chronic kidney disease (CKD)

have decreased glomerular filtration, resulting in retention of fluid, potassium, and phosphorus. Fluid
retention is initially treated with sodium restriction and diuretic therapy. Dietary adjustments should also
be made to reduce serum potassium and phosphorus.
contain high potassium levels: Dairy products (eg, milk, yogurt) and certain fruits (eg, bananas, oranges,
coconuts, watermelons, and avocados)
Dairy products also contain high phosphorus levels.
Examples of allowable foods for CKD clients include apples, pears, grapes, pineapple, blackberries,
blueberries, and plums.
dietary restrictions. These include the following:
1. Sodium restriction involves avoiding high-sodium foods such as cured meats, pickled foods,
canned soups, frankfurters, cold cuts, soy sauce, and salad dressings
2. Fluid intake must be monitored accurately and often is restricted
3. Potassium restrictions will vary depending on kidney function. Raw carrots, tomatoes, and
orange juice are high-potassium foods that clients with advanced kidney disease or on
hemodialysis should avoid.
4. Low-protein diet (0.6–0.8 g/kg/day) helps prevent kidney disease progression. If the client is
already on dialysis, liberal protein intake is recommended to prevent malnutrition.
Because renal damage often results in elevated blood pressure, clients with CKD are at risk
for uncontrolled hypertension and hypertensive emergencies.
Hypertensive encephalopathy is a type of hypertensive crisis characterized by nausea, vomiting,
and headache. Treatment is urgent (ie, within 1 hour) to prevent damage to the heart, kidney, and brain.
The client should check blood pressure at home, if possible, and then proceed to the emergency
department for further assessment and treatment (eg, titration of antihypertensive medication).
*Hypertension, elevated serum creatinine level (normal: 0.6-1.3 mg/dL [53-115 µmol/L]), nausea
associated with azotemia, and pruritus associated with dry skin are expected for chronic kidney disease
clients

Potassium chloride (KCL)

An electrolyte replacement to correct hypokalemia, is a high-alert drug that is never administered by the
IV push, intramuscular, or subcutaneous routes. The recommended peripheral infusion rate is 5-10
mEq/hr. However, the nurse should always follow institution IV guidelines and policy and procedure for
administering KCL.
The nurse's priority action is to slow the infusion rate if the client feels a burning discomfort at the IV site
shortly after initiation of the infusion. KCL irritates the vein, and irritation and discomfort at the site is
expected. Slowing the infusion rate is effective in alleviating discomfort.
KCL in concentrations 20-40 mEq/100 mL at a maximum rate of 40 mEq/hr should be administered
through a central venous access device (CVAD) (eg, PICC, centrally inserted catheter) to prevent
postinfusion phlebitis.
Assess the site at least every hour for adverse reactions (eg, redness, pain, swelling, phlebitis, thrombosis,
extravasation or infiltration), and stops the infusion if any occur.

Severe hyperkalemia (potassium >7.0 mEq/L)

Requires urgent treatment because cardiac muscle cannot tolerate very high potassium levels. Severe
hyperkalemia increases the risk for life-threatening ventricular dysrhythmias (eg, ventricular tachycardia
and fibrillation, asystole).
Administration of IV 50% dextrose and regular insulin rapidly corrects an elevated serum potassium level
by shifting potassium intracellularly. The insulin temporarily shifts the potassium from the extracellular
fluid back into the intracellular fluid. The dextrose prevents hypoglycemia associated with the increase of
insulin in the body and can be eliminated if the client has hyperglycemia. If the client has ECG changes
(peaked T waves) from hyperkalemia, calcium gluconate should be given first to stabilize cardiac muscle.
Oxybutynin (Ditropan)
An anticholinergic medication that is frequently used to treat overactive bladder. Common side effects
include: New-onset constipation, Dry mouth, Flushing, Heat intolerance, Blurred vision & Drowsiness.
Clients should be taught to prevent these side effects by increasing intake of fluids and bulk-forming
foods (prevents dry mouth and constipation) and by avoiding locations or activities that may lead to
hyperthermia.

Saw palmetto
A herbal preparation, is often used to treat benign prostatic hyperplasia. St John's wort has been used for
centuries to treat depression.

