Responses to Altered Elimination

By: Isser Jorell L. Yao, RN, MAN, Ed.D.

ANATOMY
 Urine formed by the kidneys for elimination
 Kidneys
o a pair of bean-shaped, brownish-red structures located retroperitoneally on the
posterior abdominal wall (T12 to L3 level)
o 113 to 170 g (about 4.5 oz) and is 10 to 12 cm long, 6 cm wide, and 2.5
cm thick
o (R) is lower than (L) due to the liver's location

If client complain RUQ pain

 Bile related= ingestion of too much fats
 Liver= alcohol intake
For KIDNEY
 Flank pain that radiates to the shoulder

 Adrenal glands (on top of the kidneys) function independently

 Two parts of renal parenchyma
o Cortex-SSS (Sugar (Glycogen), salt (aldosterone/mineralocorticoids), Sex
(androgen) )
 1 cm. wide
 farthest from the center of the kidney
 around the outermost edges
 It contains nephrons (functional unit).
o Medulla-Epinephrine and Norepinephrine
 5 cm. wide

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  loops of Henle
 vasa recta
 collecting ducts of the juxtamedullary nephrons
 renal pyramids—8-18 pyramids
 minor calices
 major calices
 renal pelvis—collect & transport urine

BLOOD FLOW
 Hilum
o concave portion
o renal artery entry & renal vein exit
o 20-25% to total Cardiac Output
o 12x/hour blood circulation
 Renal artery
o dividing into smaller vessels
o afferent arterioles
o Glomerulus

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 o capillary bed for glomerular filtration
 Renal Vein
o efferent arterioles
o inferior vena cava

NEPHRONS
 1 million nephrons per kidney
 initial formation of urine
 Two Types:
o Cortical nephrons
 80-85%
 outermost part of the cortex
o Juxtamedullary nephrons
 15-20%
 deeper in the cortex
 long loops of Henle
 vasa recta

 Two basic components:

o filtering element-one that performs the absorption
 composed of glomerulus and the attached tubule
 enclosed by Bowman's capsule
 Glomerular membranes' three filtering layers

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  capillary endothelium
 basement membrane
 epithelium
o tubular component-daluyan lang
 Bowman's capsule
 proximal tubule
 descending loop of Henle
 ascending loop of Henle
 distal tubule--located in the macula densa+ afferent arteriole =
afferent arteriole
 with the afferent arteriole form the juxtaglomerular
apparatus (renin production—arterial BP control)
 it is were the RAAS system is
 either the cortical or medullary duct

URETHRA
 URINE
 Renal pelvis
 Ureters
o 24 to 30 cm long
o (L) is shorter than (R)
o Made up of urothelium—prevents urine reabsorption
o Peristaltic contraction
o Three narrow areas of each ureter (prone to Renal Calculi):
 ureteropelvic junction (Where renal calculi forms)
 ureteral segment (near the sacroiliac junction)
 ureterovesical junction
 BLADDER
o Trigone of the bladder wall
o muscular, hollow sac behind the pubic bone
o 400 to 500 mL capacity; however usually @ 200-250 mL filled bladder
we often have the urge to void

FOUR LAYERS OF THE BLADDER

 adventitia
 detrusor-responsible for contraction
 submucosal layer of loose connective tissue
 innermost layer, a mucosal lining
o Vesicle--central, hollow area
o two inlets (the ureters)
o one outlet (the urethra)
 Urethrovesical junction-it relaxes when we voide
 Internal sphincter--involuntary muscle
 During micturation: no efflux of urine from ureters
URINE FORMATION
 Human body: 60% water

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 renal glycosuria: blood glucose > renal reabsorption
 proteinuria: low-molecular-weight proteins periodically excreted in small amounts (not
normal)
GLOMERULAR FILTRATION
 1200 mL/min—normal blood flow to the kidneys
 20% of the blood into the nephrons
 180 L/day of filtrate/ultrafiltrate
 Affected due to:
o hypotension
o decreased blood oncotic pressure
o increased renal tubular pressure (obstruction) ex benigh prostatic
hypertrophy
TUBULAR REABSORPTION
 180 L. (45 gallons) filtrate
 99% reabsorbed into the bloodstream
 1 to 2 liter of urine daily= 1500 mL at least

ANTIDIURETIC HORMONE
 Main job if to concentrate the urine
 a.k.a. vasopressin
 secreted by the posterior pituitary gland-
 responsible for blood osmolality (NV: 280 to 300 mOsm/kg)
 Low water intake
o increased blood osmolality (increase concentration)
o stimulate ADH release
o increased reabsorption of water in the kidneys
o less urine output
o normalize blood osmolality
 Water Specific Gravity: 1.000
o If urine is same with water= urine is not concentrated
o Hypo production of ADH (Diabetes Inspidus)
 Damii Ihi
 Ihi is same with water
o SIADH (Hyperproduction of ADH)
 Normal Urine Specific Gravity: 1.010 to 1.025

OSMOLALITY & OSMOLARITY

 Osmolarity refers to the ratio of solute (salt) to water
o 1% to 2% serum osmolarity change—conscious thirst & renal water
conservation
 Osmolality refers to the number of osmoles (the standard unit of osmotic pressure)
dissolved per kilogram of solution
 Normal Urine Osmolality: 200 to 800 mOsm/kg

WATER EXCRETION

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  Increased water intake means increased urine secretion with low specific
gravity
o 1300 mL of oral liquids daily
o 1000 mL of water in food daily
o about 900 mL is lost through the skin and lungs (called insensible loss)
o 50 mL through sweat
o 200 mL through feces
o 1 lb. is about 500 mL. fluid

ELECTROLYTE EXCRETION- RAAS (@ THE MACULA DENSA DISTAL TUBULE--)

Other Functions…
 Acid-Base Balance (reabsorption of bicarbonate)
o When pH is alkaline- the bicarbonate will be released to make is acidic
 BLOOD PRESSURE (RAAS SYSTEM)

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  RENAL CLEARANCE
o ability of the kidneys to clear solutes from the plasma
o Creatinine Clearance—for GFR [NV: 125 mL/min (1.67 to 2.0 mL/sec) to 200
mL/min] for Renal Function
 urine [ml/min] × urine creatinine [mg/dl] ÷ serum creatinine
[mg/dl]
 24-hour urine collection (for renal clearance) plus midway serum
creatinine extraction

 RBC PRODUCTION
o ↓ O₂ renal blood flow → kidneys release erythropoietin → RBC released from
bone marrow

 VITAMIN D SYNTHESIS (final activation of Vitamin D to 1,25-

dihydroxycholecalciferol)
 Secretion of Prostaglandin E and Prostacyclin (for renal vasodilation)
 Excretion of Waste Products
 Urine Storage
o Conscious awareness of bladder filling—sympathetic neuronal pathways at
T10 to T12
o Bladder filling: bladder pressure < 40 cm H2O
 Meaning bladder fills when it detects that there is less than 40 cm H20 in
the blood
o 8 glasses of water daily (1 to 2 liters)
o 2 to 4 hours of urine storage
o at night: ADH release (dec. ADH--nocturia)
 decrease ADH = Nocturia
 Bladder Emptying
o voiding: 8x daily
o Bladder compliance—detrusor muscles—parasympathetic pelvic nerves at
S1 to S4—cerebral cortex
o 150 to 200 mL initial desire to void


I. Assessment
 Subjective Data
- Nursing History
 Explore the client's health history for risk factors associated with renal
and urinary disorders, including:
 exposure to certain nephrotoxins (e.g., chemicals, tar plastics)
 history of smoking
 multiple pregnancies
 history of diabetes mellitus or hypertension.
 Elicit a description of the client’s present illness and chief complaint
including onset, course, duration, location, and precipitating and

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 alleviating factors. Cardinal signs and symptoms indicating altered urinary
and renal function include:
 dysuria
 hesitancy
 flank pain
 urinary frequency
 urethral discharge
 hematuria
 incontinence
 nocturia-usually no urination because ADH secretes most
at night
 Objective Data
- Physical Assessment
 Inspection
 Inspect the masses in the upper abdomen and flank area
 Inspect the external meatus for signs of discharge, cleanliness,
location, and size.
 Palpation
 Palpate for the lower poles of the right and left kidney noting
enlargement
 Percussion
 Percuss above the symphysis pubis for a distended bladder.
 Auscultation
 Auscultate for bruits over the renal arteries.
- Diagnostic Assessment
 Non-invasive
 Urinalysis
 24-Urine Collection
 Renal Ultrasound
 Invasive
 Serum Studies Intravenous Pyelography
II. Nursing Diagnosis
 Acute pain
 Risk for infection
 Impaired urinary elimination
 Deficient or excess fluid volume
 Imbalanced nutrition: less than body requirements
 Impaired skin integrity
 Activity intolerance
 Deficient knowledge
 Ineffective coping
III. Planning
 Relief of pain and discomfort
 Prevention of infection
 Return to normal elimination patterns
 Maintenance of fluid intake
 Maintenance of nutritional intake
 Intact skin integrity

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  Participation in activity within tolerance
 Increased knowledge of prevention and treatment
 Effective coping with disorder
IV. Elimination - Renal alterations

 Acute Renal Failure

o AKI is the sudden interruption of renal function resulting from:
 obstruction
 reduced circulation
 renal parenchymal disease.
o AKI is sometimes reversible, but if it’s left untreated, permanent damage can
lead to chronic renal failure. As a critical care nurse, you play a vital role in
assessing and treating patients with AKI.

