Download Elimination needs, renal disorders

NUR240
Urinary Tract Stressors:
UTI
Cystitis
Urolithiasis
Bladder Ca
PKD
ARF/CRF
Joy Borrero, RN, MSN
11/09
Kidney Physiology
Primary role of kidney is regulation of fluid and
electrolyte balance, additional life preserving
functions include:
• Excretion of metabolic wastes-micturition
• Water and salt regulation
• Maintenance of acid – base
balance.http://www.kidney.org/
• Regulation of BP
• Stimulation of RBC production
• Regulation of calcium – phosphate metabolism.
Urinary Tract
• Upper urinary tract:
• Kidneys – 2 bean shaped organs,
composed of nephrons. A complex
vascular system. Each weighs about 8oz.
• Ureters – extensions of the renal pelvis
and empty into the bladder.
• Lower urinary tract:
• Bladder, urethra and prostate gland
(males).
Renal and Urinary Terms
Azotem ia
Uremia
Dysuria
Frequency
Hesitency
Micturation
Nocturia
Oliguria
Polyuria
Uremia
Urgency
Anuria
Serum
creatinine
Blood urea
nitrogen
BUN/Creatinin Glomerular
e Ratio
Filtration
Rate
Assessment of Renal and Urinary
Tract Systems
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History of disease or trauma
Urinary patterns
Relevant meds
Allergies
Fluid status-edema
Pruritis
BP
LOC, level of alertness
Pain assessment
Numbness and tingling of extremities
GI symptoms- anorexia, N&V, diarrhea
Urinary Tract Pain
• Kidney- dull ache in costovertebral angle
and radiates to umbilicus
• Ureteral – pain in back that radiates to
abdomen, upper thigh, testes and labia
• Bladder- low abdominal or over
suprapubic area
• Renal Colic- flank pain radiating to lower
abdomen or epigastric area, N&V
Diagnostic Tests
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IVP
CAT Scans
Renal angiography
Ultrasounds
Cystoscopy- Dx and
Tx
• Renal BxOpen/Closed
• UA, urine electrolytes,
osmolality
• C&S
• Serum creatinine and
BUN
• Hgb and Hct
• Creatinine clearance- 24h
collection
• KUB
Cystoscopy
Pre procedure: bowel prep, NPO if general
anesthesia, IVF for adequate urine flow
Post procedure: BR for short period
Pink tinged urine is comon, retention may
occur
Pain in back, bladder spasms and a feeling
of fullness
Encourage large amts of fluids
Urinary tract infections-described
by location in the tract
• UTI – dysuria, frequency, urgency
• Assessment – flank pain, cloudy urine, possible
fever. WBC’s in urine.
• Treatment with antibiotics:
Fluoroquinolones(Cipro), nitrofurantoin(Macrobid),
Sulfonamides (Septra, Bactrim)
• Prevention: void before and after sex.
• Wipe front to back, showers better than baths.
• No perfumes to perineal area.