SIA
a surgical connection of an artery to a vein created to provide vascular access for hemodialysis therapy in
clients with kidney disease. Maturing of the fistula is aided by having the client perform hand exercises,
such as squeezing a rubber ball, that increase blood flow through the vein. After the AVF is placed, it
takes 2-4 months for it to mature to accommodate the repeated venipunctures necessary for
hemodialysis access.
A palpable thrill (vibration) over the fistula or an auscultated bruit (blowing or swooshing sound caused
by turbulent blood flow) indicates a patent fistula. Absence of the thrill or bruit can indicate potential clot
formation in the fistula. Client reports of numbness or tingling as well as decreased capillary refill can
also signal potential clotting.

Stress incontinence
The highest priority for a client newly diagnosed with stress incontinence is preventing skin breakdown
and urinary tract infections through bladder training. Teaching the client to empty the bladder every 2
hours when awake and every 4 hours at night reduces these risks
Pelvic floor exercises (eg, Kegel exercises), which strengthen the sphincter and structural supports of the
bladder, are an essential part of the teaching plan but it will take approximately 6 weeks for pelvic floor
muscle strength to improve.
Natural bladder irritants (eg, smoking, caffeine, alcohol) increase incontinence and should be eliminated.

Dialysis treatment
Prior, the nurse should assess the client's fluid status (weight, blood pressure, peripheral edema, lung and
heart sounds), vascular access (arteriovenous fistula, arteriovenous grafts), and vital signs. The amount of
fluid removed (ultrafiltration) is determined by calculating the difference between the last post-dialysis
weight and the client's current pre-dialysis weight.
After the client is connected to the dialysis machine, IV heparin is added to the blood from the client to
prevent clotting that can occur when blood contacts a foreign substance. Giving subcutaneous heparin
prior to initiation is not necessary.
Many medications that are taken once daily can be held until after the dialysis treatment to prevent their
removal. If blood pressure medications are given prior to dialysis, the client can develop hypotension
during the dialysis and then uncontrolled hypertension (decreased drug concentrations).
A thrill can be felt when palpating the fistula, and a bruit can be heard during auscultation when the
fistula is functioning properly.
Risks include medication removal, hemodialysis access dysfunction, hypotension, and fluid and
electrolyte imbalances.

Dialysis disequilibrium syndrome (DDS)

rare but potentially life-threatening complication that can occur in clients during the initial stages of
hemodialysis (HD); it can be prevented by slowing the rate of dialysis.
Associated with cerebral edema. Characteristic neurologic manifestations include nausea and vomiting,
headache, restlessness, change in mentation, and seizure activity. If DDS is suspected, the health care
provider should be contacted immediately and dialysis should be slowed or stopped.

Metabolic acidosis
Is due to an increase in the production or retention of acid (eg, lactic acidosis, ketoacidosis, renal failure)
or the depletion of bicarbonate (HCO3-) via the kidneys or gastrointestinal tract. In metabolic acidosis,
there is a decrease in pH (<7.35) and HCO3- (<22 mEq).
Acidosis damages cells, causing them to release intracellular contents (eg,
potassium). Hyperkalemia (potassium >5.0 mEq/L) frequently occurs with acidosis, putting the client at
risk for cardiac arrhythmias.
Depending on the cause and severity of acidosis, the client can exhibit altered mental status and
tachypnea. Management focuses on treating the underlying cause and administering IV sodium
bicarbonate to correct the imbalance.
Common causes of metabolic acidosis include:GI bicarbonate losses (eg, diarrhea), Ketoacidosis (eg,
diabetes, alcoholism, starvation), Lactic acidosis (eg, sepsis, hypoperfusion), Renal failure (eg,
hemodialysis with inaccessible arteriovenous shunt), Salicylate toxicity

Prostatectomy
Signs of complications- bleeding, passage of blood clots, a decrease in the urinary stream, urinary
retention, or symptoms of a urinary tract infection, should be reported to the HCP for further evaluation.

Kidney biopsy
Involves obtaining a tissue sample for pathological evaluation to determine the cause of certain kidney
diseases (eg, nephritis, transplant rejection). The kidney has extensive vasculature (similar to the liver);
therefore, bleeding from the biopsy site is the major complication.
Before the procedure, the client must give informed consent and discontinue all anticoagulants (eg,
heparin, warfarin, rivaroxaban) and antiplatelet agents (eg, aspirin, clopidogrel, nonsteroidal anti-
inflammatory drugs) for at least one week. The client should be typed and crossmatched for blood
(although the need for a transfusion is rare). Blood pressure should be well-controlled.
After the procedure, the nurse should monitor vital signs at least every 15 minutes for the first hour as
tachycardia, tachypnea, and hypotension can indicate blood loss. The nurse should also assess the
puncture site dressing for bleeding.
Post-procedure, the client should be positioned on the affected side for 30-60 minutes to provide pressure
and help prevent bleeding and on bed rest for 24 hours. The client is usually placed in the prone position
during the procedure to facilitate access to the kidney.