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Prerenal= hypo-perfusion of the kidney
Intrarenal-damage to the kidney itself caused by inflammation
Postrenal- obstruction
o how it happens
 Each classification of AKI—prerenal, intrarenal and postrenal—has its own
pathophysiology:
 Prerenal failure results from conditions that diminish blood flow
to the kidneys (hypoperfusion). Examples include hypovolemia,
hypotension, vasoconstriction, or inadequate cardiac output.
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  One condition, prerenal azotemia- BUN and CREATININ
excess (excess nitrogenous waste products in the blood),
accounts for 40% to 80% of all cases of AKI. Azotemia occurs as
a response to renal hypoperfusion.
|
 Typically, it can be rapidly reversed by restoring renal blood flow
and glomerular filtration.

 Intrarenal failure, also called intrinsic or parenchymal

kidney injury, results from damage to the filtering structures of
the kidneys, usually from acute tubular necrosis, a disorder
that causes cell death, or from nephrotoxic substances, such as
certain antibiotics or radiologic dyes.

 Postrenal failure results from bilateral obstruction of urine

outflow, as in prostatic hyperplasia or bladder outlet
obstruction.


o With treatment, the patient passes through

THREE DISTINCT PHASES:

 OLIGURIC (DECREASED URINE OUTPUT)
 Oliguria is a decreased urine output (less than 400 mL/24
hours).
 Prerenal oliguria results from decreased blood flow to the
kidney.
 Before damage occurs, the kidney responds to decreased blood
flow by conserving sodium and water. Once damage occurs,
the kidney’s ability to conserve sodium is impaired. Untreated
prerenal oliguria may lead to acute tubular necrosis.
 During this phase, BUN and creatinine rise, and the ratio of
BUN to creatinine falls from 20: 1 (normal) to 10: 1.
Hypervolemia also occurs, causing edema, weight gain, and
elevated blood pressure.

 DIURETIC (INCREASED URINE OUTPUT)
 The diuretic phase is marked by urine output that can range from
normal (1 to 2 L/day) to as great as 4 to 5 L/day. High urine
volume has two causes, including:
o the kidney’s inability to conserve sodium and water
o osmotic diuresis produced by high BUN levels.
 During the diuretic phase, which lasts several days to 1 week,
BUN and creatinine levels slowly increase and
hypovolemia and weight loss result. These conditions can
lead to deficits of potassium (heart problem), sodium
(cerebral hemorrhage), and water that can be deadly if left
untreated. If the cause of the diuresis is corrected, azotemia

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 gradually disappears and the patient improves greatly—leading to
the recovery stage.
 recovery.
 The recovery phase is reached when BUN and creatinine levels
return to normal and urine output is between 1 and 2 L/day.
o It gets complicated...
 Primary damage to the renal tubules or blood vessels results in kidney
failure (intrarenal failure). The causes of intrarenal failure are classified as
nephrotoxic, inflammatory, or ischemic.

o IRREPARABLE DAMAGE
 When nephrotoxicity or inflammation causes the damage, the delicate
layer under the epithelium (basement membrane) becomes irreparably
damaged, commonly proceeding to chronic renal failure.
 Severe or prolonged lack of blood flow (ischemia) may lead to
 renal damage (ischemic parenchymal injury)
 excess nitrogen in the blood (intrinsic renal azotemia).
o What to look for
 The SIGNS AND SYMPTOMS OF PRERENAL FAILURE depend on the
cause.
 If the underlying problem is a decrease in blood pressure and
volume, the patient may have:
 oliguria
 tachycardia
 hypotension
 dry mucous membranes
 flat jugular veins
 lethargy progressing to coma
 decreased cardiac output and cool, clammy skin in a patient with
heart failure.

 Negative progress
 As AKI progresses, the patient may show signs and symptoms of uremia
(encephalopathy) including:
 confusion
 GI complaints
 fluid in the lungs
 infection.
 About 5% of all hospitalized patients develop AKI. The condition is
usually reversible with treatment; however, if it isn’t treated, it may
progress to end-stage renal disease, excess urea in the blood (prerenal
azotemia or uremia), and death.

o What tests tell you
 These tests are used to diagnose AKI:
 Blood studies reveal elevated BUN, serum creatinine, and
potassium levels and decreased blood pH, bicarbonate, HCT, and Hb
levels.

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  Urine studies show casts, cellular debris, decreased specific gravity
and, in glomerular diseases, proteinuria and urine osmolality close to
serum osmolality. Urine sodium level is less than 20 mEq/L if oliguria
results from decreased perfusion and more than 40 mEq/L if it results
from an intrarenal problem.
 Arterial blood gas analysis reveals decreased pH and bicarbonate
levels, indicating metabolic acidosis.
 Creatinine clearance testing is used to measure the GFR and estimate
the number of remaining functioning nephrons.
 The lower the GFR the dangerous it is
 Electrocardiogram (ECG) shows tall, peaked T waves, a widening QRS
complex, and disappearing P waves if increased blood potassium
(hyperkalemia) is present.
 Other studies used to determine the cause of AKI include kidney
ultrasonography, plain films of the abdomen, KUB radiography, excretory
urography, renal scan, retrograde pyelography, computed tomography
scan, and nephrotomography.

o HOW IT’S TREATED

 Supportive measures include a diet high in calories and low in
protein, sodium, and potassium, with supplemental vitamins and
restricted fluids. Meticulous electrolyte monitoring is essential to detect
hyperkalemia.
o SEND IN THE DRUGS
 Drug therapy for AKI may include:
 sodium bicarbonate (for metabolic acidosis) and hypertonic glucose
and insulin infusions administered I.V., as well as sodium
polystyrene sulfonate Kayexalate (for hyperkalemia) by mouth or by
enema, and calcium gluconate (in an emergency) to reduce potassium
levels
 diuretics to manage hypervolemia
 fluid replacement to correct hypovolemia.

o OVERLOAD OVERVIEW
 Even with treatment, an elderly patient is susceptible to volume overload,
possibly precipitating acute pulmonary edema, hypertensive crisis,
hyperkalemia, and infection.
 If hyperkalemia can’t be reduced with drugs, acute therapy may include
dialysis. To control uremic symptoms, hemodialysis or peritoneal dialysis
may be necessary. CVVH are alternative hemodialysis techniques for
treatment of AKI.
 Emergency Dialysis= Intrajugular catheter
o severe hyperkalaemia (K+ > 7mmol/L) which is
resistant to medical therapy.
o pulmonary oedema refractory to medical therapy.
o worsening severe metabolic acidosis (pH < 7.2 or base
excess < -10)
o uremic pericarditis

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 o Uremic encephalopathy

o WHAT TO DO
 If the patient is to receive a diuretic, be sure to obtain a urine
sample for urine studies before giving the diuretic because these
drugs can alter urine results.
 Measure and record the patient’s intake and output hourly, including
wound drainage, NG tube output, and diarrhea. Insert an
indwelling urinary catheter if indicated. Assess skin turgor; evidence of
peripheral, sacral, or periorbital edema; and degree of pitting, if any.
Monitor the patient’s daily weight for trends.
 Check urine specific gravity and osmolality, as ordered. With prerenal
failure, urine specific gravity is typically greater than 1.020 and
urine osmolality is increased up to 500 mOsm; with intrarenal failure,
specific gravity is typically less than 1.010 (diuretic) and
osmolality is approximately 350 mOsm.
 Anticipate the insertion of a PA catheter to assess the patient’s
hemodynamic status. Monitor parameters, as ordered.
 Assess Hb levels and HCT and replace blood components, as ordered.

o WHOLE LOTTA BLOOD
 Don’t use whole blood to transfuse the patient if he’s prone to heart
failure and can’t tolerate extra fluid volume. Packed RBCs deliver the
necessary blood components without added volume.
 Assess the patient’s cardiopulmonary status often, including heart and
breath sounds. Monitor his cardiac rhythm. Report any shortness of
breath, crackles, gallops, pericardial friction rub, tachycardia, or
the presence of S3 or S4 heart sounds because these may be signs
of fluid overload.
 Monitor the patient’s level of consciousness at least every 2 to 4
hours, or more often if indicated.
 Maintain proper electrolyte balance. Strictly monitor the patient’s
potassium levels, especially during emergency treatment to reduce
potassium levels. Avoid administering drugs containing potassium.
 Watch the patient for symptoms of hyperkalemia (malaise, anorexia,
paresthesia, or muscle weakness) and ECG changes (tall, peaked T
waves; widening QRS complex; and disappearing P waves), and
report them immediately.
 Provide a high-calorie, low-protein, low-potassium, low-sodium
diet, with vitamin supplements. Give anorectic patients small, frequent
meals.
 Use sterile technique when performing procedures because a critically ill
patient with renal failure is highly susceptible to infection.
 Encourage coughing and deep breathing and perform passive ROM
exercises to reduce complications of bed rest.
 Consult the pharmacy regarding modifying the dose to account for the
patient’s impaired renal function.
o DRY NO MORE

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 Use a lubricating lotion to combat dry skin. Provide mouth care frequently
because mucous membranes become dry.
 Assess the patient for signs and symptoms of GI bleeding. Administer
drugs carefully, especially antacids and stool softeners. Use aluminum-
hydroxide-based antacids; magnesium-based antacids can cause
serum magnesium levels to increase critically.
 Use appropriate safety measures, such as side rails or assistance with
ambulation, because the patient with central nervous system involvement
may be dizzy or confused. Institute bleeding precautions to
minimize the patient’s risk for bleeding.
 Provide appropriate care to a patient receiving hemodialysis, peritoneal
dialysis, or CRRT. Provide emotional support to the patient and his
family and explain diagnostic tests, treatments, and procedures. Caring
for the patient with AKI requires the involvement of a multidisciplinary
team.

