Interventions for Clients with Renal Disorders

Pyelonephritis  Bacterial infection in the kidney (upper urinary tract)  Key features include:  Fever, chills, tachycardia, and tachypnea  Flank, back, or loin pain  Abdominal discomfort  Turning, nausea and vomiting, urgency, frequency, nocturia  General malaise or fatigue

Key Features of Chronic Pyelonephritis  Hypertension  Inability to conserve sodium  Decreased concentrating ability  Tendency to develop hyperkalemia and acidosis

Acute Pain Interventions  Pain management interventions  Lithotripsy  Percutaneous ultrasonic pyelolithotomy  Diet therapy  Drug therapy  Antibiotics  Urinary antiseptics

Surgical Management  Preoperative care  Antibiotics  Client education  Operative procedure: pyelolithotomy, nephrectomy, ureteral diversion, ureter reimplantaton  Postoperative care for urologic surgery

Potential for Renal Failure  Interventions include:  Use of specific antibiotics  Compliance with therapies and regular follow-up  Blood pressure control  Fluid therapy  Diet therapy  Other interventions

Potential for Renal Failure  Interventions include:  Use of specific antibiotics  Compliance with therapies and regular follow-up  Blood pressure control  Fluid therapy  Diet therapy  Other interventions

Renal Abscess  A collection of fluid and cells caused by an inflammatory response to bacteria  Manifestations: fever, flank pain, general malaise  Drainage by surgical incision or needle aspiration  Broad-spectrum antibiotics

Renal Tuberculosis  Diagnosis  Antitubercular therapy with rifampin, isoniazid, and pyrazinamide  Complications renal failure, kidney stones, obstruction, and bacterial superinfection of the urinary tract  Surgical excision possible

Acute Glomerulonephritis  Assessment  Management of infection  Prevention of complications  Diuretics  Sodium, water, potassium, and protein restrictions  Dialysis, plasmapheresis  Client education

Chronic Glomerulonephritis  Develops over a period of 20 to 30 years or longer  Assessment  Interventions include:  Slowing the progression of the disease and preventing complications  Diet changes (Continued)

Chronic Glomerulonephritis (Continued)  Fluid intake  Drug therapy  Dialysis, transplantation

Nephrotic Syndrome  Condition of increased glomerular permeability that allows larger molecules to pass through the membrane into the urine and be removed from the blood  Severe loss of protein into the urine (Continued)

Nephrotic Syndrome (Continued  Treatment involves:  Immunosuppressive agents  Angiotensin-converting enzyme inhibitors  Heparin  Diet changes  Mild diuretics

Nephrosclerosis  Thickening in the nephron blood vessels, resulting in narrowing of the vessel lumen  Occurs with all types of hypertension, atherosclerois, and diabetes mellitus  Collaborative management: control high blood pressure and preserve renal function

Renovascular Disease  Profoundly reduces blood flow to the kidney tissue  Causes ischemia and atrophy of renal tissue  Diagnosis  Interventions: drugs to control high blood pressure and procedures to restore the renal blood supply

Diabetic Nephropathy  Diabetic nephrophathy is a microvascular complication of either type 1 or type 2 diabetes.  First manifestation is persistent albuminuria.  Avoid nephrotoxic agents and dehydration.  Assess need for insulin.

Cysts and Benign Tumors  Thorough evaluation for cancer is needed.  Cyst can fill with fluid and cause local tissue damage as it enlarges.  Many cysts cause no symptoms.  Cysts are a structural birth defect that occur in fetal life.  Simple renal cysts are drained by percutaneous aspiration.

Renal Cell Carcinoma  Paraneoplastic syndromes include anemia, erythrocytosis, hypercalcemia, liver dysfunction, hormonal effects, increased sedimentation rate, and hypertension. (Continued)

Renal Cell Carcinoma (Continued)  Nonsurgical management includes:  Radiofrequency ablation, although effect is not known  Chemotherapy: limited effect  Biological response modifiers and tumor necrosis factor: lengthen survival time

Surgical Management  Preoperative care  Operative procedure  Postoperative care: monitoring, pain management, and prevention of complications

Renal Trauma  Minor injuries such as contusions, small lacerations  Major injuries such as lacerations to the cortex, medulla, or branches of the renal artery  Collaborative management  Nonsurgical management: drug therapy and fluid therapy  Surgical management: nephrectomy or partial nephrectomy

Polycystic Kidney Disease  Inherited disorder in which fluid-filled cysts develop in the nephrons  Key features include:  Abdominal or flank pain  Hypertension  Nocturia  Increased abdominal girth

Polycystic Kidney Disease (Continued)  Constipation  Bloody or cloudy urine  Kidney stones

