RENAL DISORDERS

DISORDERS OF THE RENAL SYSTEM

• RENAL FAILURE
• Loss of kidney function
• Types: Acute, Chronic Renal
Failure
• Prerenal
• Intrarenal
• Postrenal
Acute Renal Failure
– Sudden loss of kidney function caused by renal cell damage
from ischemia or toxic substance
– Leads to hypoperfusion, cell death and decompensation in
renal function
– Causes:
» Infection
» Renal artery occlusion
» Obstruction
» Dehydration
» Diuretic therapy
» Ischemia
» Toxic substances
– Phases:
» Oliguric Phase
» Diuretic Phase
» Recovery Phase
Chronic Renal Failure
– Progressive loss and ongoing deterioration of kidney function
– Affects all the major body system and requires dialysis or
kidney transplant
– Stages:
» Stage I – Diminished renal reserve
» Stage II – Renal Insufficiency
» Stage III – End Stage
– Causes:
» May follow Acute RF
» Renal artery occlusion
» Chronic urinary obstruction
» Recurrent infections
» Hypertension
» Diabetes Mellitus
» Autoimmune disorders
Assessment:
• Hypertension
• Confusion and lethargy followed by convulsion
and coma
• Kussmaul’s respiration
• Muscle twitching and numbness of extremities
• Decrease urine output
• Decrease specific gravity
• Proteinuria
• Anemia
• Azotemia
• Fluid overload and signs of heart failure
• Uremic frost
Interventions:
• Monitor urine and intake and outpu
• Monitor BUN, crea and electrolytes
• Monitor for acidosis
• Assess urinalysis for protein, hematuria, casts
and specific gravity
• Monitor level of consciousne
• Monitor for fluid overload
• Monitor for edema
• Administer prescribed diet
– Moderate protein, ↑ carbohyrates, ↓K+
– Restrict Na intake
• Administer Na polystyrene sulfonate
(Kayexalate) to ↓ K level
• Prepare client for dialysis
Hemodialysis
• Cleanses the blood of accumulated wastes
• Removes excess fluids
• Maintains or restores the buffer system of the
body
• Maintains or restores electrolyte levels
• Interventions:
» Monitor v/s
» Monitor laboratory values
» Assess client for fluid overload before procedure
» Assess patency of the blood access device
» Weigh the client before and after the procedure
» Hold anti-HPN and other medications that can
affect the BP before the procedure
» Monitor for shock and hypovolemia during the
procedure
» Provide adequate nutrition
Complications:
• Dysequilibrium syndrome
– rapid change in the composition of ECF than
in the brain
• Dialysis Encephalopathy
– aluminum toxicity
• Assessment:
» Nausea and vomiting
» headache
» hypertension
» restlessness and agitation
» confusion, dementia
» speech disturbance
» seizures
• Interventions:
» Monitor for signs of
disequilibrium syndrome
» Notify physician
» ↓environmental stimuli
» prepare to dialyze client for a
shorter period and ↓blood flow
rates to prevent occurrence
» administer aluminum chelating
agents
Access for Hemodialysis
Subclavian and Femoral Catheter
For short term use in Acute RF
– May be used until fistula or graft matures or when fistula or
graft access is infected or clotted
– Catheter is usually filled with heparin and capped to maintain
patency
– Femoral: Client should not sit up more than 45degrees or
lean forward
– Asses for circulation, temperature and pulses
– Prevent pulling or disconnecting of the catheter
External AV Shunt/ Graft
Surgical insertion of 2 Silastic cannulas into an artery and vein
in the forearm or leg to form an external blood path
 Advantages:
» Can be used immediately
» No venipuncture necessary
 Disadvantages:
 External danger of disconnecting
 Internal AV Fistula
» Provides the access of choice for chronic dialysis
clients
» Anastomosis of a large artery and large vein in the
arm
» Maturity takes 1-2 wks
» Advantages:
» Clotting and bleeding is less
» ↓incidence of infection
» no external dressing required
» allows freedom of movement
» Disadvantage:
» Cannot be used immediately
» needle insertion is required
» infiltration and hematomas can occur
» aneurysm can form
» arterial steal syndrome
» CHF can occur
PERITONEAL DIALYSIS
A. ACCESS FOR PERITONEAL DIALYSIS
– Surgical insertion of a siliconized rubber catheter into
the abdominal cavity
– Preferred insertion site is 3-5 cm below the umbilicus
B. Types of Peritoneal Dialysis
 Continuous ambulatory peritoneal dialysis
(CAPD)
» Client performs self dialysis 24 hrs/day, 7 days a
week
» 4 cycles in 24hrs including 8 hr dwell time overnight
» 1 ½ or 2 liters of dialysate are instilled in the
abdomen 4x daily and allowed to dwell as
prescribed
» After dwell, the bag is placed lower than the
insertion site so that fluid drains by gravity flow.
• Interventions Before Treatment:
» Monitor v/s
» Obtain weight
» have client void
» assess electrolyte and glucose level
• Interventions During Treatment:
» Monitor v/s
» monitor for respiratory distress, pain or discomfort
» monitor for signs of pulmonary edema
» Monitor for hypotension and hypertension
» Monitor for malaise, nausea and vomiting
» assess the catheter site dressing for wetness or bleeding
» monitor dwell time and initiate outflow
» do not allow dwell time to extend
» turn patient from side to side if outflow is slow to start
» monitor outflow (continuous stream, color and clarity)
» monitor intake and output accurately
COMPLICATIONS OF PERITONEAL DIALYSIS