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  CHRONIC RENAL FAILURE
o CRF is the end result of progressive, irreversible loss of functioning renal
tissue.
o It usually develops gradually, possible taking up to several years to develop.
o In some cases, it may occur rapidly because of an acute disorder (e.g,
unresolved acute renal failure).
o Etiology
 Hypertensive nephropathy
 Diabetic nephropathy
 Chronic glomerulonephritis
 Chronic pyelonephritis
 Lupus nephritis
 Polycystic kidney disease
 Chronic hydronephrosis

o STAGES OF CRF

 Decreased renal reserve

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  renal function is 40% to 50% of normal homeostasis is
maintained
 Renal insufficiency
 renal function is 20% to 40% of normal
 GFR, clearance, and urine concentration are decreased
 homeostasis is altered
 End-stage renal disease
 renal function is less than 10% to 15% of normal
 all renal functions are severely decreased
 homeostasis is significantly altered
o When a patient has sustained enough kidney damage to require renal
replacement therapy on a permanent basis, the patient has moved into the
fifth or final stage of CKD, also referred to as chronic renal failure (CRF) or
ESRD.
o Pathophysiology
 As renal function declines, the end products of protein metabolism
(normally excreted in urine) accumulate in the blood BUN and
Creatinine Increase Severely.
 Uremia develops and adversely affects every system in the body. The
greater the buildup of waste products, the more pronounced the
symptoms are- encephalopathy
 The rate of decline in renal function and progression of ESRD is related to
the underlying disorder, the urinary excretion of protein, and the
presence of hypertension. The disease tends to progress more rapidly
in patients who excrete significant amounts of protein or have elevated
blood pressure than in those without these conditions.

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 Grey Bronze Skin =
o Assessment and Diagnostic Findings
 ↓ Glomerular Filtration Rate <15%
 ↓ Creatinine Clearance
 ↑ Creatinine (better renal function indicator) >1.010 or
1.30
 ↑ BUN (CHON intake, catabolism, TPN, Corticosteroids) >20
 Sodium and Water Retention
 risk for edema, heart failure, and hypertension (RAAS activation)
 Erratic kidney function, some may lose water and sodium
o Hypotension and hypovolemia
 Acidosis
 ↓ ammonia (acid) excretion
 ↓ bicarbonate reabsorption
o Sodium Bicarbonate
 ↓ phosphates and other organic acids
 Anemia
 inadequate erythropoietin production
o Administration of Erythropoietin
 the shortened lifespan of RBCs-120 days

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  nutritional deficiencies
 GI bleeding tendency
 profound anemia, fatigue, angina, and shortness of breath
 Calcium and Phosphorus Imbalance
 Normally: ↑ Serum Calcium = ↓ Serum Phosphorus
 ↑ Serum Phosphate — ↓ Serum Calcium — ↑ parathormone
(parathyroid gland)
 No response to parathormone — continuous calcium release
from bones (bone changes and blood vessel calcification)
 Also, ↓ active metabolite of vitamin D
 Uremic bone disease (renal osteodystrophy)
 Color skin changes—toxin build-up
 An unhealthy pale color
 Gray hue
 Yellowish color
 Areas of darkened skin, as shown here
 Yellowish, thick skin with bumps and deep lines (from scratching)
 Cysts and spots that look like whiteheads (from scratching)

o Complications
 Hyperkalemia due to decreased excretion, metabolic acidosis,
catabolism, and excessive intake (diet, medications, fluids)
 Pericarditis, pericardial effusion, and pericardial tamponade due
to retention of uremic waste products and inadequate dialysis
 Hypertension due to sodium and water retention and malfunction
of the renin–angiotensin–aldosterone system
 Anemia due to decreased erythropoietin production, decreased RBC
lifespan, bleeding in the GI tract from irritating toxins and ulcer
formation, and blood loss during hemodialysis
 Bone disease and metastatic and vascular calcifications due to
retention of phosphorus, low serum calcium levels, abnormal vitamin
D metabolism, and elevated aluminum levels
o Medical Management
 The goal of management is to maintain kidney function and homeostasis
for as long as possible. All factors that contribute to ESRD and all factors

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 that are reversible (eg, obstruction) are identified and treated.
Management is accomplished primarily with medications and diet
therapy, although dialysis may also be needed to decrease the level of
uremic waste products in the blood and to control electrolyte balance.
o Pharmacologic Therapy
Complications can be prevented or delayed by administering prescribed:
 phosphate-binding agents
 calcium carbonate (Os-Cal), calcium acetate (PhosLo),
sevelamer hydrochloride (Renagel)
 calcium supplements
 antihypertensive and cardiac medications
 diuretic agents, digoxin (Lanoxin), dobutamine (Dobutrex)
 anti-seizure medications, and
 diazepam (Valium) for prompt treatment, phenytoin (Dilantin)
for prevention
 erythropoietin (Epogen) for anemia
 recombinant human erythropoietin (Epogen)
o Nutritional Therapy
 Careful regulation of protein intake, fluid intake to balance fluid losses,
sodium intake to balance sodium losses, and some restriction of
potassium
 Adequate caloric (carbohydrates and fats to prevent wasting) intake and
vitamin supplementation
 High biologic value (dairy products, eggs, meats)
 Usually, the fluid allowance per day is 500 mL to 600 mL more than
the previous day’s 24-hour urine output.
 Additionally, the patient on dialysis may lose water-soluble vitamins
during the dialysis treatment.
 Sodium polystyrene sulfonate (Kayexalate), a cation-exchange resin,
may be needed for acute hyperkalemia.
o Dialysis
 The patient with increasing symptoms of renal failure is referred to a
dialysis and transplantation center early in the course of progressive renal
disease. Dialysis is usually initiated when the patient cannot maintain a
reasonable lifestyle with conservative treatment

V. Implementation
 Medical/Surgical Management
 Fluid Resuscitation
 PERITONEAL DIALYSIS
o Like hemodialysis, peritoneal dialysis is used to remove toxins from the
blood of a patient with acute or chronic renal failure who doesn’t respond to
other treatments. Unlike hemodialysis, peritoneal dialysis uses the patient’s
peritoneal membrane as a semipermeable dialyzing membrane.
o How it’s done
 In peritoneal dialysis, the dialysate (the solution instilled into the
peritoneal cavity by catheter) draws waste products, excess fluid,
and electrolytes from the blood across the semipermeable peritoneal

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 membrane. (See Principles of peritoneal dialysis.) After a prescribed
period, the dialysate is drained from the peritoneal cavity, removing
impurities with it. The dialysis procedure is then repeated, using a new
dialysate each time, until waste removal is complete and fluid,
electrolyte, and acid-base balance has been restored.
 With special preparation, the critical care nurse may perform
peritoneal dialysis using an automatic or semiautomatic cycle machine.
o Upside
 Peritoneal dialysis has several advantages over hemodialysis—it’s
simpler, less costly, and less stressful. Also, it’s nearly as effective as
hemodialysis while posing fewer risks.
o Downside
 Even so, peritoneal dialysis can cause severe complications. The most
serious one, peritonitis, results from bacteria entering the peritoneal
cavity through the catheter or the insertion site. In addition to causing
infection, peritonitis can scar the peritoneum, causing thickening of the
membrane and preventing its use as a dialyzing membrane.
 Other complications include catheter obstruction from clots, lodging
against the abdominal wall, or kinking; hypotension; and
hypovolemia from excessive plasma fluid removal.

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o Nursing considerations
 For the first-time peritoneal dialysis patient, explain the purpose of the
treatment and what he can expect during and after the procedure.
 Explain that the doctor first inserts a catheter into the abdomen
to allow instillation of dialysate .

22 | P a g e
 Before catheter insertion, take and record the patient’s baseline vital
signs and weight.
 Ask the patient to urinate to reduce the risk of bladder perforation and
increase comfort during catheter insertion. If he can’t urinate, perform
straight catheterization, as ordered, to drain the bladder.
 During dialysis, monitor the patient’s vital signs every 10 minutes until
they stabilize, then every 2 to 4 hours or as ordered. Report any
abrupt or significant changes.

