk factors: diffuse, bilateral disease of the kidneys with progressive destruction and
scarring of the entire nephron, AKI, autoimmune disease, proteinuria, or a family
history of kidney disease
C. Pathophysiology
1. Glomerulosclerosis and interstitial inflammation and fibrosis are characteristic of
CKD
2. Early stages: nephron units gradually destroyed, remaining functional nephrons
hypertrophy
3. Progresses over a period of months to many years
4. ESRD: final stage of CKD; GFR is less than 15 mL/min and renal replacement
therapy is necessary to sustain life
D. Manifestations and complications
1. May not be identified until final, uremic stage (uremia occurs)

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a) Early manifestations of uremia: nausea, apathy, weakness, and fatigue
2. Fluid and electrolyte effects
a) Proteinuria, hematuria, decreased urine-concentrating ability, risk for dehydration
increases, polyuria, nocturia, sodium and water retention, hyperkalemia,
hyperphosphatemia, hypocalcemia, hypermagnesemia, metabolic acidosis
3. Cardiovascular effects
a) Cardiovascular disease is leading cause of death in CKD patients
b) Accelerated atherosclerosis, hypertension, hyperlipidemia, inflammation, cerebral
and peripheral vascular manifestations of atherosclerosis, systemic hypertension,
pericarditis, cardiac tamponade
4. Hematologic effects
a) Anemia, impaired platelet function, increasing the risk of bleeding disorders such as
epistaxis and GI bleeding
5. Immune system effects
a) Uremia increases the risk for infection, decreased WBC, impaired humoral and cell-
mediated immunity, defective phagocyte function, acute inflammatory response and
delayed hypersensitivity responses affected
6. Gastrointestinal effects
a) Anorexia, nausea, vomiting, hiccups, gastroenteritis, ulcerations, increased risk of GI
bleeding, uremic fetor
7. Neurologic effects
a) CNS manifestations: changes in mentation, difficulty concentrating, fatigue, and
insomnia, psychotic symptoms, seizures, and coma
b) Peripheral neuropathy, restless leg syndrome, paresthesias and sensory loss typically
occur in a “stocking-glove” pattern, impaired motor function
8. Musculoskeletal effects
a) Renal osteodystrophy, bone cysts, increased risk for spontaneous fractures
9. Endocrine and metabolic effects
a) Elevated serum creatinine and BUN levels, increased risk of gout, glucose
intolerance, accelerated atherosclerotic process, reproductive function affected
10. Dermatologic effects
a) Pallor and yellowish hue to skin, dry skin with poor turgor, bruising and excoriations,
itching and pruritus, uremic frost

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E. Interprofessional care
1. Diagnosis
a) Urinalysis
b) Urine culture
c) BUN and serum creatinine
d) eGFR
e) Serum electrolytes
f) CBC
g) Renal ultrasonography
h) Kidney biopsy
2. Medications
a) Angiotensin-converting enzyme (ACE) inhibitors and angiotensin receptor blockers
(ARBs), diuretics, diuretic therapy, antihypertensive agents (calcium channel blockers
diltiazem and verapamil), statin drugs
b) Drugs to manage electrolyte imbalances and acidosis: sodium bicarbonate or calcium
carbonate, oral phosphorus binding agents
c) Folic acid and iron supplements, multivitamins
3. Nutrition and fluid management
a) Daily protein intake of 0.6 to 0.75 g/kg of body weight, or approximately 40 to 50
g/day
b) Carbohydrate and fat intake is increased
c) Sodium intake regulated
d) In stages 4 and 5, potassium and phosphorous intake are restricted
4. Renal replacement therapies
a) Dialysis
(1) 70% of people treated for ESRD in the U.S. are receiving dialysis
(2) Peritoneal dialysis is choice for at-home treatment
(3) Patients on long-term dialysis have a higher risk for complications and death
(4) Manages symptoms but doesn’t cure it

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(5) Dialysis dose determined by body size and residual renal function, dietary intake,
and concurrent illness
(6) Continuous ambulatory peritoneal dialysis (CAPD): most common form of
peritoneal dialysis
(a) Continuous cyclic peritoneal dialysis (CCPD)
b) Kidney transplant: treatment of choice for ESRD
(1) Most are from deceased donors, transplants from living donors are increasing
(2) Match of ABO blood is necessary
(3) Requirements for deceased donor: meet the criteria for brain death, are less than
60 years old, and are free of systemic disease, malignancy, or infection, including
HIV and hepatitis B or C
(4) Immunosuppressive drugs minimize the immune response stimulated by grafted
organ
(5) Acute rejection: develops within months of transplant
(6) Chronic rejection: may develop months to years following the transplant
(7) Complications of transplant: hypertension, glomerular lesions, manifestations of
nephrosis, infection, tumors, increased risk of congenital anomalies in infants
whose mothers have undergone immunosuppressive therapy, bone problems,
gastrointestinal disorders, cataract formation
F. Nursing care
1. Health promotion
a) Promote early and effective treatment of all infections
b) Discuss measures to reduce the risk for urinary tract infections and stress the
importance of prompt treatment to eradicate the infecting organism
c) Discuss the relationship between diabetes, hypertension, and kidney disease
d) Emphasize that maintaining blood glucose levels and the blood pressure within the
recommended ranges reduces the risk of adverse effects on the kidneys
e) Ensure that all patients with less than optimal renal function are well-hydrated
f) Encourage the patient with CKD to investigate options for early transplantation to
avoid long-term dialysis
2. Assessment