 Peritonitis
» Maintain sterile technique
» Monitor temperature
» Monitor for fever, cloudy outflow and rebound
abdominal tenderness
» (+) Peritonitis: Obtain culture of the outflow
» Administer antibiotics
 Abdominal Pain
» Pain during inflow is common during the 1st few
exchanges
» Dialysate should be warmed before use
» Place a heating pad on the abdomen during the
inflow
 Insufficient Flow
» May be caused by catheter migration out of the
peritoneal area
» May be caused by a full colon
» Maintain drainage below the clients abdomen
» Change outflow position by turning the patient on
his/her side
» Check for kinks in the tubing
» Encourage ↑ fiber diet
» Administer stool softeners
 Leakage around the Catheter site
 Characteristic of Outflow:
» 1st initial exchanges may be bloody; outflow
should be clear and colorless thereafter
» Brown: Bowel perforation
» Same color are urine: Bladder perforation
» Cloudy: Peritonitis
UREMIC SYNDROME
• Accumulation of nitrogenous waste products in the
blood
• Assessment:
• Oliguria
• Proteinuria, hematuria and casts in the urine
• ↑urea, uric acid, K and Mg in urine
• Hypotension or HPN
• Altered level of consciousness
• Interventions:
• Monitor v/s
• Monitor electrolyte values
• Monitor intake and output
• Low protein diet
CYSTITIS/ UTI
– inflammation of the bladder from infection or obstruction of urethra
– Common causative organism: E. coli
– More common in women
– Causes:
– Allergens or irritants
– Calculu
– Indwelling urethral catheter
– Sexual intercourse
– Synthetic underwear
– Urinary stasis
– Assessment:
– Frequency and urgency
– Burning on urination
– Incomplete emptying of the bladder
– Lower abdominal discomfort or back discomfort
– Cloudy, dark, foul smelling urine
– Hematuria
– Malaise, chills, fever
– Nausea and vomiting
• Interventions:
• Obtain urine specimen for culture and sensitivity
• ↑fld intake to 3000ml/da
• Maintain an acid urine
• Use strict aseptic technique when inserting a
urinary catheter
• Provide meticulous perineal care
• Provide heat to the abdomen or sitz bath
• Instruct client to take medications as prescribed
• Teach preventive measures
– Wipe perineal area from front to back
– Void every 2-3 hrs
– Void and drink a glass of water after intercourse
– Wear cotton pants and avoid wearing tight clothes or
pantyhose
URETHRITIS
– Inflammation of urethra commonly associated with STD
– Men: Caused by gonorrhea or Chlamydia
– Women: Caused by hygienic sprays, perfumed toilet paper or
sanitary napkins, UTI’s
– Assessment:
» Burning on urination
» Frequency
» Urgency
» Nocturia
» Dysuria
» Penile discharge
» Lower abdominal discomfort
– Interventions:
» Encourage to ↑ fluid intake
» Prepare the client for STD test
» Administer antibiotics
» Administer sitz bath
» Instruct client to avoid intercourse until symptoms subside
or until treatment of STD is complete
» Avoid use of perfumed toilet paper or sanitary napkins
URETERITIS AND PYELONEPHRITIS
• Ureteritis
– Inflammation of ureter commonly associated with
pyelonephritis
• Pyelonephritis
– Acute – occurs after bacterial contamination of urethra or
following an invasive procedure of urinary tract
• Assessment:
» Fever, chills
» flank pain
» costovertebral angle tenderne
» dysuria
» frequency and urgency
» cloudy, bloody or foul smelling urine
» ↑WBC in urine
• Chronic - Slow, progressive disorder associated
with recurrent acute attacks
– Can lead to renal failure
– Assessment:
» Pyuria
» azotemia
» proteinuria
» anemia
– Interventions:
» ↑fluid up to 3000ml/day
» ↑calorie, ↓protein diet
» warm, moist compress to flank area
» administer analgesics, antipyretics,
antibiotics, anti-emetics
GLOMERULONEPHRITIS
• Commonly caused by immunologic reaction
• Proliferative and inflammatory changes within
the glomerulus
• Causes:
» Immunologic or autoimmune diseases
» Streptococcal infection, group A B-hemolytic
» History of pharyngitis, or tonsillitis 2-3 wks before
symptoms appear
• Types:
» Acute GN – occurs 2-3 wks after streptococcal
infection
» Chronic GN – can occur after acute phase
• Complications:
– Heart failure
– Pulmonary edema
– Renal failure