23 | P a g e
  Periodically check the patient’s weight and report any gain.
 Using sterile technique, change the catheter dressing every 24
hours or whenever it becomes wet or soiled.
 To determine whether a wet abdominal dressing around the catheter site
is from leakage of dialysate or wound drainage, use a dextrose test
strip. Because of its high dextrose content, dialysate reacts positively
while wound drainage doesn’t.
 Monitor the patient for signs of infection.
 If you detect signs or symptoms of peritonitis, notify the
practitioner and send a dialysate specimen to the laboratory for
smear and culture.
 Watch closely for these signs and symptoms:
o fever
o persistent abdominal pain and cramping
o slow or cloudy dialysis drainage
o swelling and tenderness around the catheter
o increased white blood cell count.
o Collecting the empties
 When emptying the collection bag and measuring the solution, wear
protective eyewear and gloves.
 Observe the outflow drainage for blood.
 Keep in mind that drainage is commonly blood-tinged after catheter
placement but should clear after a few fluid exchanges. Notify the
practitioner of bright red or persistent bleeding.
 Watch the patient for respiratory distress (raise HOB) which may
indicate fluid overload or leakage of dialyzing solution into the pleural
space. If it’s severe, drain the patient’s peritoneal cavity and call the
practitioner.
 Periodically check the outflow tubing for clots or kinks that may be
obstructing drainage.
 Have the patient change position often. Provide passive range-of-
motion (ROM) exercises and encourage deep breathing and
coughing to improve comfort, reduce the chance of skin breakdown and
respiratory problems, and enhance dialysate drainage.
 Maintain adequate nutrition, following any prescribed diet. The patient
loses protein through the dialysis procedure and, therefore, requires
protein replacement.
 To prevent fluid imbalance, calculate the patient’s fluid balance at the end
of each dialysis session or after every 8-hour period in a longer session.
Include oral and I.V. fluid intake as well as urine output, wound drainage,
and perspiration. Record and report any significant imbalance, whether
positive or negative.

 Hemodialysis
o Hemodialysis is used to remove toxic wastes and other impurities from the
blood of a patient with renal failure. It’s also used to restore or maintain acid-
base and electrolyte balance and prevent the complications associated with
uremia. To do so, this method extracts the by-products of protein

24 | P a g e
 metabolism—notably urea and uric acid—as well as creatinine and excess
water from the patient’s blood.
o Blood, out and back
 During hemodialysis, the patient’s blood is removed from the body
through a surgically created access site, pumped through a dialyzing unit
to remove toxins, and then returned to the body.
o Osmosis, diffusion, and filtration
 The extracorporeal dialyzer works through a combination of osmosis,
diffusion, and filtration.

How hemodialysis works

 In hemodialysis, blood flows from the patient to an external dialyzer (or
artificial kidney) through an arterial access site.
Inside the dialyzer
 Inside the dialyzer, blood and dialysate flow countercurrently, divided by a
semipermeable membrane. The composition of the dialysate resembles
normal extracellular fluid. The blood contains an excess of specific solutes
(such as metabolic waste products and electrolytes), and the dialysate
contains electrolytes that may be at abnormal levels in the patient’s
bloodstream. The dialysate’s electrolyte composition can be modified to raise
or lower electrolyte levels, depending on the patient’s needs.
Diffusion
 Excretory function and electrolyte homeostasis are achieved by diffusion—
the movement of molecules across the dialyzer’s semipermeable membrane
—from an area of higher solute concentration to an area of lower
concentration.
Ultrafiltration
 Water (a solvent) crosses the membrane from the blood into the dialysate by
ultrafiltration. Excess water, waste products, and other metabolites are
removed through osmotic pressure, the movement of water across the
semipermeable membrane from an area of lesser solute concentration to
one of greater solute concentration, and hydrostatic pressure, which forces
water from the blood compartment into the dialysate compartment.

After it’s cleaned of impurities and excess water, the blood returns to the body through
a venous site.

Three systems
 Three system types are used to deliver dialysate:
o The proportioning system—the most common type—mixes
concentrate with water to form dialysate, which then circulates
through the dialyzer and goes down a drain after a single pass,
followed by fresh dialysate.
o The batch system uses a reservoir for circulating dialysate.
o The regenerative system uses sorbents to purify and regenerate
recirculating dialysate.
Hollow-filter dialyzer
 The hollow-filter dialyzer, contains fine capillaries with a semipermeable
membrane enclosed in a plastic chamber. Blood flows through these
capillaries as the system pumps dialysate in the opposite direction on the
outside of the capillaries.

o Acute use or long-term therapy

25 | P a g e
  Hemodialysis can be done in an emergency in acute renal failure or
as regular long-term therapy in end-stage renal disease. In chronic renal
failure, the frequency and duration of treatments depend on the patient’s
condition; up to several treatments per week, each lasting 3 to 4
hours, may be required. Rarely, hemodialysis is done to treat acute
poisoning or drug overdose.
 Specially trained nurses usually perform the procedure in a
hemodialysis unit; in the critically ill patient, it’s performed at the
bedside using portable equipment.
o Nursing considerations
 If the patient is undergoing hemodialysis for the first time, explain its
purpose and what to expect during and after treatment. Explain that
he’ll first undergo a procedure to create a vascular access.
o Access obtained
o After vascular access
 Weigh the patient, take his vital signs, and assess breath and heart
sounds. Check for edema and jugular vein distention.
 Use good hand-washing technique and wear protective eyewear, gown,
and gloves during the hemodialysis procedure.
 Discard (don’t recap) all needles used in the procedure in designated
containers.
 Assess the vascular access site for the presence of a bruit and thrill and
keep the vascular access site well supported and resting on a sterile
drape or sterile barrier shield.
 As ordered, prepare the hemodialysis equipment. Follow the
manufacturer’s and your facility’s protocols and maintain strict sterile
technique to prevent the introduction of pathogens into the patient’s
bloodstream during treatment.
 Check and record the patient’s vital signs every 30 minutes or
according to your facility’s policy, during treatment to detect possible
complications. Fever may point to infection from pathogens in the
dialysate or equipment; give an antipyretic, an antibiotic, or both, as
ordered. Hypotension may indicate hypovolemia or a drop in HCT; give
blood or fluid supplements I.V., as ordered. Rapid respirations may signal
hypoxemia or fluid overload. Assess breath sounds and oxygen saturation
and give supplemental oxygen, as ordered.
o He’s got rhythm
 Monitor the patient’s cardiac rhythm for arrhythmias that may result from
electrolyte and pH changes in the blood due to hemodialysis.
 Periodically check the dialyzer blood lines to make sure all connections
are secure. Monitor the lines for clotting.
 Assess the patient for headache, muscle twitching, backache, nausea or
vomiting, and seizures, which may indicate disequilibrium syndrome
caused by rapid fluid removal and electrolyte changes.
 If disequilibrium syndrome occurs, notify the practitioner
immediately; he may reduce the blood flow rate or stop dialysis. Muscle
cramps may also result from rapid fluid and electrolyte shifts. As

26 | P a g e
 ordered, relieve cramps by injecting normal saline solution into the
venous return line.
 Observe the patient carefully for signs and symptoms of internal
bleeding, such as apprehension; restlessness; pale, cold, clammy skin;
excessive thirst; hypotension; rapid, weak, thready pulse; increased
respirations; and decreased body temperature. Report any of these signs
immediately and prepare to decrease heparinization or administer a blood
transfusion, as ordered
o Patient access
 After completion of hemodialysis, monitor the vascular access site for
bleeding. If bleeding is excessive, maintain pressure on the site and
notify the practitioner. If a temporary catheter is used for dialysis, flush
the catheter according to your facility’s policy.
 Make sure that the arm used for vascular access isn’t used for
another procedure, including I.V. line insertion, blood pressure
monitoring, and venipuncture.
 Assess circulation at the access site by auscultating for the presence
of bruits and palpating for thrills. Lack of bruits at a vascular access site
for dialysis may indicate a blood clot, requiring immediate surgical
attention.
 Keep an accurate record of the patient’s food and fluid intake
and encourage him to comply with prescribed restrictions, such as
increased calorie intake, decreased fluid intake, and limited protein,
potassium, and sodium intake.

May Watch PD vs. HD on YouTube: https://www.youtube.com/watch?v=SgBMoCArNak

May Watch CRRT on YouTube: https://www.youtube.com/watch?v=H6JfCxUnDmw

 Continuous Renal Replacement Therapy (CRRT)

o CRRT is used to treat a patient with acute renal failure. Unlike the more
traditional intermittent hemodialysis (IHD), CRRT is administered around the
clock, providing the patient with continuous therapy without the destabilizing
hemodynamic and electrolytic changes of IHD.
o CRRT is used for a patient who can’t tolerate traditional hemodialysis, such as
one with hypotension. Also, a patient who has had abdominal surgery and can’t
receive peritoneal dialysis because of an overwhelming risk of infection is a
candidate for CRRT.
o Understanding CRRT
 Continuous renal replacement therapy (CRRT) filters toxic wastes
from a patient’s blood and may include a replacement solution. It’s
used to correct fluid overload that doesn’t respond to diuretics
and to treat critically ill patients who have acute renal failure, can’t
tolerate hemodialysis, or have some electrolyte and acid-base
disturbances.
o Hemofilter how-to
 All CRRT equipment is located at the patient’s bedside. The procedure
doesn’t require the immediate supervision of a dialysis nurse. The
patient’s blood may be accessed by catheter, internal arteriovenous (AV)