• Avoid sitting in wet bathing suits
• Avoid pantyhose with slacks or tight clothing
UTI-Lower and Upper
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Risk Factors:
Aging
Increased incidence with DM
Increased risk of urinary stasis
Impaired immune response
Females: short urethra, cystocele, rectocele
Males: BPH
Obstructions: tumor, calculi, strictures
EBP- UTI Bundles
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Assess daily for need for catheter
Foley bag below level of bladder
Closed system
Secure cath to prevent movement, tugging
Use of smallest size catheter possible
Cystitis
• Most common UTI (superficial, bladder
mucosa)
• Manifestations:dysuria, frequency,
urgency, nocturia, foul odor urine,
hematuria
• Older patients:nocturia, incontinence,
confusion, behavioral changes, lethargy,
anorexia, fever or hypothermia
Dx for cystitis
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UA
Urine for Gram Stain
Urine for C & S
Evaluation of urinary tract
Interventions
Uncomplicated:
1. Single dose regimen
2. Antispasmodics
Recurrent or chronic
1. Sulfonamides
2. Antiseptics
3. Analgesics
4. Surgical Management
Management of Cystitis
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Increase fluid intake
Acidify urine
Ascorbic acid
Avoid bladder irritants
Antibiotics based on C&S
Patient teaching
Upper Urinary Tract Infections
• Pyelonephritis: inflammation of kidney
caused by bacterial infection following a
bladder infection
• Infection begins in lower urinary tract with
organisms ascending into renal pelvis
• E coli causes most cases of pyelonephritis
• Affects filtration,reabsorption and secretion
= decrease in renal function
Risk Factors
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Women over age 65
Older men with prostate problems
Chronic urinary stone disorder
Spinal cord injury
Pregnancy
Congenital malformations
Bladder tumors
Chronic illness: HTN, DM, chronic cystitis
Recurrence is common
Physical Assessment
• Patient presents with acute distress
• Hx of dysuria, frequency, urgency and
other signs of cystitis
• Costovertebral tenderness
• Fever, chills, nausea and flank pain
• N & V, malaise, fatigue
• Cloudy urine or hematuria
Diagnostic Assessment
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UA and C&S
WBC with diff
Blood Cultures
Serum creatinine and BUN
CRP-C-reactive protein
ESR
KUB, IVP
Nursing Interventions
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Pain management
Antibiotic therapy
Increase fluid intake
Monitor temperature
Provide emotional support
Assist with personal hygiene
Follow-up urine cultures
Assess for Complications
• Septic shock
• Renal Failure
• Hypertension
Urolithiasis
• Etiology- presence of calculi (stones) in the
urinary tract, by an unknown cause
• Recurrence is increased 35-50% in pt with +
family hx or if first stone occurs <25 yrs of age
• Increased incidence in males
• Majority of stones (75%) are composed of Ca
oxalate or Ca phosphate
• Hi doses of Vitamin C
• Conditions causing urinary stasis, dehydration,
urinary retention
Physical Assessment
• Pain, obstruction, tissue trauma with secondary
hemorrhage and infection
• Sharp, severe pain (renal colic) with sudden
onset deep in lumbar region around to side
• N&V
• Urinary frequency or dysuria
• Pallor, diaphoresis
• VS:
• Oliguria, anuria, hematuria
Diagnostic Assessment
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UA-RBCs, WBCs, bacteria, turbidity,odor
Serum Ca, PO4, Uric Acid levels
Elevated serum WBC if infection is present
KUB, IVP, Xrays, Ultrasound
Non-surgical Management
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Pain management- MSO4, NSAIDS
Antispasmotics-Ditropan, Pro-Banthine
Antiemetics- Zofran
Strain all urine- send stones for analysis
Increase fluid intake to 3000mL/day
Client education re: meds/diet
Methods of Stone Removal
• Stenting
• ESWL- Extracorporeal Shock Wave
Lithotripsy
• Retrograde ureteroscopy/cystoscopy
• Percutaneous or open
ureterolithotomy/pyelolithotomy/nephrolith
otomy
Urinary Drainage Tubes
Ureteral Stents
• Maintain ureteral flow in pts with ureteral
obstruction
• Divert urine
• Promote healing of ureter
• Maintain patency of ureter after sugery
• Temporary or permanent-inserted via
nephrostomy tube, cystoscopy or open sx.