• Assessment
– Gross hematuria
– Dark, smoky, cola-colored urine
– Proteinuria
– Moderately ↑ specific gravity
– ↓urine pH
– Oliguria or anur
– Facial, ankle edema or anasarca
– Shortness of breath, ascites, pleural effusion and CHF
– HPN
– ↑BUN, creatinine
– ↑ASO titer
• Interventions
– Monitor intake and output
– Monitor daily weight
– Monitor for edema
– Monitor for fluid overload
– Restrict sodium and fluid intake
– Provide ↑calories and ↓protein diet
– Provide bed rest
– Instruct client to obtain treatment for infections
– Administer diuretics, anti-HPN and antibiotics
– Monitor for signs of renal failure, cardiac failure
– Instruct client to report signs of bloody urine, headache
and edema
NEPHROTIC SYNDROME
• Set of clinical manifestations arising from protein wasting caused
by diffuse glomerular damage
• Assessment:
• Proteinuria
• Hypoalbuminemia
• Edema
• Hyperlipidemia
• Anemia
• Hematuria
• Interventions:
• Monitor intake and output
• Normal to low protein diet
• Monitor daily weight
• Mild Na restriction
• Administer diuretics
• Administer corticosteroids and cytotoxic medications
• Administer plasma volume expanders
• Administer anti-coagulants
HYDRONEPHROSIS
• Distention of renal pelvis and calices caused by obstruction of
normal urine flow
• Causes:
– Calculus, Tumor, Scar tissue
– Ureter obstruction, Hypertrophy of prostate
• Assessment:
• HPN
• Flank pain
• Electrolyte imbalance
• Interventions:
• Monitor v/s
• Monitor fluid and electrolyte imbalance
• Monitor weight daily
• Monitor for urine specific gravity, albumin and glucose
• Administer fluid replacement
POLYCYSTIC KIDNEY DISEASE
• Cystic formation and hypertrophy of kidneys, which leads to cystic
rupture, infection and formation of scar tissue and damaged nephrons
• Types:
• Infantile
• Adult
• Assessment:
• Flank, lumbar or abdominal pai
• UTI
• Hematuria, proteinuria and pyruria
• Calculuses
• HPN
• Palpable abdominal masses and enlarged kidneys
• Interventions
• Monitor for gross hematuria
• Increase fluid intak
• Prepare client for percutaneous cyst puncture
• Administer anti-HPN
• Prepare for dialysis or renal transplant
UROLITHIASIS AND NEPHROLITHIASIS