27 | P a g e
 graft, or AV shunt. The hemofilter is made up of hollow fiber capillaries
that filter blood at a rate of about 150 to 300 mL/minute, driven by the
patient’s arterial blood pressure in continuous AV hemofiltration or by a
blood pump in continuous venovenous hemofiltration. Because the
amount of fluid removed is greater than the patient’s intake, the patient
gradually loses fluid (12 to 15 L/day).
o CRRT techniques vary in complexity:
 Slow continuous ultrafiltration (SCUF) uses arteriovenous (AV)
access and the patient’s blood pressure to circulate blood through a
hemofilter. Because the goal of this therapy is fluid removal, the
patient doesn’t receive any replacement fluids.
 Ultrafiltration little to no solure clearance
 No dialysate or replacement
 Continuous venovenous hemofiltration (CVVH) combines fluid
removal with a venous blood pump. A double-lumen catheter provides
access to a vein, and a pump moves blood through the hemofilter.
 Principle: ultrafiltration and convection
 Must use replacement fluide
 Indicated for severe acidbase or electrolytes disorder
 Small and large molecules ph impacted by buffer
 No dialysiate- but use of replacement fluid
 In continuous venovenous hemodialysis (CVVH-D), a vein provides
the access while a pump is used to move dialysate solution across the
hemofilter concurrent with blood flow.
 Procedd of removing waste and solures
 Principle: diffusion
 Small and medium size molecules pH impact by buffer
 Can safely remove fluid
o Nursing Considerations
 If the patient is undergoing CRRT for the first time, explain its
purpose and what to expect during treatment.
 Prime the hemofilter and tubing according to the manufacturer’s
instructions. (See Setup for CVVH, page 529.)
 Assist with catheter insertion, if necessary, using strict sterile
technique.
 If ordered, flush the catheters with a heparin flush solution to prevent
clotting.
o Get dressed
 Apply occlusive dressings to the insertion sites, and mark the dressings
with the date and time.
 Before treatment, weigh the patient, take baseline vital signs, and
make sure all necessary laboratory studies have been done (usually
electrolyte levels, coagulation factors, CBC, BUN, and creatinine studies).
 Monitor the patient’s vital signs and oxygen saturation.
 If a pulmonary artery (PA) catheter has been placed, assess the
patient’s hemodynamic parameters, including central venous pressure
(CVP), pulmonary artery pressure (PAP), and pulmonary artery wedge
pressure (PAWP).

28 | P a g e
  Be alert for indications of hypovolemia (such as decreasing blood
pressure and decreases in PAP, CVP, and PAWP) from too rapid
removal of ultrafiltrate or hypervolemia due to excessive fluid
replacement with a decrease in ultrafiltrate.
 Provide continuous cardiac monitoring because arrhythmias can occur
with electrolyte imbalances.
 Monitor the patient’s weight and vital signs frequently.
o Color is key
 Inspect the ultrafiltrate during the procedure. It should remain clear
yellow, with no gross blood.
 Pink-tinged or bloody ultrafiltrate may signal a membrane leak in
the hemofilter, which permits bacterial contamination. With a CVVH
system, look for the blood leak detector to signal this. If a leak occurs,
notify the doctor so the hemofilter can be replaced.
 Assess the leg used for vascular access for signs of obstructed blood flow,
such as coolness, pallor, and weak pulse. Check the groin area on the
affected side for signs of hematoma. Ask the patient if he has pain at the
insertion sites.
 Calculate the amount of replacement fluid every hour or as ordered,
according to your facility’s policy. When calculating the amount of
replacement fluid, add the amount of fluid in the collection device from
the previous hour with any other fluid losses the patient has, such as
blood loss, emesis, or NG tube drainage. From this total, subtract the
patient’s fluid intake for the past hour and the net fluid loss prescribed by
the practitioner.
 Infuse heparin in low doses (usually starting at 500 units/hour), as
ordered, into an infusion port on the arterial side of the setup to prevent
blood clotting during CVVH.
 Measure thrombin clotting time or activated clotting time (ACT). A normal
ACT is 100 seconds; during CRRT, keep it between 100 and 300 seconds,
depending on the patient’s clotting times.
o Setup for CVVT
 Continuous renal replacement therapy is typically performed using
continuous venous hemofiltration (CVVH). For this technique, the doctor
inserts a special double-lumen catheter into a large vein, commonly the
subclavian, femoral, or internal jugular vein. Because the catheter is in a
vein, an external pump is used to move blood through the system. The
patient's venous blood moves through the “arterial” lumen to the pump,
which then pushes the blood through the catheter to the hemofilter.
Here, water and toxic solutes (ultrafiltrate) are removed from the
patient's blood and drain into a collection device. Blood cells aren't
removed because they are too large to pass through the filter. As the
blood exits the hemofilter, it's then pumped through the ”venous“ lumen
back to the patient.
 Several components of the pump provide safety mechanisms. Pressure
monitors on the pump maintain the flow of blood through the circuit at a
constant rate. An air detector traps air bubbles before the blood returns
to the patient. A venous trap collects blood clots that may be in the

29 | P a g e
 blood. A blood-leak detector signals when blood is found in the dialysate;
a venous clamp operates if air is detected in the circuit or if there's
disconnection in the blood line.

o No bending allowed
 Make sure the patient doesn’t bend the affected leg more than 30
degrees at the hip, to prevent catheter kinking.

30 | P a g e
  Obtain serum electrolyte levels every 4 to 6 hours or as ordered;
anticipate adjustments in replacement fluid or dialysate based on the
results.
 If the patient is receiving CVVH, monitor the arterial and venous
pressure alarms.
 Inspect the site dressing for infection and bleeding. Perform skin
care at the catheter insertion sites every 48 hours, using sterile
technique. Cover the sites with an occlusive dressing.
 If the ultrafiltrate flow rate decreases, raise the bed to increase
the distance between the collection device and the hemofilter.
Lower the bed to decrease the flow rate.
 Clamping the ultrafiltrate line is contraindicated with some types of
hemofilters because pressure may build up in the filter, clotting it and
collapsing the blood compartment.
 Record the time the treatment begins, fluid balance figures, vital signs,
weight, times of dressing changes, complications, medications given, and
the patient’s tolerance of the procedure. Document patient assessment
parameters when the treatment course has ended.
 Pharmacologic Management
o Alkalinizing agents
 bicitra
 Shohi's solution
 sodium bicarbonate
o Antibiotics
 ciprofloxacin
 nitrofurantoin
 sulfisoxazole
 trimethoprim-sulfamethoxazole
o Antiemetics
 benzquinamide
 dimenhydrinate
 promethazine
 scopolamine
 thrimethobenzamide hydrochloride
o Calcium supplements
 parenteral calcium salts (e.g., calcium gluconate, chloride, gluceptate)
 Os-Cal
o Erythropoietin
 epogen
 epoietin alfa
o Folic acid supplement
 apo-folic
 folvite
o Histamine receptor antagonists
 cimetidine
 famotidine
 ranitidine
o Iron exchange resins

31 | P a g e
  sodium polystyrene sulfonate
o Iron supplements
 ferrous sulfate
 iron-dextran injection
o Opioid analgesics
 hydrocodone
 hydromorphone
 meperidine
 morphine
 propoxyphene
o Phosphate-binding agents
 aluminum hydroxide
o Proton pump inhibitor
 omeprazole

Drugs Indications Adverse Reactions Practice Pointers

Alkalinizing To correct Metabolic alkalosis, • Use with caution in patients with heart failure
agent: metabolic hypernatremia, local pain or renal insufficiency and patients receiving
Sodium acidosis in and irritation at the corticosteroids.
bicarbonate patients with injection site, hypokalemia • Assess the patient’s cardiopulmonary status.
renal failure • Monitor the patient for metabolic alkalosis and
electrolyte imbalance, especially hypocalcemia
and hypokalemia.
• Monitor the I.V. site for irritation and
infiltration. (Extravasation may cause tissue
damage and necrosis.)

Loop diuretics: To inhibit Dizziness, muscle cramps, • Monitor the patient for fluid and electrolyte
Bumetanide sodium hypotension, headache, imbalance.
(Bumex) resorption in fluid and electrolyte • Monitor the patient for cardiac arrhythmias,
Furosemide the renal imbalance (hypokalemia, especially ventricular.
(Lasix) tubule, hypochloremia, and • Avoid using in the patient with sulfonamide
Torsemide promote hyponatremia), hypersensitivity.
(Demadex) diuresis, and electrocardiogram (ECG) • Use is contraindicated in anuria.
manage edema changes, chest pain, renal • Be aware that ototoxicity may result with rapid
failure I.V. administration of high dosages.
• Carefully monitor the patient’s intake and
output.

Sulfonate To correct GI irritation, anorexia, • Monitor the patient for electrolyte imbalance,
cation- hyperkalemia nausea, vomiting, hypokalemia, and hypocalcemia.
exchange constipation, hypokalemia, • Monitor the patient for ECG changes (flat,
resin: hypocalcemia, diarrhea inverted T wave and prominent U wave) and
ventricular arrhythmias.
Sodium • For oral administration, mix resin with water or
polystyrene sorbitol—never orange juice because of high
sulfonate potassium content.
(Kayexalate) • Monitor elderly patients for constipation and
fecal impaction.
• Use cautiously in patients who require sodium
restriction, such as those with heart failure or
hypertension, to prevent the risk of sodium
overload.