Interventions  Pain management  Bowel management  Medication management  Energy management  Fluid monitoring  Urinary retention care  Infection protection

Interventions/Complicatio ns  Acute and chronic pain  Constipation  Hypertension and renal failure  Nursing interventions to promote self- management and understanding  Fluid therapy  Drug therapy  Measure and record blood pressure  Diet therapy

Hydronephrosis, Hydroureter, and Urethral Stricture  Provide privacy for elimination.  Conduct Credé maneuver as necessary.  Apply double-voiding technique.  Apply urinary catheter as appropriate.  Monitor degree of bladder distention. (Continued

Hydronephrosis, Hydroureter, and Urethral Stricture (Continued)  Catheterize for residual.  Intermittently catheterize as appropriate.  Follow infection protection measures.

Nephrostomy  Client preparation  Procedure  Follow-up care including:  Assess for  amount of drainage.  type of urinary damage expected.  manifestations of infection.  Monitor nephrostomy site for leaking urine.

Interventions for Clients with Acute and Chronic Renal Failure

Acute Renal Failure  Pathophysiology  Types of acute renal failure include:  Prerenal  Intrarenal  Postrenal

Phases of Acute Renal Failure  Phases of rapid decrease in renal function lead to the collection of metabolic wastes in the body.  Phases include:  Onset  Diuretic  Oliguric  Recovery  Acute syndrome may be reversible with prompt intervention.

Assessment  History  Clinical manifestations  Laboratory assessment  Radiographic assessment  Other diagnostic assessments such as renal biopsy

Drug Therapy  Cardioglycides  Vitamins and minerals  Biologic response modifiers  Phosphate binders  Stool softeners and laxatives  Monitor fluids  Diuretics  Calcium channel blockers

Treatment  Diet therapy  Dialysis therapies  Hemodialysis  Peritoneal dialysis

Continuous Renal Replacement Therapy  Standard treatment  Dialysate solution  Vascular access  Continuous arteriovenous hemofiltration  Continuous venovenous hemofiltration

Posthospital Care  If renal failure is resolving, follow-up care may be required.  There may be permanent renal damage and the need for chronic dialysis or even transplantation.  Temporary dialysis is appropriate for some clients.

Chronic Renal Failure  Progressive, irreversible kidney injury; kidney function does not recover  Azotemia  Uremia  Uremic syndrome

Stages of Chronic Renal Failure  Diminished renal reserve  Renal insufficiency  End-stage renal disease

Stages of Chronic Renal Failure Changes KidneyKidney MetabolicMetabolic –Urea and creatinine ElectrolytesElectrolytes – Sodium – Potassium Acid-base balanceAcid-base balance Calcium and phosphorusCalcium and phosphorus

Stages of Chronic Renal Failure Changes (Continued) CardiacCardiac – Hypertension – Hyperlipidemia – Congestive heart failure – Uremic pericarditis HematologicHematologic GastrointestinalGastrointestinal

Clinical Manifestations  Neurologic  Cardiovascular  Respiratory  Hematologic  Gastrointestinal  Urinary  Skin

Hemodialysis  Client selection  Dialysis settings  Works using passive transfer of toxins by diffusion  Anticoagulation needed, usually heparin treatment

Hemodialysis Nursing Care  Postdialysis care:  Monitor for complications such as hypotension, headache, nausea, malaise, vomiting, dizziness, and muscle cramps.  Monitor vital signs and weight.  Avoid invasive procedures 4 to 6 hours after dialysis.  Continually monitor for hemorrhage

Complications of Hemodialysis  Dialysis disequilibrium syndrome  Infectious diseases  Hepatitis B and C infections  HIV exposure—poses some risk for clients undergoing dialysis

Peritoneal Dialysis  Procedure involves siliconized rubber catheter placed into the abdominal cavity for infusion of dialysate.  Types of peritoneal dialysis:  Continuous ambulatory peritoneal  Automated peritoneal  Intermittent peritoneal  Continuous-cycle peritoneal

Complications  Peritonitis  Pain  Exit site and tunnel infections  Poor dialysate flow  Dialysate leakage  Other complications

Nursing Care During Peritoneal Dialysis  Before treating, evaluate baseline vital signs, weight, and laboratory tests.  Continually monitor the client for respiratory distress, pain, and discomfort.  Monitor prescribed dwell time and initiate outflow.  Observe the outflow amount and pattern of fluid.

Renal Transplantation  Candidate selection criteria  Donors  Preoperative care  Immunologic studies  Surgical team  Operative procedure

Postoperative Care  Urologic management  Assessment of urine output hourly for 48 hours.  Complications include:  Rejection  Acute tubular necrosis

Postoperative Care  Thrombosis  Renal artery stenosis  Other complications  Immunosuppressive drug therapy  Psychosocial preparation