Download Renal - Faculty Sites

MCC NURSING
Diana Blum MSN
• Play role in:
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Maintaining fluid balance
Maintaining acid/base balance
Producing erythropoiten
Secreting renin
• Renin angiotensin cycle
• Activating vitamin D
• Regulating ADH
• Eliminating metabolic wastes
Congenital: Polycystic Kidney Disease
• Medical treatment
• Supportive treatment is recommended to preserve kidney function, treat
UTI, and control hypertension
• Infections treated promptly with antibiotics
• Dialysis, nephrectomy, and transplantation once end-stage renal disease
develops
• Inflammation of the renal pelvis
• Acute pyelonephritis most often caused by ascending
bacterial infection, but it may be blood borne
• Chronic pyelonephritis often the result of reflux of urine from
inadequate closure of the ureterovesical junction during
voiding
• Medical treatment
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Antibiotics, urinary tract antiseptics, analgesics, and antispasmodics
Drink at least eight 8-ounce glasses of fluids daily
Intravenous fluids may be ordered if nausea and vomiting
Dietary salt and protein restriction for patient with chronic disease
• Patho
• Complications of UTI; tissue necrosis leads to scarring—wall off infection
• Strept is usual cause
s/s
fever, flank pain, dysuria
• Interventions
• antibiotics
• Patho
• Spread by hematogenesis route from pulmonary disease
• Usually bilateral
s/s
few, males more than females; dormant for years; pain in pelvis
Interventions
INH
• Pathophysiology
• Immunologic disease: inflammation of the capillary loops in the
glomeruli
• Signs and symptoms
• Urine becomes tea colored as output decreases
• Peripheral and periorbital edema
• As glomerular filtration decreases, mild to severe hypertension occurs
and hypervolemia results
• Medical diagnosis
• Patient assessment and laboratory tests
• Urinalysis, BUN, creatinine, and albumin
• Renal ultrasound, renal biopsy, or both
• Assessment
• Signs and symptoms, recent infections, and changes in urine
• Nursing Diagnosis
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Excess Fluid Volume
Activity Intolerance
Self-Care Deficit
Anxiety
• Patho
• Rapid, causes damage to small structures that filter waste
• s/s
• Edema, blood in urine, abd pain, joint pain
Interventions
corticosteroids, plasmaphoresis, watch for kidney failure
• Patho
• Due to repeated episodes of acute glomerulonephritis,
hyperlipidemia, hypertensive nephrosclerosis and chronic
tubulointerstitial injury
• s/s
• Progressive; acute nosebleed, stroke or seizure; malnourished,
edema, diminished DTR, mucous membranes pale, gallop
rhythm, distended neck veins
• Interventions
• Fluid and electrolyte imbalance (labs);emotional support;
anxiety high; teaching client about treatment plan and need
for follow up.
• Patho
• Cluster of findings: Increase protein, decrease albumin, edema, high serum
cholesterol; serious damage to the glomerular capillary membrane; occurs
with intrinsic renal disease; disorder of childhood; caused by DM, lupus,
Multiple myeloma
• s/s
• Edema: periorbital, lower extremity, abdomen (ascites); patients have
irritability, HA and malaise
• Interventions
• Early stages: similar to acute glomerulonephritis
• Late stages: Chronic Renal Failure
• Patho:
• Malignant: associated with malignant hypertension
• Young adults, men>women; progress is rapid
• Benign: associated with atherosclerosis and hypertension
• Older adults
• s/s
• Rare early in the disease; renal insufficiency occurs late in the disease
• Interventions
• Aggressive antihypertensives; ACE inhibitors
• Patho
• 3-16% of arteries become blocked and shrinkage of the
kidney occurs leading to HTN and reduced blood flow
causing release of excess renin and reinitiates the cycle.
• s/s
• HTN above 180/100 and resistent to 2 or more meds
• Interventions
• Lipid management, Smoking cessation, antiplatelet therapy,
weight reduction, ACE-I,
• Endovascular therapy (stents)
• Monitor VS, monitor insertion site, etc.
• Patho
• Characterized by a period of hyperfiltrationand increased GFR to
proteinuria and decreased GFR with increase in creatinine
• s/s
• Asymptomatic, found on routine lab screen with microalbuminuria,
BP starts increasing, neurogenic bladder, infection,
• Interventions
• ACE-I/ARB, monitor BP, monitor UO, monitor Lab values, dialysis,
transplant, monitor Wt, Monitor A1C, Sodium Restriction
• Early symptoms:
• anemia, weakness, and weight loss; painless, gross hematuria classic sign,
but usually occurs in the advanced stage. A dull ache in the flank area
also is a late symptom
• Medical diagnosis
• Excretory urography, IVP, retrograde pyelography, ultrasound,
arteriography, computed tomography, magnetic resonance imaging, and
renal biopsy
• Medical treatment
• Radical nephrectomy
• In general, renal tumors are not responsive to radiation or chemotherapy;
radiation is sometimes used as a palliative measure for inoperable cancer
• Biotherapy with alpha-interferon and interleukin-2 for metastatic disease
• Nursing Diagnoses
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Acute Pain
Risk for Deficient Fluid Volume
Ineffective Breathing Pattern
Risk for Injury
Risk for Infection
Ineffective Coping
Deficient Knowledge
• Causes
• Prerenal failure: decreased blood flow to glomeruli
• Intrarenal failure: nephrotoxic agents, kidney infections, occlusion of
intrarenal arteries, hypertension, diabetes mellitus, or direct trauma to
the kidney
• Postrenal failure: obstructions beyond the kidneys that cause urine to
back up
• Onset stage
• Short (1-3 days); increasing BUN and serum creatinine with normal to
decreased urine output
• Oliguric stage
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The urine output decreases to 400 mL/day or less
Serum values for BUN, creatinine, potassium, and phosphorus increase
Serum calcium and bicarbonate decrease
