Chapter 54 Management of Patients With Kidney Disorders

Kidney Disorders Fluid and electrolyte imbalances Most accurate indicator of fluid loss or gain, in an acutely ill patient, is weight Refer to Table 54-1

Question Is the following statement true or false? The most accurate indicator of fluid loss or gain in an acutely ill patient is weight.

Answer True The most accurate indicator of fluid loss or gain in an acutely ill patient is weight. An accurate daily weight must be obtained and recorded. A 1-kg weight gain is equal to 1000 mL of retained fluid.

Causes of Acute Kidney Failure Hypovolemia Hypotension Reduced cardiac output and heart failure Obstruction of the kidney or lower urinary tract Obstruction of renal arteries or veins

Causes of Chronic Kidney Failure Diabetes mellitus Hypertension Chronic glomerulonephritis Pyelonephritis or other infections Obstruction of urinary tract Hereditary lesions Vascular disorders Medications or toxic agents

Glomerular Diseases Inflammation of the glomerular capillaries Acute nephritic syndrome Chronic glomerulonephritis Nephrotic syndrome

Acute Nephritic Syndrome A type of renal failure with glomerular inflammation Postinfectious glomerulonephritis, rapidly progressive glomerulonephritis, and membranous glomerulonephritis Manifestations include hematuria, edema, azotemia (abnormal nitrogenous wastes), proteinuria, and hypertension May be mild or may progress to acute renal failure or death Medical management includes supportive care and dietary modifications; treat cause if appropriate— antibiotics, corticosteroids, and immunosuppressants

Nursing Management: Acute Nephritic Syndrome Patient assessment Maintain fluid balance Fluid and dietary restrictions Patient education Follow-up care

Chronic Glomerulonephritis Inflammation of the glomerular capillaries Repeated acute glomerular nephritis, hypertensive nephrosclerosis, hyperlipidemia, and other causes of glomerular damage Renal insufficiency or failure: asymptomatic for years as glomerular damage increases before signs and symptoms develop Abnormal laboratory test results: urine with fixed specific gravity, casts, proteinuria, electrolyte imbalances and hypoalbuminemia Medical management determined by symptoms

Nursing Process Assessment Potential fluid and electrolyte imbalances Cardiac status Neurologic status Emotional support Education in self-care

Nephrotic Syndrome Type of renal failure with increased glomerular permeability and massive proteinuria Any condition that seriously damages the glomerular membrane and results in increased permeability to plasma proteins Results in hypoalbuminemia and edema Causes include chronic glomerulonephritis, diabetes mellitus with intercapillary glomerulosclerosis, amyloidosis (proteins that form in tissues and organs), lupus erythematosus, multiple myeloma, and renal vein thrombosis Medical management includes drug and dietary therapy

Kidney Failure Results when the kidneys cannot remove wastes or perform regulatory functions A systemic disorder that results from many different causes Acute renal failure is a reversible syndrome that results in decreased glomerular filtration rate and oliguria Chronic renal failure (ESRD) is a progressive, irreversible deterioration of renal function that results in azotemia

Nursing Process: The Care of Patients With Chronic Kidney Disease and Acute Kidney Injury—Assessment Fluid status Nutritional status Patient knowledge Activity tolerance Self-esteem Potential complications

Nursing Process: The Care of Patients With Chronic Kidney Disease and Acute Kidney Injury—Diagnosis Excess fluid volume Imbalanced nutrition Deficient knowledge Risk for situational low self-esteem

Collaborative Problems and Complications Hyperkalemia Pericarditis Pericardial effusion Pericardial tamponade (pressure on heart from fluid buildup around the heart) Hypertension Anemia Bone disease and metastatic calcifications

Nursing Process: The Care of Patients With Chronic Kidney Disease and Acute Kidney Injury—Planning Goals may include maintaining of IBW (ideal body weight) without excess fluid, maintenance of adequate nutritional intake, increased knowledge, participation of activity within tolerance improved self-esteem, and absence of complications.

Excess Fluid Volume Assess for s/s of fluid volume excess, keep accurate I&O, and daily weights Limit fluid to prescribe amounts Identify sources of fluid Explain to patient and family the rationale for fluid restrictions Assist patient to cope with the fluid restrictions Provide or encourage frequent oral hygiene

Imbalanced Nutrition: Assessment Nutritional status; weight changes, laboratory data Nutritional patterns, history, preferences Provide food preferences within restrictions Encourage high-quality nutritional foods while maintaining nutritional restrictions Stomatitis or anorexia: modify intake related to factors that contribute to alterations Adjust medication times related to meals

Risk for Situational Low Self-Esteem Assess patient and family responses to illness and treatment Assess relationships and coping patterns Encourage open discussion about changes and concerns Explore alternate ways of sexual expression Discuss role of giving and receiving love, warmth, and affection

Hemodialysis System

Hemodialysis Catheter

Internal Arteriovenous Fistula and Graft

Peritoneal Dialysis

Peritoneal Dialysis

Question Is the following statement true or false? Failure of the temporary dialysis access accounts for most hospital admissions of patients undergoing chronic hemodialysis.

Answer False Failure of the permanent dialysis access accounts for most hospital admissions of patients undergoing chronic hemodialysis.

Nursing Process: The Care of the Hospitalized Patient on Dialysis—Assessment Protect vascular access; assess site for patency, signs of potential infection, do not use for blood pressure or blood draws Carefully monitor fluid balance, IV therapy, accurate I&O, IV administration pump s/s of uremia and electrolyte imbalance, regularly check lab data Monitor cardiac/respiratory status carefully Cardiovascular medications must be held prior to dialysis

Nursing Process: The Care of the Hospitalized Patient on Dialysis—Interventions Monitor all medications and medication dosages carefully Address pain and discomfort Stringent infection control measures Dietary considerations: sodium, potassium, protein, fluid, individual nutritional needs Skin care: pruritus, keep skin clean and well moisturized, trim nails, and avoid scratching CAPD catheter care

Kidney Surgery Preoperative considerations Perioperative concerns Postoperative management Potential hemorrhage and shock Potential abdominal distention and paralytic ileus (obstruction of intestine caused by paralysis of part of intestinal muscles, aka pseudo-obstruction) Potential infection Potential thromboembolism

Positioning and Incisional Approaches

Kidney Transplantation

Postoperative Nursing Management Assessment: include all body systems, pain, fluid and electrolyte status, and patency and adequacy of urinary drainage system Diagnoses: ineffective airway clearance, ineffective breathing pattern, acute pain, fear and anxiety, impaired urinary elimination, and risk for fluid imbalance Complications: bleeding , pneumonia, infection, and DVT

Postoperative Interventions Pain relief measures, analgesic medications Promote airway clearance and effective breathing pattern, turn, cough, deep breathe, incentive spirometry, positioning Monitor UO and maintain patency of urinary drainage systems Use strict asepsis with catheter Monitor for signs and symptoms of bleeding Encourage leg exercises, early ambulation, and monitor for signs of DVT

Patient Education Instruct both patient and family Drainage system care Strategies to prevent complications Signs and symptoms Follow-up care Fluid intake Health promotion and health screening