 Diet and Nutrition Management

 Electrolytes Restrictions
 Fluid Restrictions

32 | P a g e
 High CHO Diet
 Complimentary/Alternative Therapy
 “Halamang Gamot”

o Reminders on the Use of Herbal Medicine

 Avoid the use of insecticide as these may leave poison on plants.
 In the preparation of herbal medicine, use a clay pot and remove cover
while boiling at low heat.
 Use only part of the plant being advocated.
 Follow accurate dose of suggested preparation.
 Use only one kind of herbal plant for each type of symptoms or sickness.
 Stop giving the herbal medication in case untoward reaction such as
allergy occurs.
 If signs and symptoms are not relieved after 2 to 3 doses of herbal
medication, consult a doctor.
o Sambong (Blumea balsamifera L. DC)
 Sabong is an amazing medical plant. Coming from the family of
Compositae, it goes by several names locally. It is known in the Visayas
as bukadkad and as subsud in ilocos. This plant possesses a multitude of
properties that make it worthy of the DOH approval.
 Common names: Sambong (Tagalog); lakad-bulan (Bikol); Ngai camphor
(English)
 Indications: Diuretic in hypertension; dissolves kidney stones
 Found in: In roadsides, fields, lowland and mountainous regions
 Parts used: Leaves and flowering tops
 Special precautions: Avoid using with other diuretics. When taking
diuretics, eat at least one banana a day.
o Pansit-pansitan/ulasimang bato or clear weed or silver bush (Peperomia
pellucida)

33 | P a g e
  This herbal plant is powerful in treating arthritis and gout. The folklore
also believes that it can be a medicine for eye inflammation, high blood
pressure and kidney problems.
 It’s usually taken as part of a meal or in a salad.
o Banaba or giant crape myrtle (Lagerstroemia speciosa)
 This herbal plant can be used to treat diabetes and kidney failure, as well
as obesity and high fever.
 In folklore, banaba is used to prevent constipation, kidney inflammation,
and urinary dysfunctions.

VI. Client Education

VII. Evaluation of the Outcome of Care
VIII. Reporting and documentation of Care

Bibliography:
 Hargrove-Huttel, R.A. (2005). Medical-surgical nursing (4th. ed.). Hong Kong: Lippincott Williams
& Wilkins.
 Berman, A., Snyder, S., Kozier, B., & Erb, G. (2008). Kozier & Erb’s fundamentals of nursing:
Concepts, process, and practice (8th ed.). Philadelphia: Pearson Education.
 Smeltzer, S.C., Bare, B.G., Hinkle, J.L., & Cheever, K.H. (2010). Brunner & Suddarth's textbook of
medical-surgical nursing (12th. ed.). China: Wolters Kluwer Health / Lippincott Williams &
Wilkins.
 12-lead ECG placement guide with illustrations (n.d.). Retrieved on August 12, 2021 from:
https://www.cablesandsensors.com/pages/12-lead-ecg-placement-guide-with-illustrations
 Patients with renal failure (n.d.). Retrieved on August 21, 2021 from
https://www.meddean.luc.edu/lumen/meded/mech/cases/case24/Caseqa_f.htm
 Kidney disease: 11 ways it can affect your skin (2019). Retrieved on August 22, 2021 from
https://www.aad.org/public/diseases/a-z/kidney-disease-warning-signs
 Daulog, M. (2020). 10 Philippines herbal medicine approved by DOH [Updates]. Retrieved on
August 24, 2021 from https://rnspeak.com/philippines-herbal-medicine-plants-approved-by-
doh/
 Domingo, R.K.M.M. (2017). DOH-recommended herbal plants in the Philippines. Retrieved on
August 24, 2021 from https://businessmirror.com.ph/2017/08/10/doh-recommended-herbal-
plants-in-the-philippines/

34 | P a g e
The client with acute renal failure has a serum
potassium level of 6.0 mEq/L. The nurse would
plan which of the following as a priority action?
 Check the sodium level.
 Place the client on a cardiac monitor.
 Encourage increased vegetables in the
diet.
 Allow an extra 500 mL of fluid intake to
dilute the electrolyte concentration.
RATIONALE: The client with hyperkalemia is at
risk of developing cardiac dysrhythmias and
cardiac arrest. Because of this, the client should
be placed on a cardiac monitor.
 Fluid intake is not increased because it
contributes to fluid overload and would
not affect the serum potassium level
significantly
 Vegetables are a natural source of
potassium in the diet, and their use
would not be increased.
 The nurse also may assess the sodium
level because sodium is another
electrolyte commonly measured with
the potassium level. However, this is
not a priority action of the nurse
The client being hemodialyzed suddenly
becomes short of breath and complains of chest
pain. The client is tachycardic, pale, and
anxious. The nurse suspects air embolism. The
priority action for the nurse is to:
 Discontinue dialysis and notify the
physician.
 Monitor vital signs every 15 minutes for
the
 next hour.
 Continue dialysis at a slower rate after
checking the lines for air.
 Bolus the client with 500 mL of normal
saline to break up the air embolus.
RATIONALE: If the client experiences air
embolus during hemodialysis, the nurse should
35 | P a g e
terminate dialysis immediately, notify the
physician, and administer oxygen as needed.
Options 2, 3, and 4 are incorrect.
 Recalling that air embolism is an
emergency situation that affects the
cardiopulmonary system suddenly and
profoundly will direct you to option 1.
The client arrives at the emergency department
with complaints of low abdominal pain and
hematuria. The client is afebrile. The nurse next
assesses the client to determine a history of:
 Pyelonephritis
 Glomerulonephritis
 Trauma to the bladder or abdomen
 Renal cancer in the client’s family
RATIONALE: Bladder trauma or injury should be
considered or suspected in the client with low
abdominal pain and hematuria. Use the
process of elimination. Eliminate options 1 and
2, knowing that any inflammatory disease or
infection is accompanied by fever. Review renal
assessment techniques and findings if you had
difficulty with this question.
 Glomerulonephritis and pyelonephritis
would be accompanied by fever and
are thus not applicable to the client
described in this question.
 Renal cancer would not cause pain that
is felt in the low abdomen; rather pain
would be in the flank area.
  Presence of a radial pulse in the left
The client is admitted to the emergency
department following a motor vehicle accident.
The client was wearing a lap seat belt when the
accident occurred and now the client has
hematuria and
lower abdominal pain. To assess further
whether the pain is caused by bladder trauma,
the nurse asks the client if the pain is referred
to which of the following areas?
 Hip
 Shoulder
 Umbilicus
 Costovertebral angle
RATIONALE: Bladder trauma or injury is
characterized by lower abdominal pain that
may radiate to one of the shoulders due to
phrenic nerve irritation. Bladder injury pain
does not radiate to the umbilicus,
costovertebral angle, or hip
The female client is admitted to the emergency
department following a fall from a horse and
the physician prescribes insertion of a Foley
catheter. While preparing for the procedure,
the nurse notes blood at the urinary meatus.
The nurse should:
 Notify the physician.
 Use a small-sized catheter.
 Administer pain medication before
inserting the catheter.
 Use extra povidone-iodine solution in
cleansing the meatus.
RATIONALE: The presence of blood at the
urinary meatus may indicate urethral trauma or
disruption. The nurse notifies the physician,
knowing that the client should not be
catheterized until the cause of the bleeding is
determined by diagnostic testing. Therefore
options 2, 3, and 4 are incorrect.
A nurse is assessing the patency of a client’s left
arm arteriovenous fistula prior to initiating
hemodialysis. Which finding indicates that the
fistula is patent?
 Palpation of a thrill over the fistula
wrist
 Absence of a bruit on auscultation of
the fistula
 Capillary refill less than 3 seconds in the
nail beds of the fingers on the left hand
RATIONALE: The nurse assesses the patency of
the fistula by palpating for the presence of a
thrill or auscultating for a bruit. The presence
of a thrill and bruit indicate patency of the
fistula. Although the presence of a radial pulse
in the left wrist and capillary refill shorter than 3
seconds in the nail beds of the fingers on the
left hand are normal findings, they do not
assess fistula patency
36 | P a g e