Nephrostomy Tubes
• Catheter is placed into renal pelvis for urine
drainage (placed in flank area)
• Relieve obstruction, route for insertion of
ureteral stent
• Drainage for when ureter doesn’t drain
• Administer meds, biopsy
• Never clamp a nephrostomy tube-can lead to
pyelonephritis
• Never irrigate without specific order
• Monitor urine output
Nursing Interventions in client
education
• Restrictions based on stone analysis
• Ca Phosphate- Limit foods high in animal
protein, limit Na and Ca intake
• HCTZ- to increase Ca reabsorption
• Ca Oxalate- Limit oxalate sources: spinach,
black tea, cocoa, beets, pecans, limit Na intake
• Uric Acid: Limit foods high in purines: organ
meats, poultry, fish, gravies, red wine and
sardines. Allopurinol (Zyloprim)
Assess for Complications
• Hydronephrosis
• Infection
• Ureteral obstruction
Bladder Cancer
• Etiology: about 54,000 new cases yearly,
more common in >age 60
• Industrial exposure
• Long term use of Cyclophosphamide
(Cytoxan) and Aziothioprine (Imuran)
• Tobacco use
• Secondary to mets
Diagnostic Assessment
• Urinalysis-presence of gross or
microscopic hematuria
• Cystoscopy-Bladder-wash specimens and
bladder biopsy
• CT scans and MRI –to assess for mets
Physical Assessment
• Painless hematuria- major sign
• Assess general health, exposure to
cigarette smoke, harmful environmental
agents
• Changes is urinary habits
Nonsurgical Interventions
• Intravesical immunotherapy- instillation
into the bladder
Bacille Calmette-Guerin (BCG)
• Intravesical chemotherapy-mitomycin
(Mutamycin), Doxorubicin (Adriamycin)
• Complications: bladder irritation,
frequency, dysuria, contact dermatitis
• Systemic chemotherapy
Surgical Interventions
• Radiation used to reduce tumor size preop
• Cystoscopic tumor resection by excision,
fulguration, laser photocoagulation
• TURBT- Transuretheral Resection of
Bladder Tumor
• Simple or radical cystectomy-urinary
diversion necessary (ileal conduit)
Methods of Urinary Diversion After
Cystectomy
Urinary Diversion- divert urine away from
kidney and leaves body via another route
1.Continent urinary diversion- ureters
implanted into portion( pouch) of ileum
(reservoir) for urine, stoma to abdomen
2.Incontinent diversions: ileal conduit
3.Uretersigmoidostomy
4. Bladder reconstruction, neobladder
Post-op Care
• Routine post op care including pain
management
• Disturbed body image
• Risk for impaired skin integrity
• Assess urinary drainage
• Sexual dysfunction
• Pt and family education re: meds, fluids, care of
urinary diversion system
• Referral to www.acs.org and local support
groups
PKD
Polycystic Kidney Disease
• Congenital disorder-grapelike clusters of
cysts in the nephrons, progressive
• Affects 250,00-500,000 people in the US
• Men=Women
• S&S: abdominal or flank pain, HTN,
nocturia, Increased abdominal girth,
constipation, bloody or cloudy urine,
kidney stones
• Renal insufficiency and CRF by age 50-60
Diagnostic Assessment
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UA-proteinuria, hematuria
Urine C&S
Rising BUN and Creatinine levels
Decreased creatinine clearance
Renal sonograms,CT and MRI
Interventions
• Mainly supportive- prevent renal damage from
HTN, UTI, obstruction
• Pain management-caution with NSAIDS and
ASA
• Antibiotic tx for UTIs
• Constipation prevention
• HTN control- ACE inhibitors
• Diet management- Low NA, protein
• Emotional support
Acute and Chronic Renal
Failure
Acute renal failure (ARF)
Three causes of ARF:
• 1. Prerenal
• 2. Intrarenal (intrinsic)
• 3. Postrenal
1.Prerenal- conditions that cause decreased
cardiac output: shock, CHF, pulmonary
embolism, sepsis,
anaphylaxis,hypotension
ARF
2. Intrarenal - caused by damage to renal
tissue.
• Causes –
glomeruonephritis,infection,drugs
pyelonephritis, vasculitis, acute tubular
necrosis (ATN), tumors
3. Postrenal- obstructions of outflow of urine:
calculi, tumors, atony of bladder, urethral
stricture, trauma
4 Phases of ARF
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Onset
Oliguric
Diuretic
Recovery
1.Onset
ARF
Oliguric phase – urinary output decreased.
Renal insult,gradual accumulation of
nitrogenous wastes (BUN and creatinine),
can last hrs to 3 weeks.
• Increasing BUN, hyperkalemia, metabolic
acidosis, hypocalcemia, hypermagnesemia,
hyperphosphatemia.
• As plasma levels of nitrogenous wastes
increase changes in:
• Oxygenation, metabolism, immune response,
perception and coordination result.
ARF
3.Diuretic phase – high output phase, up to
10L/day. This phases lasts 1 – 2 weeks.
4.Recovery phase – begins when BUN stabilizes
at normal, client begins to return to normal
activities.