– Urolithiasis – urinary stones formed in the ureters

– Nephrolithiasis – formation of stones in the renal
parenchyma
– Urinary stasis result in infection, impairment of renal
function and results to hydronephrosis and
irreversible kidney damage
– Causes:
– Family history
– Diet ↑ in Ca, Vit D, milk, protein, prunes or alkali
– Dehydration
– Use of diuretics
– UTI and prolonged catheterization
– Immobilization
– Hypercalcemia and hyperparathyroidism
– Gout
• Assessment:
• Renal colic
• Ureteral colic
• Nausea and vomiting, pallor and diaphoresis during acute pain
• Urinary frequency with retention
• Signs of UTI
• Low grade fever
• ↑RBC, WBC and bacteria in urinalysis
• Interventions:
• Assess for fever, chills, infection
• ↑fluid intake up to 3000ml/day
• Strain all urine for presence of stones
• Send stones to the lab for analysis
• Provide warm baths and heat to flank area
• Administer analgesics
• Administer IVF
• Prepare client for surgery
• Special diet:
– Alkaline ash diet  ↓acidity of urine (fruits, milk, most
vegetables, small amount of beef and salmon
– Acid ash diet  makes urine more acidic (bread
cereal, whole grains, cheese, eggs, corn, legumes,
cranberries, prunes, tomatoes, meat, fish, oysters)
• Stone Composition:
• Ca Phosphate – acid ash food
• Ca oxalate – acid ash food
• Struvite stones – acid ash food
• Uric acid stones – alkaline ash diet and ↓purine sources
• Cystine stones – alkaline ash diet
• Surgical Management for Kidney Stones:
– Cystoscopy
– Extracorporeal Shock Wave Lithotripsy
– Percutaneous Lithotripsy
BENIGH PROSTATIC HYPERTROPHY OR
HYPERPLASIA (BPH)

• Assessment:
• Urgency, frequency and hesitancy
• Change in size and force of urine stream
• Urinary retention
• Dribbling
• Nocturia
• Hematuria
• Urinary stasis
• Recurrent UTI
• Interventions:
• ↑fluid intake
• Prepare for bladder drainage via urinary catheterization
• Avoid medications that causes urinary retention
• Administer Finasteride (Proscar)
• Prepare client for surgery
• Surgical Intervention:
– Transurethral Resection of the Prostate (TURP)
» Insertion of a scope into the urethra to excise prostatic
tissue
» Continuous bladder irrigation (CBI) is prescribed post-op
» Sterility may or may not occur
– Suprapubic Prostatectomy
» Removal of the prostate gland by an abdominal incision
with a bladder incision
» Change dressing frequent
» CBI is prescribed to keep the urine pink
» Sterility occurs
– Retropubic Prostatectomy
• Removal of the prostate by a low abdominal incision without
opening the bladder
– Perineal Prostatectomy
• Prostate gland is removed through an incision between the
scrotum and anus
EPISPADIAS AND HYPOSPADIAS

• Assessment:
• Epispadias – urethral orifice located on the dorsal surface
of the penis
• Hypospadias – urethral orifice located below the glans
penis along the ventral surface
• Surgical Intervention:
• Done before the age of toilet training (16-18 mos)
• Child should not be circumcised
• Interventions: Post-op
• (+) Pressure dressing and may have urinary diversion or a
urinary sten
• ↑fluid int
• Administer pain medications
• Administer antibiotics