The male client has a tentative diagnosis of
urethritis. The nurse assesses the client for
which of the following manifestations of the
disorder?
 Hematuria and pyuria
 Dysuria and proteinuria
 Hematuria and urgency
 Dysuria and penile discharge
RATIONALE: The nurse is assessing the client
Urethritis in the male client often results from
chlamydial infection and is characterized by
dysuria, which is accompanied by a clear to
mucopurulent discharge. Because this disorder
often coexists with gonorrhea, diagnostic tests
are done for both and include culture and rapid
assays.
The nurse is assessing the client with
epididymitis. The nurse anticipates which of the
following findings on physical examination?
 Fever, diarrhea, groin pain, and
ecchymosis
 Nausea, vomiting, scrotal edema, and
ecchymosis
 Fever, nausea, vomiting, and painful
scrotal edema
 Diarrhea, groin pain, testicular torsion,
and scrotal edema
RATIONALE: Typical signs and symptoms of
epididymitis include scrotal pain and edema,
which often are accompanied by fever, nausea
and vomiting, and chills. Epididymitis most
often is caused by infection, although
sometimes it can be caused by trauma.
Epididymitis needs to be distinguished correctly
from testicular torsion
 Use the process of elimination. Any
disorder that ends in -itis results from
inflammation or infection. Therefore an
expected finding would be elevated
temperature. With this in mind,
eliminate options 2 and 4 because they
do not contain fever as part of the
option. Knowing that ecchymosis
results from bleeding, which is not part
of this clinical picture, directs you to
option 3. Review the clinical
manifestations of epididymitis if you
had difficulty with this question.
The client complains of fever, perineal pain,
and urinary urgency, frequency, and dysuria.
To assess whether the client’s problem is
related to bacterial prostatitis, the nurse would
look at the
results of the prostate examination, which
should reveal that the prostate gland is
 Soft and swollen
 Reddened, swollen, and boggy
 Tender and edematous with ecchymosis
 Tender, indurated, and warm to the
touch
RATIONALE: The client with prostatitis has a
swollen and tender prostate gland that is also
warm to the touch, firm, and indurated.
Systemic symptoms include fever with chills,
perineal and low back pain, and signs of urinary
tract infection, which often accompany the
disorder.
 Use the process of elimination. Begin to
answer this question by reasoning that
inflammation of the prostate gland
would cause the area to be tender. This
would allow you to eliminate options 1
and 2. Recalling that inflammation is
accompanied by local warmth will
direct you to option 4. Review the signs
of prostatitis if you had difficulty with
this question.
The nurse is taking the history of a client who
has had benign prostatic hyperplasia in the
past. To determine whether the client currently
is experiencing difficulty, the nurse asks the
client
about the presence of which early symptom?
 Nocturia-LATE SIGN
 Urinary retention-LATE SIGN
 Urge incontinence-LATE SIGN
 Decreased force in the stream of urine
37 | P a g e
RATIONALE: Decreased force in the stream of
urine is an early sign of benign prostatic
hyperplasia. The stream later becomes weak
and dribbling. The client then may develop
hematuria, frequency, urgency, urge
incontinence, and nocturia. If untreated,
complete obstruction and urinary retention can
occur.
 Use the process of elimination and note
the strategic word early. If you know
that benign prostatic hyperplasia can
lead to urinary obstruction, look for the
option that identifies the least severe
symptom. Review early signs of benign
prostatic hyperplasia if you had
difficulty with this question
The client newly diagnosed with chronic renal
failure recently has begun hemodialysis.
Knowing that the client is at risk for
disequilibrium syndrome, the nurse assesses
the client during dialysis for
 Hypertension, tachycardia, and fever
 Hypotension, bradycardia, and
hypothermia
 Restlessness, irritability, and
generalized weakness
 Headache, deteriorating level of
consciousness, and twitching
RATIONALE: Disequilibrium syndrome is
characterized by headache, mental confusion,
decreasing level of consciousness, nausea,
vomiting, twitching, and possible seizure
activity. Disequilibrium syndrome is caused by
rapid removal of solutes from the body during
hemodialysis. At the same time, the blood-
brain barrier interferes with the efficient
removal of wastes from brain tissue. As a
result, water goes into cerebral cells because of
the osmotic gradient, causing increased
intracranial pressure and onset of symptoms.
The syndrome most often occurs in clients who
are new to dialysis and is prevented by
dialyzing for shorter times or at reduced blood
flow rates.
The hemodialysis client with a left arm fistula is
at risk for arterial steal syndrome. The nurse
assesses this client for which of the following
manifestations?
 Warmth, redness, and pain in the left
hand
 Pallor, diminished pulse, and pain in
the left hand
 Edema and reddish discoloration of the
left arm
 Aching pain, pallor, and edema of the
left arm
RATIONALE: Steal syndrome results from
vascular insufficiency after creation of a fistula.
The client exhibits pallor and a diminished
pulse distal to the fistula. The client also
complains of pain distal to the fistula, caused by
tissue ischemia.
 Warmth and redness probably would
characterize a problem with infection.
The manifestations described in options
3 and 4 are incorrect.
The nurse is reviewing the client’s record and
notes that the physician has documented that
the client has a renal disorder. On review of
the laboratory results, the nurse most likely
would expect to note which of the following?
 Decreased hemoglobin level
 Elevated creatinine level
 Decreased red blood cell count
 Decreased white blood cell count
RATIONALE: Measuring the creatinine level is a
frequently used laboratory test to determine
renal function. The creatinine level increases
when at least 50% of renal function is lost. A
decreased hemoglobin level and red blood cell
count may be noted if bleeding from the urinary
tract occurs or if erythropoietic function by the
kidney is impaired. An increased white blood
cell count is most likely to be noted in renal
disease
 Use the process of elimination.
Recalling the relationship between the
creatinine level and renal function will
direct you to option 2
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The client with chronic renal failure returns to
the nursing unit following a hemodialysis
treatment. On assessment, the nurse notes
that the client’s temperature is 100.2 F. Which
of the following is the appropriate nursing
action?
 Encourage fluids.
 Notify the physician.
 Continue to monitor vital signs.
 Monitor the site of the shunt for
infection
RATIONALE: The client may have an elevated
temperature following dialysis because the
dialysis machine warms the blood slightly. If the
temperature is elevated excessively and
remains elevated, sepsis would be suspected
and a blood sample would be obtained as
prescribed for culture and sensitivity
determinations.
 Use the process of elimination and
focus on the data in the question.
Recalling that an elevation in
temperature is expected following
dialysis will direct you to
The nurse is performing an assessment on a
client who has returned from the dialysis unit
following hemodialysis. The client is
complaining of headache and nausea and is
extremely restless. Which of the following is
the most appropriate nursing action?
 Monitor the client.
 Notify the physician.
 Elevate the head of the bed.
 Medicate the client for nausea
RATIONALE: Disequilibrium syndrome may be
caused by the rapid decreases in the blood
urea nitrogen level during hemodialysis. These
changes can cause cerebral edema that leads to
increased intracranial pressure. The client is
exhibiting early signs of disequilibrium
syndrome and appropriate treatments with
anticonvulsive medications and barbiturates
may be necessary to prevent a life-threatening
situation. The physician must be notified.
 Use the process of elimination and
focus on the client’s signs and
symptoms. Recalling the complications
associated with hemodialysis will direct
you to option 2. Review the signs and
symptoms of disequilibrium yndrome if
you had difficulty with this question.
A client newly diagnosed with renal failure has
just been started on peritoneal dialysis. During
the infusion of the dialysate, the client
complains of abdominal pain. Which action by
the nurse is appropriate?
 Stop the dialysis.
 Slow the infusion.
 Decrease the amount to be infused.
 Explain that the pain will subside after
the first few exchanges.
RATIONALE: Pain during the inflow of dialysate
is common during the first few exchanges
because of peritoneal irritation; however, the
pain usually disappears after 1 to 2 weeks of
treatment. The infusion amount should not be
decreased, and the infusion should not be
slowed or stopped.
 Use the process of elimination.
Eliminate options 1, 2, and 3 because
they are comparable or alike actions.
Review the complications associated
with peritoneal dialysis and the
appropriate nursing actions if you had
difficulty with this question
The nurse is instructing a client with diabetes
mellitus about peritoneal dialysis. The nurse
tells the client that it is important to maintain
the prescribed dwell time for the dialysis
because of the risk of:
 Infection
 Hyperglycemia
 Hypophosphatemia
 Disequilibrium syndrome
RATIONALE: An extended dwell time increases
the risk of hyperglycemia in the client with
diabetes mellitus as a result of absorption of
glucose from the dialysate and electrolyte
39 | P a g e
changes. Diabetic clients may require extra
insulin when receiving peritoneal dialysis.
 Use the process of elimination. Noting
the client’s diagnosis and recalling that
the dialysate solution contains glucose
will direct you to option 2.
A week after kidney transplantation, the client
develops a temperature of 101 F, the blood
pressure is elevated, and the kidney is tender.
The x-ray indicates that the transplanted kidney
is enlarged. Based on these assessment
findings, the nurse would suspect which of the
following complications?
 Acute rejection
 Kidney infection
 Chronic rejection
 Kidney obstruction
RATIONALE: Acute rejection most often occurs
in the first 2 weeks after transplantation.
Clinical manifestations include fever, malaise,
elevated white blood cell count, acute
hypertension, graft tenderness, and
manifestations of deteriorating renal function.
Chronic rejection occurs gradually over a
period of months to years. Although kidney
infection or obstruction can occur, the
symptoms presented in the question do not
relate specifically to these disorders.
 words a week after kidney
transplantation.
The client is admitted to the hospital with a
diagnosis of benign prostatic hyperplasia, and a
transurethral resection of the prostate is
performed. Four hours after surgery, the nurse
takes the client’s vital signs and empties the
urinary drainage bag. Which of the following
assessment findings would indicate the need
to notify the
physician?
 Red bloody urine
 Pain related to bladder spasms
 Urinary output of 200 mL higher than
intake
 Blood pressure, 100/50 mm Hg; pulse,
130
 beats/min
RATIONALE: Frank bleeding (arterial or venous)
may occur during the first day after surgery.
Some hematuria is usual for several days after
surgery. A urinary output of 200 mL more than
intake is adequate. Bladder spasms are
expected to occur following surgery. A rapid
pulse with a low blood pressure is a
potential sign of excessive blood loss. The
physician should
be notified
A client with bladder cancer undergoes surgical
removal of the bladder with construction of an
ileal conduit. What assessments by the nurse
indicate that the client is developing
complications? Select all that apply.
 1. Urine output greater than 30 ml/
hour
 2. Dusky appearance of the stoma
 3. Stoma protrusion from the skin
 4. Mucus shreds in the urine collection
bag
 5. Edema of the stoma during the first
24 hours after surgery
 6. Sharp abdominal pain with rigidity
RATIONALE: A dusky appearance of the stoma
indicates decreased blood supply; a healthy
stoma should appear beefy-red. Protrusion
indicates prolapse of the stoma, and sharp
abdominal pain with rigidity indicates peritonitis
 A urine output greater than 30 ml/hour
is a sign of adequate renal perfusion
and is a normal finding.
 Because mucous membranes are used
to create the conduit, mucus in the
urine is expected.
 Stomal edema is a normal finding
during the first 24 hours after surgery.
A client with fever and urinary urgency is asked
to provide a urine specimen for culture and
sensitivity analysis. The nurse should instruct
the client to collect the specimen from the:
 1. first stream of urine from the
bladder.
40 | P a g e
  2. middle stream of urine from the
bladder.
 3. final stream of urine from the
bladder.
 4. full volume of urine from the bladder.
RATIONALE: . The midstream specimen is
recommended because it’s less likely to be
contaminated with microorganisms from the
external genitalia than other specimens. It isn’t
necessary to collect a full volume of urine for a
urine culture and sensitivity.
A client is diagnosed with cystitis. The nurse
recommends the client drink cranberry juice.
What assessment parameter should the nurse
consider to determine if this recommendation
has been effective?
 1. Urine specific gravity
 2. White blood cell (WBC) count
 3. pH
 4. Protein
RATIONALE: Because cranberry juice is an acid-
ash food that lowers the urine pH, monitoring
urine pH would be most useful in evaluating the
effectiveness of the intervention. Urine specific
gravity, WBC count, and protein level won’t
pinpoint the effectiveness of acid-ash food.
A client with dysuria is prescribed
phenazopyridine (Pyridium). The nurse should
teach the client to expect urine to be:
 1. greater in volume.
 2. orange in color.
 3. pungent in odor.
 4. concentrated in consistency.
RATIONALE: Phenazopyridine causes the urine
to have an orange color. Phenazopyridine
doesn’t cause higher urine volume, a pungent
urine odor, or concentrated urine.
The nurse is instructing a client with oxalate
renal calculi. Which foods should the nurse
urge the client to eliminate from his diet?
 1. Citrus fruits, molasses, and dried
apricots
 2. Milk, cheese, and ice cream
 3. Sardines, liver, and kidney
 4. Spinach, rhubarb, and asparagus
RATIONALE: To reduce the formation of
oxalate calculi, urge the client to avoid foods
high in oxalate, such as spinach, rhubarb, and
asparagus. Other oxalate-rich foods to avoid
include tomatoes, beets, chocolate, cocoa,
Ovaltine, nuts, celery, and parsley. Citrus fruits,
molasses, dried apricots, milk, cheese, ice
cream, sardines, and organ meats don’t
produce oxalate and need not be omitted from
the client’s diet.
A nurse is instructing the client about
recommended daily fluid consumption. The
nurse should tell the client to drink
approximately:
 1. 4 cups per day.
 2. 8 cups per day.
 3. 12 cups per day.
 4 16 cups per day.
RATIONALE: 3. A client with renal calculi should
drink 3 L of fluid per day. This amount is
equivalent to 12 cups.
A client with chronic renal failure reports
pruritus. Which instruction should the nurse
include in this client’s teaching plan?
 1. Rub the skin vigorously with a towel.
 2. Take frequent baths.
 3. Apply alcohol-based emollients to the
skin.
 4. Keep fingernails short and clean.
RATIONALE: Calcium-phosphate deposits in the
skin may cause pruritus. Scratching leads to
excoriation and breaks in the skin that increase
the client’s risk of infection. The nurse should
tell the client to keep his fingernails short and
clean to reduce the risk of infection. Vigorous
rubbing with a towel can cause skin irritation,
leading to further itching or breaks in the skin.
Frequent bathing can dry the skin, which
contributes to itching. Emollients without
alcohol should be used to soothe the skin and
help it retain moisture.
A client in acute renal failure becomes severely
anemic and the physician prescribes two units
41 | P a g e
of packed red blood cells (RBCs). The nurse
should plan to administer each unit:
 1. as quickly as the client can tolerate
the infusions.
 2. over 30 minutes to an hour.
 3. between 1 and 4 hours.
 4. up to 4 hours but no longer
RATIONALE: 3. It’s standard practice to infuse a
unit of packed RBCs between 1 to 4 hours.