Renal calculi (ie, kidney stones)

Manifestations include sudden, severe abdominal or flank pain and nausea/vomiting.
When caring for a client with renal calculi, the nurse should provide adequate analgesia for pain,
encourage increased fluid intake, and assist with ambulation as tolerated to promote clearance of calculi.
All urine should be strained to retrieve any stones for analysis to determine preventive measures.

Antimuscarinic/anticholinergic medications
Tolterodine (Detrol LA), oxybutynin (Ditropan), and solifenacin (Vesicare)
used for overactive bladder and urge urinary incontinence. They decrease urinary urgency and frequency
but the number should not decrease below typical urination frequency. The most common side effects are
anticholinergic (eg, dry mouth, constipation, cognitive dysfunction).
Terazosin
An alpha-adrenergic blocker that can relieve urinary retention in clients with BPH.
It relaxes the smooth muscle in the bladder neck and prostate gland; however, it also relaxes smooth
muscle in the peripheral vasculature, which can cause orthostatic hypotension, syncope (blacking out),
and falls.
The serious effects can be avoided by instructing the client to take the medication at bedtime, change
positions slowly when going from lying to standing, and avoid any medications that also increase smooth
muscle relaxation (eg, phosphodiesterase-5 inhibitors[sildenafil or vardenafil] used to treat erectile
dysfunction). Some clients may also experience ejaculatory dysfunction (decreased or absent
ejaculation).

Transurethral resection of the prostate (TURP)

the insertion of a resectoscope to excise obstructing prostate tissue. Continuous bladder irrigation is
initiated after the procedure. The large catheter and balloon apply direct pressure on the bleeding tissue
and allow urine to drain. A specific rate is not prescribed; the nurse is expected to adjust irrigation flow
so that the urine remains light pink without clots. Typically, the irrigation rate will gradually decrease
during the first 24 hours.
Painful bladder spasms are expected after TURP and catheter placement. The spasms are typically
treated with belladonna-opium suppositories or other antispasmodics (eg, anticholinergics such as
oxybutynin [Ditropan]). The nurse should remind the client to refrain from trying to void around the
catheter as this can trigger the spasms. ensure first that urinary flow is intact prior to treating the pain with
analgesics.

Peritoneal dialysis
Uses the abdominal lining (ie, peritoneum) as a semipermeable membrane to dialyze a client with
insufficient renal function. A catheter is placed into the peritoneal cavity, and dialysate (ie, dialysis fluid)
is infused. The tubing is clamped to allow the fluid to remain in the cavity, usually for 20-30 minutes
(dwell phase). The catheter is then unclamped to allow dialysate to drain via gravity.
Insufficient outflow results most often from constipation when distended intestines block the catheter's
holes. If outflow becomes sluggish, the nurse should assess the client's bowel patterns and administer
appropriate prescribed medications (eg, stool softeners). The nurse should also check the tubing for
kinks and reposition the client to a side-lying position or assist with ambulation. The drainage bag should
be maintained below the abdomen to promote gravity flow. The nurse should assess for fibrin clots and
milk the tubing to dislodge or administer fibrinolytics (eg, alteplase) as prescribed. If these measures are
ineffective, an x-ray may be needed to check the catheter location.
Peritonitis is a major complication of peritoneal dialysis. Signs of developing peritonitis are low-grade
fever, tachycardia, and cloudy outflow (effluent). Bloody effluent can indicate intestinal perforation or
that the client may be menstruating. Using sterile technique when spiking and changing bags of dialysate
is a priority to avoid contamination and reduce the risk of peritonitis.
During the instillation and dwell portions of the cycle, clients are monitored closely for indications
of respiratory distress (eg, difficulty breathing, rapid respirations, crackles) that can result from instilling
the dialysate too rapidly, overfilling of the abdomen, or fluid entering the thoracic cavity. Crackles can
also occur if over time there is more dialysate infused than is removed (fluid gain).