• The mortality rate for ARF- greater than 50%
and for those requiring dialysis, between 60 90%
• Prerenal is the most common cause and is
usually reversible with prompt interventions
ARF
• Lab findings
• Drug therapy –
prerenal – fluid
challenges and
diuretics used to
promote perfusion.
• Oliguric phase –
dopamine- small
dose, continuous
renal perfusion.
Test
Normal
Range
Serum
Creatinine
0.61.2mg/dL
Serum
BUN
1020mg/dL
24hr Urine
Creatinine
Clearance
80140mL/min
ARF
• Diet – high calorie diet needed for
catabolic state, if client cannot eat enough,
then TPN is considered.
• During the oliguric phase of ARF, the
following diagnoses may apply :
• High risk for fluid volume excess
• High risk for injury
• High risk for altered nutrition.
ARF- Physical Assessment
1.Prerenal – hypotension, tachycardia,
decreased cardiac output and CVP,
decreased urine output and lethargy.
2. Intrarenal and postrenal-:
• Renal – oliguria or anuria
• Cardiac- hypertension, tachycardia, JVD,
increased CVP, peripheral edema,
efffusions,
ARF- Assessment
• Respiratory – SOB, orthopnea, crackles,
pulmonary edema.
• GI – anorexia, nausea, vomiting, flank
pain,metallic taste, gastritis
• Neuro- lethargy, headache, tremors,
confusion, insomnia, seizures
• Hematology-anemia, bruising
• Weight gain. 1kg=approx 1L fluid retained
Management and Prognosis of
ARF
• Tx precipitating cause
• Fluid restriction (500-600mL) plus fluid
loss
• Nutritional management
• Measures to lower serum K
• Phosphate binding agents
• TPN or enteral nutrition
• Initiation of dialysis is necessary
Nursing Management &
Interventions
1. Fluid volume deficit r/t…
2. Fluid volume excess r/t…
3. Nutrition: Less than body requirements
r/t
4, Impaired gas exchange r/t…
5. PC: Hyperkalemia r/t….
6. PC Metabolic acidosis r/t…
7. PC Decreased Calcium r/t…
• The patient is a 64-year-old man. He visits the primary care provider
because of mild lower abdominal pain, decreased urine output, and
increased shortness of breath. He is 5 feet, 8 inches tall and weighs 246
pounds. The only drugs he takes include a daily multivitamin, a beta
blocker, and occasionally acetaminophen for headache. His past medical
history includes kidney stones 1 year ago and mild hypertension over the
past 5 years. Physical assessment reveals bilateral crackles in the lung
bases. Vital signs are T, 98.8 F; P, 96/min, R, 28/min, and BP, 148/92.
• 1. For which type(s) of acute renal failure is he at risk? Why?
• 2. Do any of his usual drugs increase his risk for ARF? Which one(s) and
why?
• 3. Is there any specific assessment data you could obtain without a
prescription to evaluate his risk for acute renal failure? If so, which ones
and why?
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• The physician prescribes these interventions:
• IV placement with a 20-gauge cannula, NS at 20 mL/hr
• Accurate intake and output
• Ibuprofen 600 mg orally
• Furosemide 40 mg IV
Chronic renal failure (CRF)
• CRF is a chronic,progressive, irreversible
disease, leading to end stage renal disease
• Five stages:
• Stage 1- diminished renal reserve, increased
BP, increased pressure on glomerular
apparatus, decreased ability to concentrate
urine- nocturia and polyuria.
• Stage 2 – Renal Insufficiency- metabolic wastes
begin to accumulate
CRF
• Stage 3- End stage renal disease,
excessive amounts urea and creatinine in
blood.
• Treatment by dialysis is necessary.
• Sodium:
• Early in CRF – hyponatremia, polyuria
causes sodium depletion.
• Later, ESRD – sodium retention – but
dilutional hyponatremia (masked by fluid
volume excess).
CRF
• Potassium – hyperkalemia – 7 -8 meq/L,
ECG changes and fatal dysrhythmias.
• Acid – base balance: Acid excretion (H
ions)- restricted results in metabolic
acidosis. Kussmaul respirations.