A nurse is teaching a client with chronic renal

failure about foods to avoid. It would be most
accurate for the nurse to teach the client to
avoid:
 1. yogurt and milk.
 2. whole grain breads.
 3. fresh fruits and vegetables.
 4. beef and pork.
RATIONALE: Proteins are typically restricted in
clients with chronic renal failure because of
their metabolites. The diet should be high in
both calories and carbohydrates.

A client with bladder cancer receives local

radiation therapy and experiences a dry skin
reaction. When teaching the client about skin
care, the nurse should instruct the client to
avoid:
 1. lubrication.
 2. cleansers.
 3. cold packs.
 4. cotton garments
RATIONALE: Cold packs over the area of a dry
reaction to radiation therapy are
contraindicated because they reduce capillary
circulation to the site and hamper healing.
Lubrication, cleansers, and cotton garments
aren’t unconditionally contraindicated.

42 | P a g e
The client who has a cold is seen in the
emergency department with an inability to void.
Because the client has a history of benign
prostatic hyperplasia, the nurse determines that
the client should be questioned about the use
of which of the following medications?
 Diuretics
 Antibiotics
 Antitussives
 Decongestants
Nalidixic acid (NegGram) is prescribed for a
client with a urinary tract infection. On review
of the client’s record, the nurse notes that the
client is taking warfarin sodium (Coumadin)
daily. Which prescription should the nurse
anticipate for this client?
 Discontinuation of warfarin sodium
(Coumadin)
 2. A decrease in the warfarin sodium
(Coumadin) dosage
 3. An increase in the warfarin sodium
(Coumadin) dosage
 4. A decrease in the usual dose of
nalidixic acid (NegGram)
A nurse is providing discharge instructions to a
client receiving sulfisoxazole. Which of the
following would be included in the list of
instructions?
 Restrict fluid intake.
 2. Maintain a high fluid intake.
 3. If the urine turns dark brown, call the
physician immediately.
 4. Decrease the dosage when
symptoms are improving to prevent an
allergic response.
. Trimethoprim-sulfamethoxazole (TMP-SMZ;
Bactrim) is prescribed for a client. A nurse
would instruct the client to report which
symptom if it developed during the course of
this medication therapy?
 Nausea
 . Diarrhea
 . Headache
 . Sore throat
. Phenazopyridine hydrochloride (Pyridium) is
prescribed for a client for symptomatic relief of
pain resulting from a lower urinary tract
infection. The nurse teaches the client:
 To take the medication at bedtime
 2. To take the medication before meals
 3. To discontinue the medication if a
headache occurs
 4. That a reddish orange discoloration
of the urine may occur
. Bethanechol chloride (Urecholine) is
prescribed for a client with urinary
retention. Which disorder would be a
contraindication to the administration of
this medication?
 Gastric atony
 2. Urinary strictures
 3. Neurogenic atony
 4. Gastroesophageal reflux
. A nurse who is administering bethanechol
chloride (Urecholine) is monitoring for acute
toxicity associated with the medication. The
nurse checks the client for which sign of
toxicity?
 Dry skin
 2. Dry mouth
 3. Bradycardia
 4. Signs of dehydration
. Oxybutynin chloride (Ditropan) is prescribed
for a client with neurogenic bladder. Which sign
would indicate a possible toxic effect related to
this medication? 1. Pallor 2. Drowsiness 3.
Bradycardia 4. Restlessness 761. Following
kidney transplantation, cyclosporine
(Sandimmune) is prescribed for a client. Which
laboratory result would indicate an adverse
effect from the use of this medication? 1.
Decreased creatinine level 2. Decreased
hemoglobin level 3. Elevated blood urea
nitrogen level 4. Decreased white blood cell
count 762. A nurse is providing dietary
instructions to a client who has been prescribed
cyclosporine (Sandimmune). Which food item
would the nurse instruct the client to avoid? 1.
43 | P a g e
Red meats 2. Orange juice 3. Grapefruit juice 4.
Green leafy vegetables 763. Tacrolimus
(Prograf) is prescribed for a client. Which
disorder, if noted in the client’s record, would
indicate that the medication needs to be
administered with caution? 1. Pancreatitis 2.
Ulcerative colitis 3. Diabetes insipidus 4.
Coronary artery disease 764. A nurse is
reviewing the laboratory results for a client
receiving tacrolimus (Prograf). Which laboratory
result would indicate to the nurse that the
client is experiencing an adverse effect of the
medication? 1. Blood glucose of 200 mg/dL 2.
Potassium level of 3.8 mEq/L 3. Platelet count
of 300,000 cells/mm3 4. White blood cell count
of 6000 cells/mm3 765. The nurse receives a
call from a client concerned about eliminating
brown-colored urine after taking nitrofurantoin
(Furadantin) for a urinary tract infection. Which
of the following is the appropriate response
from the nurse? 1. “Discontinue taking the
medication and make an appointment for a
urine culture.” 2. “Continue taking the
medication because the urine is discolored from
the medication.” 3. “Decrease your medication
to half the dose because your urine is too
concentrated.” 4. “Take magnesium hydroxide
(Maalox) with your medication to lighten the
urine color.” 766. A client with chronic renal
failure is receiving epoetin alfa (Epogen,
Procrit). Which laboratory result would indicate
a therapeutic effect of the medication? s894
UNIT XIV The Adult Client With a Renal System
Disorder 1. Hematocrit of 32% 2. Platelet count
of 400,000 cells/mm3 3. Blood urea nitrogen
level of 15 mg/dL 4. White blood cell count of
6000 cells/mm3 Alternate Item Format:
Chart/Exhibit 767. Cinoxacin (Cinobac), a
urinary antiseptic, is prescribed for the client.
The nurse reviews the client’s medical record
and would contact the physician regarding
which documented finding to verify the
prescription? 1. Renal insufficiency 2. Chest x-
ray: normal 3. Blood glucose, 102 mg/dL 4. Folic
acid (vitamin B6) 0.5 mg, orally daily

44 | P a g e