Follows onset stage and continues for up to 14 days
• Diuretic stage
• Urine output exceeds 400 mL/day; may rise above
4 L/day
• Kidneys excrete BUN, creatinine, potassium, and phosphorus and
retain calcium and bicarbonate
• Recovery stage
• As renal tissue recovers, serum electrolytes, BUN, and creatinine return
to normal
• This stage lasts 1 to 12 months
• Medical treatment
• Fluid and dietary restrictions, restoration of electrolyte balance, and
dialysis
• Drug therapy
• Diet
• Fluids
• Hemodialysis and peritoneal dialysis
• Continuous renal replacement therapy
• ARF:
• Hypovolemia; hypotension; reduced cardiac output; obstruction of the
kidney; obstruction of the renal arteries or veins
• CRF:
• DM; hypertension;polycystic kidney disease, vascular disorders, infections,
meds, environmental agents (lead, mercury, chromium)
• Progressive nephron destruction of both kidneys
• Creatinine clearance: important measure of renal function
• <15 mL/min, dialysis or transplantation necessary
• Uremia: when kidneys unable to maintain fluid and electrolyte
or acid-base balance
• Also called end-stage renal disease
• Causes: hypertension, diabetes mellitus, and atherosclerosis
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Azotemia
Hyperkalemia
Hypocalcemia
Metabolic acidosis
Fluid balance (hypernatremia and
hypervolemia)
Insulin resistance
Anemia
Suppressed immunologic function
Cardiovascular system (CHF and
dysrhythmias)
• Neurologic system (mental
status changes)
• Integumentary system
(accumulation of waste
products)
• GI system (irritation, nausea,
vomiting, a metallic taste in the
mouth, and bleeding)
• Musculoskeletal system (renal
osteodystrophy)
• Reproductive system (sex
hormones decline and libido is
diminished)
• Endocrine function
(hyperparathyroidism)
• Emotional and psychological
effects
• IV glucose and insulin, calcium carbonate, calcium acetate, or sodium
polystyrene sulfonate to treat hyperkalemia
• Calcium, active vitamin D, and phosphate binders to treat hypocalcemia
• Fluid restriction and diuretics to treat hypervolemia
• Diuretics, beta blockers, calcium channel blockers, and ACE inhibitors for
hypertension
• Iron supplements, folic acid, and synthetic erythropoietin to treat anemia
• Hypertonic glucose to treat disequilibrium syndrome
• High-carbohydrate, low-protein diet to prevent excess urea
Hemodialysis
Blood is removed and circulated through an “artificial kidney” to remove
excess fluid, electrolytes, wastes
Dialyzed blood then returned to the patient
Requires vascular access
By catheter, cannula, graft, or fistula
Subclavian or femoral catheters for temporary access for dialysis during
acute renal failure while a graft or fistula matures (dilates and toughens) or
for patients on peritoneal dialysis who need immediate access for
hemodialysis
• Arteriovenous fistula: is formed by creating a surgical incision
and anastomosing a vein and an artery usually in the forearm
• Arteriovenous graft: a Gortex tube is surgically implanted into
to the forearm with the vein and artery
• Hemodialysis (during and post care)
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Aseptic technique
Do not cannulate new sites
Watch for pseudoaneurysms
Do not obtain blood pressure/ iv access on AV fistula site
Teach client how to develop fistula thru exercise like squeezing a ball
Monitor weight and vitals
Monitor meds and diet before and after
Monitor labs before
• Peritoneal dialysis
• Uses the patient’s own peritoneum as a semipermeable dialyzing
membrane
• Fluid instilled into peritoneal cavity
• Waste products drawn into the fluid, which is then drained from the
peritoneal cavity
• May be temporary or permanent
• Temporary: catheter inserted into the peritoneal cavity through the
abdominal wall
• Long-term: catheter is implanted into the peritoneal cavity
• Assessment
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Frequent monitoring for changes important
Fluid balance evaluated closely
Accurate intake and output records
Signs and symptoms of fluid volume excess that can lead to cardiac
failure: increasing edema, dyspnea, tachycardia, bounding pulse, rising
blood pressure
• Signs and symptoms of electrolyte imbalances
• Appetite, usual daily intake, weight gain or loss pattern, and prescribed
diet
• Kidney donation
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Healthy kidney from live donor (a relative) or cadaver
Tissues must match or recipient will reject new kidney
Matching based on ABO blood groups and human leukocyte antigens
Crossmatching reveals any cytotoxic preformed antibodies—would
certainly result in organ rejection
• Kidney donors must be at least 18 years of age, free of systemic
disease or infection, have no history of cancer or renal disease, have
normal renal function, and be without major medical problems
• Preoperative nursing care
• Patient must be prepared mentally and physically
• Recipient and live donor have complete diagnostic workups to rule out
other medical problems and evaluate function of the urinary tract
• Recipient given medications to bring blood pressure within normal limits
• Immunosuppressants: to control the body’s response to foreign tissue
• Postoperative nursing care
• Assessment
• Fluid intake, urine output, weight changes, and vital signs
• Interventions
• Impaired Urinary Elimination
• Deficient Fluid Volume
• Risk for Infection
• Ineffective Management of Therapeutic Regimen
• Anxiety
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Physical care of the donor similar to that for a nephrectomy
Nephrectomy may be conventional or laparoscopic
Pain worse with conventional approach; provide good pain control
Conventional approach: patient hospitalized 4 to 7 days and return to
work in 6 to 8 weeks
• Laparoscopic approach: donor hospitalized 2 to 4 days and can return to
work in 4 to 6 weeks
• Donor usually feels good about the experience
• If kidney fails, donor may be disappointed; be sensitive