• Calcium and phosphate – demineralization.
• Uremic pruritis- toxic accumulation of
nitrogenous wastes.
CRF- Affects all body systems
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Cardiac Alterations
Hypertension
CHF and LV hypertrophy
Uremic Pericarditis
Hematologic Alterations
GI alterations
MS
Neuro
Dermatological
Endocrine
Goals of Therapy
• Retain kidney function and maintain
homeostasis as long as possible
• Improve nutrition
• Monitor electrolytes
• Manage anemia
• Control HTN
• Maintain glycemic control
• Emotional support
ESKD Concept Map
Risk for
Injury
Risk for
Infection
Fatigue
ESKD
Imbalance
Nutrition
Anxiety
Fluid
Volume
Excess
Decreased
Cardiac
Output
CRF
• Common Nursing diagnoses:
• 1. Altered nutrition less than body
requirements r/t nausea, vomiting,
decreased appetite, effects of catabolic
state, decreased LOC, altered taste, or
dietary restrictions.
CRF- Interventions
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Dietary restrictions: limit protein intake
Limitation of fluid intake
Restriction of K, NA, phosphorous
Administration of Vitamins and minerals
Adequate calories to meet metabolic
demands
• Collaborate with MD and dietician
CRF
• Fluid volume excess r/t inability of kidney
to maintain body fluid balance.
• Interventions: Fluid restriction depends on– Urinary output
– Based on fluid wt. gain
– With hemodialysis, 500 -700 ml/day plus
amount of urinary output.
Nursing Diagnoses
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Impaired skin integrity
Risk for injury
Activity intolerance
Constipation
Diarrhea
Anticipatory Grieving
CRF- Drug Therapy
Cardiac glycosides: digoxin
• Monitor for signs and symptoms of toxicity
and hypokalemia
Vitamins and minerals- FeSo4 and Folic
Acid
Erythropoietin- Epogen, Procrit
Phosphate Binders- Renagel, Tums
Stool Softeners- Colace
Assessment for patients with CRF
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Assess CV and respiratory systems:
VS, especially BP, heart sounds
Chest pain?, Edema?, JVD?
Dyspnea?, Crackles?
Assess nutritional status- Protein, fluid, K,
Na, P restrictions
• Weight gain or loss
• Anorexia, nausea, vomiting
Assessment
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Assess renal statusAmount, frequency and appearance urine
Bone Pain?
Hyperglycemia-stress need for control
Assess hematologic status, including_
Petichiae, purpura, ecchymosis?
Fatigue?, SOB?
Assessment
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Assess GI statusStomatitis
Melena
Assess neurological statusChange in mental status?
Seizure activity?
Sensory changes?, Lower ext. weakness?
Assessment
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Assess Integumentary systemSkin integrity
Discoloration?
Pruritis?
Assess lab data, including:
BUN, creatinine, creatinine clearance,
CBC, electrolytes.
Assessment
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Assess psychosocial status, includingAnxiety?
Maladaptive behavior
Refer to a community resource group
Interventions to Manage ESRD
Peritoneal Dialysis and Hemodialysis
Functions:
1. Rid the body of excess fluids and
electrolytes
2. Achieve acid-base balance
3. Eliminate waste products, toxins
4. Restore internal fluid balance through
osmosis, diffusion and ultrafiltration
Concepts of Dialysis
• Dialysate: solution of electrolytes,modified
salt, acetate, glucose and heparin
• Dialyzer- Artificial kidney with a
semipermeable membrane (Hemodialysis)
or the peritoneum as a semipermeable
membrane (Peritoneal Dialysis)
• Diffusion• Osmosis-
Peritoneal Dialysis
• May be hemodynamically unstable, can’t tolerate
anticoagulation.
• Peritonitis is a major complication.
• Procedure- surgically inserted tube into abdominal
cavity- infusion of dialysate.
ONE EXCHANGE:
Fill time: Infuse 1-2 liters by gravity over 20 min.
Dwell time: Dialysate dwells in abdomen over
specified period of time.
Drain Time- 10-15 min. Output usually 100-200mL.
input
PD
• Fluid then drains out by gravity.
