1. Care of Patients with Renal Disorders
Chapter 70
External surface (A) and internal surface (B) of a polycystic kidney.
Care of Patients with Renal Disorders

2. Polycystic Kidney Disease (PKD)
Inherited disorder; fluid-filled cysts develop in nephrons
Symptoms:
Abdominal or flank pain
Hypertension
Nocturia
Increased abdominal girth
Constipation
Bloody or cloudy urine
Kidney stones

3. Assessment Patient history Physical assessment/clinical manifestations
Psychosocial assessment
What is the impact of this disease, as an inherited disorder?
Diagnostic assessment

4. Interventions Acute and chronic pain Constipation
Hypertension and renal failure

5. Hydronephrosis, Hydroureter, urethral Strictures
Problems of urine outflow obstruction
Hydronephrosis is caused by obstruction in the upper part of the ureter. Hydroureter is caused by obstruction in the lower part of the ureter.

6. Interventions
Urologic
Radiologic

7. Pyelonephritis
Bacterial infection in kidney and renal pelvis (upper urinary tract)
Acute symptoms:
Fever, chills, tachycardia, tachypnea
Flank, back, or loin pain
Abdominal discomfort
Turning, nausea and vomiting, urgency, frequency, nocturia
General malaise or fatigue

8. Chronic Pyelonephritis
Hypertension
Inability to conserve sodium
Decreased concentrating ability
Development of hyperkalemia and acidosis

9. Concept Map Manifestations Preventative measures Treatment
Priority collaboration
Assessment of treatment (for efficacy)
Teaching needs

10. Glomerulonephritis
An immune complex precipitating in the glomerulus of a patient with glomerulonephritis.

11. Acute Glomerulonephritis
Patient assessment
Connection with sore throat?
Proteinuria
Physical assessment
Clinical manifestations
Laboratory assessment
Other diagnostic tests

12. Collaborative Care Management of infection Prevention of complications
Dialysis
Plasmapheresis
Patient education

13. Chronic Glomerulonephritis
Develops over period of 20 to 30 years or longer
Assessment
Interventions:
Slowing progression, preventing complications
Diet changes
Fluid intake
Drug therapy
Dialysis, transplantation

14. Nephrotic Syndrome
Condition of increased glomerular permeability; allows larger molecules to pass through the membrane into urine and be excreted
Severe loss of protein into urine, edema formation, and decreased plasma albumin levels

15. Nephrotic Syndrome Treatment: Immunosuppressive agents ACE inhibitors
Heparin
Diet changes
Mild diuretics

16. Nephrosclerosis
Thickening in nephron blood vessels; results in narrowing of vessel lumen
Occurs with all types of hypertension, atherosclerosis, diabetes mellitus
Collaborative management—control high blood pressure, preserve kidney function

17. Renovascular disease
Processes affecting renal arteries; may severely narrow lumen, greatly reduce blood flow to kidneys
Assessment
Priority goals for care
Interventions

18. Diabetic nephropathy
Microvascular complication of type 1 or type 2 diabetes
First manifestation: persistent albuminuria
Priority goals in prevention of ESKD

19. Renal cell carcinoma Adenocarcinoma of kidney
Paraneoplastic syndromes:
Anemia
Erythrocytosis
Hypercalcemia
Liver dysfunction
Increased sedimentation rate
Hypertension

20. assessment Patient history Physical assessment/clinical manifestations
Diagnostic assessment
Nonsurgical management
Surgical management
“Cues” for readiness for teaching

21. Kidney trauma Minor injuries—contusions, small lacerations
Major injuries—lacerations to cortex, medulla, or branches of renal artery
Collaborative management
Nonsurgical management—drug therapy, fluid therapy
Surgical management—nephrectomy or partial nephrectomy

22. Kidney trauma
Common types and locations of kidney trauma.

23. Case Study
A 35-year-old patient is admitted to the ED with fever, chills, and severe right flank pain. His heart rate is 112/min and respiration rate is 32/min. He was recently treated for a urinary tract infection. Assessment reveals tenderness of the right costovertebral angle (CVA).
What diagnosis does the nurse expect?
What laboratory tests does the nurse anticipate?
Acute pyelonephritis.
Urinalysis – positive leukocyte esterase and nitrite dipstick test, presence of WBCs and bacteria; urine C&S; blood cultures; C-reactive protein; erythrocyte sedimentation rate.

24. Case Study
The patient is diagnosed with possible acute pyelonephritis and is admitted to the acute medical unit.
What is the nurse’s priority concern on admission?
Potential for infection
Acute pain
Activity intolerance
Insufficient knowledge
ANS: B
The primary problem for this patient is acute pain.

25. Case Study
Which orders and interventions should be implemented for the priority patient problem on admission to the unit? (Select all that apply.)
Administer analgesics as ordered.
Assess patient pain level often.
Send a daily urinalysis to the laboratory.
Administer nitrofurantoin (Macrodantin) 50 mg with meals and at bedtime.
Encourage 2 to 3 L of fluid intake per day.
ANS: A, B, D, E
Daily urinalysis is not necessary. The major patient concern with acute pyelonephritis is acute pain. Pain should be assessed regularly and analgesics administered. Nitrofurantoin is a urinary antiseptic drug that can also help with comfort. Adequate fluid intake of 2 to 3 L per day is essential.

26. Case Study
Which imaging test would the nurse expect to be ordered for this patient?
Abdominal CT scan
Thoracic MRI
Abdominal x-ray
IV urography
ANS: D
IV urography or x-ray of the kidneys, ureters, and bladder (KUB) is performed to diagnose stones or obstructions.

27. Case Study
Two days later during morning assessment, the patient expresses embarrassment about his illness. He says that he did not take all of the antibiotics prescribed to treat his UTI 2 weeks ago.
What is the nurse’s best response?
“You should always take antibiotics as prescribed.”
“Do you realize that when you don’t take your antibiotics, superbugs can develop?”
“Why did you choose not to take all of your medication?”
“Can you tell me more about why you didn’t take all of your antibiotics?”
ANS: D
Response D is non-judgmental, and encourages the patient to open up and share more. This response may also offer an opportunity for patient teaching. Responses A and B are true, but will not help relieve the patient’s embarrassment. Response C is somewhat judgmental.

28. Audience Response System Questions
Chapter 70
Audience Response System Questions 28

29. Question 1
The older adult patient with acute glomerulonephritis is often misdiagnosed with:
Cerebrovascular accident
Transient ischemic attack
Aortic aneurysm
Congestive heart failure
Answer: D
Rationale: The less common manifestation of acute glomerulonephritis is more likely to occur in older adults. Circulatory congestion often dominates the patient’s clinical picture. Acute glomerulonephritis is easily confused with congestive heart failure.

30. Question 2
Which assessment parameter requires immediate attention in a patient with polycystic kidney disease?
Fever
Hypertension
Tachycardia
Urine output less than 30 cc/hour
Answer: B
Rationale: Patients with polycystic kidney disease often have high blood pressure. The cause of hypertension is related to kidney ischemia from the enlarging cysts. As the vessels are compressed and blood flow to the kidneys decreases, the renin-angiotensin system is activated, raising blood pressure. Control of hypertension is a top priority because proper treatment can disrupt the process that leads to further kidney damage.

31. Question 3
What percentage of patients with end-stage kidney disease treated by dialysis or kidney transplant have diabetes mellitus?
12%
28%
44%
57%
Answer: C
Rationale: Diabetes is the most common cause of kidney failure, accounting for nearly 44% of new cases.
(Source: Accessed August 15, 2011, from