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a) Health history: complaints of anorexia, nausea, weight gain, or edema; current
treatment (if any), including type and frequency of dialysis or previous kidney
transplant; chronic diseases such as diabetes, heart failure, or kidney disease
b) Physical examination: mental status; vital signs including temperature, heart and
lung sounds, and peripheral pulses; urine output (if any); weight; skin color,
moisture, condition; presence of edema (periorbital or dependent); bowel tones;
presence and location of an AV fistula, shunt, graft, or peritoneal catheter
3. Diagnoses, outcomes, and interventions
a) Impaired kidney function
(1) Monitor intake and output, vital signs including orthostatic blood pressures, and
weight
(2) Monitor respiratory status, including lung sounds, every 4 to 8 hours
(3) Monitor BUN, serum creatinine, eGFR, pH, electrolytes, and CBC; report
significant changes
(4) Report manifestations of electrolyte imbalances
(5) Administer medications to treat electrolyte imbalances as ordered
(6) Collaborate with the patient who has diabetes to maintain the blood glucose
within a range of 90–130 mg/dL
(7) Administer antihypertensive medications as ordered
(8) Time activities and procedures to allow rest periods
b) Imbalanced nutrition: less than body requirements
(1) Monitor food and nutrient intake as well as episodes of vomiting
(2) Weigh daily before breakfast
(3) Administer antiemetic agents 30 to 60 minutes before eating
(4) Assist with mouth care prior to meals and at bedtime
(5) Serve small meals and provide between-meal snacks
(6) Arrange for a dietary consultation
(7) Monitor nutritional status by tracking weight, laboratory values such as serum
albumin and BUN, and anthropometric measurements
(8) Administer enteral or parenteral nutrition as prescribed; routinely monitor blood
glucose levels, and use strict aseptic technique when handling parenteral nutrition
solutions and the venous access site
c) Risk for infection
Page 21 of 23
(1) Use standard precautions and good hand hygiene technique at all times
(2) Monitor temperature and vital signs at least every 4 hours
(3) Monitor WBC count and differential
(4) Culture urine, peritoneal dialysis fluid, and other drainage as indicated
(5) Monitor clarity of dialysate return
(6) Provide good respiratory hygiene
(7) Restrict visits from obviously ill people; teach the patient and family about the
risk for infection and measures to reduce the spread of infection
d) Disturbed body image
(1) Involve the patient in care, including meal planning, dialysis, and catheter, port,
or incision care to the extent possible
(2) Encourage expression of feelings and concerns, accepting perceptions and
feelings without criticism
(3) Include the patient in decision making and encourage self-care
(4) Support positive gains, but do not support denial
(5) Help the patient develop and achieve realistic goals
(6) Provide positive reinforcement and feedback
(7) Reinforce effective coping strategies
(8) Facilitate contact with a support group or other community members affected by
renal failure
(9) Refer for mental health counseling as indicated or desired
G. Continuity of care
1. Nature of chronic kidney disease and renal failure, including expected progression
and effects
2. Monitoring weight, vital signs, and temperature
3. Prescribed medications, including purpose, intended effect, and potential adverse
effects and their management
4. Prescribed dietary restrictions
5. How to assess and protect a fistula or shunt for hemodialysis
6. Peritoneal catheter care and the procedure for peritoneal dialysis as indicated

Page 22 of 23
7. Following kidney transplant, prescribed medications, adverse effects and their
management, infection prevention, graft protection, and manifestations of organ
rejection
8. The benefits of, and strategies for, incorporating physical activity into daily life and
the treatment plan
X. Chapter Highlights
A. Congenital and acquired disorders of the kidneys can profoundly affect urinary
elimination and ultimately all body systems.
B. Glomerulonephritis, inflammation of the glomerulus of the kidney, leads to loss
of proteins and blood cells in the urine, a decrease in the glomerular filtration
rate, and severe edema.
C. The renal and cardiovascular systems are closely interrelated. Vascular
disorders, such as hypertension, renal artery stenosis, or obstruction of the renal
artery or vein, can have serious consequences in terms of renal function.
D. Renal cell malignancies, while uncommon, often are not evident until the cancer
is advanced and has metastasized to other sites.
E. Acute kidney injury is a frequent complication of hospitalization and critical
illness that increases mortality, length of stay, costs, and the risk for subsequent
chronic kidney disease. Nurses play a key role in preventing and recognizing
acute kidney injury, thus minimizing its negative consequences.
F. Ischemic and nephrotoxic damage to the kidney are the most common
precipitating factors for AKI.
G. Diabetes mellitus and hypertension are the leading causes of chronic kidney
disease and kidney failure. Aggressive glycemic control and blood pressure
management reduce the risk of kidney disease; likewise, early identification and
effective management of chronic kidney disease can delay the onset of kidney
failure.
H. When the kidneys fail, renal replacement therapies are necessary to eliminate
metabolic waste products and sustain life. Dialysis and kidney transplant are the
primary renal replacement therapies used.

Page 23 of 23

Nursing Care of Patients With Kidney Disorders

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Chapter 28:

Nursing Care of Patients with Kidney Disorders

©2015 by Pearson Education, Inc.

©2015 by Pearson Education, Inc.

II. The Patient with Polycystic Kidney Disease

©2015 by Pearson Education, Inc.

III. The Patient with a Glomerular Disorder

©2015 by Pearson Education, Inc.

IV. The Patient with a Vascular Kidney Disorder

©2015 by Pearson Education, Inc.

V. The Patient with Kidney Trauma

VI. The Patient with a Renal Tumor

VII. Kidney Failure

©2015 by Pearson Education, Inc.

©2015 by Pearson Education, Inc.

©2015 by Pearson Education, Inc.

IX. The Patient with Chronic Kidney Disease (CKD)

©2015 by Pearson Education, Inc.

©2015 by Pearson Education, Inc.

©2015 by Pearson Education, Inc.

©2015 by Pearson Education, Inc.

©2015 by Pearson Education, Inc.

©2015 by Pearson Education, Inc.

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