Prevent recurrent UTIs:

 Take all antibiotics as prescribed even if symptoms have improved as bacteria may still be present
 Increase fluid intake; this dilutes the urine (minimizing bladder irritation), promotes frequent
urination, and prevents urinary stasis. The client should void at least every 2-4 hours. Some
 health care providers recommend drinking cranberry juice as it inhibits bacterial attachment to the
bladder wall, but there is no clinical evidence to support its effectiveness in preventing UTIs.
 Wipe from front to back to prevent introducing bacteria from the vagina and anus into the urethra
 Avoid synthetic fabrics as these materials (eg, nylon, spandex) seal in moisture and create an
environment conducive to bacterial proliferation; cotton underwear is recommended instead
 Void after sexual intercourse to flush out bacteria that may have entered the urethra
 Avoid douching and using feminine perineal products (eg, deodorants, powders, sprays). Take
showers instead of baths as bath products (eg, bubble bath, oils) and bacteria in bath water can
irritate the urethra and increase the risk of infection.
 Avoid spermicidal contraceptive jelly as it can suppress the production of protective vaginal
flora. Discontinue diaphragm use temporarily (until symptoms subside and antibiotic course is
completed); a diaphragm increases pressure on the urethra and bladder neck, which may inhibit
complete bladder emptying.

Cytoscopy
a procedure that uses a flexible fiber-optic scope inserted through the urethra into the urinary bladder with
the client in the lithotomy position to directly visualize the bladder wall and urethra.
Complications associated with cystoscopy include urinary retention, hemorrhage, and infection.
Therefore, clients are instructed to notify the health care provider (HCP) immediately if they have bright
red blood when urinating, blood clots, inability to urinate, fever >100.4 F (38 C) and chills, or abdominal
pain unrelieved by analgesia. may require antibiotic therapy or the insertion of a urinary catheter to
irrigate the bladder, remove clots, or drain the bladder
Pink-tinged urine, frequency, and dysuria are expected for up to 48 hours following a cystoscopy. Clients
are instructed to increase fluids, drink 4-6 glasses of water daily to help dilute the urine, and avoid alcohol
and caffeine for 24-48 hours as these can irritate the bladder.
Abdominal discomfort and bladder spasms may occur for up to 48 hours following the procedure. Clients
are taught to take a mild analgesic (eg, acetaminophen, ibuprofen) and a warm tub/sitz bath (except with
recurrent urinary tract infections) for pain relief. Irritation of the urethral and bladder lining from the
insertion and manipulation of the cystoscope may cause a slight burning sensation with voiding for a day
or two.

Renal arteriogram
A radiologic test performed to visualize renal blood vessels to detect abnormalities (renal artery stenosis
or aneurysm). A contrast medium is injected into the femoral artery; therefore, the client should be taught
to increase fluid intake after the procedure to flush the dye from the body. Increased output is an expected
finding.

Portable ultrasonic bladder scanners

Used at the bedside to determine the amount of residual urine in the bladder. Amounts >100 mLshould be
reported as the client may be experiencing urinary retention

Urine culture
values >10,000 organisms/mL can suggest UTI.

Extracorporeal shock wave lithotripsy (ESWL)

a noninvasive procedure used to break up kidney stones.
It is typically done on an outpatient basis, although the client will require local or general anesthesia. The
shock waves break up the stone(s) into a fine sand that can then be excreted in the urine. Ureteral stents
are often placed after the procedure to help with the passage of the sand and prevent buildup within the
ureter. The stents are removed within 1-2 weeks.
The client will be encouraged to drink large amounts of fluids to facilitate washing out of the stone
fragments and sand created by the shock waves. Infection is a serious complication after the procedure as
the breakup of stones can release organisms and cause sepsis. Pain can be severe and require analgesics.
Hematuria is common, and the urine should go from bright red to pink-tinged over several hours.
Hematuria is concerning if the urine remains bright red over a prolonged period (>24 hr). Bruising on the
back or abdomen after the procedure is normal. The client may need to rest for the remainder of the day
following anesthesia, but ambulation is encouraged to facilitate removal of stone fragments.

Pessary
a vaginal support device recommended for pelvic organ prolapse. Pessaries are fitted by an HCP; many
clients can then remove, clean, and replace these themselves. Clients can remain sexually active with a
pessary in place.
Increased vaginal discharge is a common side effect. However, if an odor is present, the client should be
instructed to notify the HCP to be treated for a possible infection.

Phenazopyridine hydrochloride (Pyridium)

a urinary analgesic prescribed to relieve symptoms of dysuria associated with a urinary tract infection.
An expected side effect of the drug is orange-red discoloration of urine. suggest that the client use
sanitary napkins and wear eyeglasses while taking the medication.