• This effluent contains dialysate, excess
water, electrolytes and nitrogenous
wastes.
• The number and frequency of exchanges
depend on client’s condition and lab data.
• Types of PD – Continuous ambulatory PD
(CAPD), multiple bag CAPD, automated or
continuous cycle.
PD- Complications
Peritonitis, manifested by:
• Cloudy outflow (effluent)
• Rebound abdominal tenderness
• Abdominal pain
• General malaise
• Nausea, vomiting
• Intervention – send C and S, Tx. with
appropriate Antibiotic.
PD- Complications
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Pain – pain initially
Exit site and tunnel infection
Insufficient flow of dialysate
Dialysate leakage.Dyspnea
Formation of fibrin clots
Altered body image
Care of the Tenckhoff Catheter
• Mask for yourself and client
• Put on clean gloves. Remove the old dressing,
remove contaminated gloves.
• Assess area for signs of infection, swelling,
redness, or discharge around catheter site.
• Use aseptic technique:
• Sterile field, 2 4x4”s, cotton swabs soaked in
providone iodine, put on sterile gloves.
• Use cotton swabs to clean around catheter site,
in a circular motion.
• Apply pre-cut gauze pads over catheter site.
• Tape edges of gauze pads.
Care of patient during PD
• Before treatment – monitor vitals, weight,
lab values.
• During dialysis – continually monitor pt.,
VS taken regularly, assess for pain,
assess catheter site for leaking.. Monitor
dwell time, and document.
• Record amount outflow, note clarity of
effluent, I and O.
Hemodialysis
http://kidney.niddk.nih.gov/kudiseases/pub/
• Vascular access – AV fistula,anastomosis of an
artery and a vein or AV shunt
• Temporary double lumen catheter in subclavian,
IJ or femoral vein
• Pre-dialysis Interventions• Assess patency – bruit, thrill,distal pulses
• Common complications of access• Thrombosis or stenosis, infection, aneurysm
formation, ischemia, bleeding
• Determime if meds should be held
Post Dialysis Nursing Care
Assess for Complications:
• Hypotension
• Headache
• Nausea, vomiting
• Malaise
• Dizziness
• Muscle cramps
• Monitor BUN/Creat/Lytes/Hct
• LOC
• Bleeding
HD
• Heparinization – used for dialysis:
• All invasive procedure avoided 4-6 hrs.
after dialysis.
• Nurse monitors for signs of hemorrhage
during dialysis and 1 hr. after.
• Complications – Disequilibrium syndrome
• Infectious diseases – can be transmitted,
hepatitis and HIV
HD
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Nursing Care- Get report.
Weigh client before and after dialysis
Know the client’s dry weight
Measure vitals, observe for bleeding
Assess LOC, HA?, nausea? Vomiting?
Renal Transplantation
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Candidates must be:
Free from medical problems
Usually age 40 – 70 years old.
Candidates excluded:
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Active infection
IV drug abuse
Malignant neoplasm
Severe obesity
Acute vascultitis
Severe psych problems
Long standing pulmonary disease
Advanced cardiac disease
Renal Transplantation
Donors- Absence of systemic disease/ infection
No history of cancer
Absence hypertension and renal disease
Adequate renal function – diagnostic tests.
Renal Transplantation
• Complications• Rejection- immunosuppressive drug
therapy, corticosteroids.
• Renal artery stenosis – HTN, bruit,
decreased renal function.
• Post – op care- Monitor vitals, renal
function, I and O, urine output, color.
• Diuretics may be ordered.
Renal Transplantation
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Daily weights
Carefully monitor I and O.
Monitor for electrolyte imbalances.
Patient teaching for discharge regarding:
meds, diet, wound care,signs of infection
and rejection, and follow up care with
PMD.
Review of Terminology
Acute Renal Failure
• Usually temporary
and may be reversed,
leaving no permanent
or serious damage to
kidneys
• Sudden loss of the
ability of the kidneys
to excrete wastes,
concentrate urine and
conserve electrolytes
Chronic Renal Failure
• Long term and
irreversible
• Usually occurs over a
number of years as
the internal structures
of the kidney are
slowly damaged