Ketorolac (Toradol)
a highly potent nonsteroidal anti-inflammatory drug (NSAID) often used for pain and available in
intravenous form. However, NSAIDs (eg, indomethacin, ibuprofen, naproxen, ketorolac)
are nephrotoxic and should be avoided in clients with kidney disease. Also, the client should not be
given 2 types of NSAIDs simultaneously (eg, naproxen plus ibuprofen) as they can be toxic to the
stomach and kidneys.

Acute urinary retention

Best treated with rapid, complete bladder decompression rather than the intermittent urine drainage that is
limited to 500 to 1000 mL at a time. Rapid decompression can be associated with hematuria,
hypotension, and postobstructive diuresis. Carefully assess for hypotension and bradycardia, which are
potential complications.

Percutaneous nephrolithotripsy
a procedure to remove large kidney stones from the renal pelvis. Post procedure, a nephrostomy tube
may be placed to prevent obstruction by stone fragments and to promote healing of injured tissue. Gentle
irrigation of the nephrostomy tube with sterile normal saline may be necessary to maintain tube patency.

Bladder cancer
the most common presenting symptom of bladder cancer Painless hematuria. Cigarette smoking or
other tobacco use is the primary risk factor.
Occupational carcinogen exposure is the second most common risk factor. Occupational exposures
include printing, iron and aluminum processing, industrial painting, metal work, machining, and mining.
Clients are exposed to carcinogens through direct skin contact and inhalation (aerosols and vapors).

erythropoietin (Epogen/Procrit, epoetin)

Hypertension is a major adverse effect of erythropoietin administration. Therefore, uncontrolled
hypertension is a contraindication to recombinant erythropoietin therapy. Blood pressure should be well
controlled prior to administering erythropoietin. Administered intravenously or in any subcutaneous area.
Iron in the form of iron sucrose (Venofer) or ferric gluconate (Ferrlecit) may be prescribed to promote an
adequate response to erythropoietin. Adequate stores of iron, vitamin B12, and folic acid are required for
the erythropoietin to work. dose should be held if the client has a hemoglobin level >11 g/dL (110 g/L) or
uncontrolled hypertension.
Scleroderma
an overproduction of collagen that causes tightening and hardening of the skin and connective tissue.
This is a progressive disease without a cure, and treatment is aimed at managing complications. Renal
crisis is a life-threatening complication that causes malignant hypertension (abrupt onset of
hypertension and headache) due to narrowing of the vessels that provide blood to the kidneys. Early
recognition and treatment of renal crisis is needed to prevent acute organ failure. Even with treatment,
this can be fatal.
Raynaud phenomenon can develop secondary to scleroderma. It is characterized by vasospasm-induced
color changes in the fingers, toes, ears, and nose. This requires urgent treatment (eg, immersing hands in
warm water) but is not life-threatening.
Pulmonary fibrosis is a progressive complication of scleroderma that is defined as scarring of lung tissue,
which then causes reduced function, dry cough, and dyspnea. Some clients may be placed on oxygen.
This is not immediately life-threatening.
Heartburn and dysphagia (difficulty swallowing) are common symptoms associated with scleroderma.

This is due to the disease process of internal scarring, and it is not life-threatening.
**Potassium-sparing diuretics (eg, spironolactone, triamterene, eplerenone), ACE inhibitors (eg,
lisinopril, ramipril), and angiotensin II receptor blockers (eg, losartan, valsartan, candesartan) cause
hyperkalemia. Therefore, these should be held in clients with underlying hyperkalemia

**Iodinated contrast used for CT scan or cardiac catheterization can cause kidney injury. Metformin
(Glucophage) can worsen lactic acidosis in the presence of kidney injury. Metformin should be withheld
prior to the contrast exposure and can be resumed when kidney function is within normal limits.

** NPO status preoperatively, dehydration, intraoperative fluid losses, antibiotic therapy, and advanced
age can negatively affect renal function. An elevated serum creatinine level preoperatively increases the
risk for postoperative kidney injury.

** Nutritional deficiencies (eg, zinc, protein, vitamin C) and dehydration (hypernatremia, elevated BUN)
can impair wound healing.

** Pain in pyelonephritis is dull, constant, and maximal at the costovertebral angle area. Pain from renal
stones is excruciating, sharp, and often radiates toward the groin from the flank. Suprapubic pain
indicates bladder distension or cystitis. Spasms can be seen with infection (cystitis) or manipulation of
the bladder.