RENAL SYSTEM

✓ The primary purpose of the renal and urinary systems is to maintain the body’s state of homeostasis by carefully
regulating fluid and electrolytes, removing wastes, and providing other functions.
FUNCTIONS OF THE KIDNEYS
1. Controls fluid and electrolyte balance.
2. Controls of acid-base balance
3. Excrete end products of body metabolism
4. Secrete renin & eryhtropoietin
5. Manufacture & activation of vitamin D
6. Secretes urine
ANATOMY AND PHYSIOLOGY
✓ The renal and urinary systems include the kidneys, ureters, bladder, and urethra.
✓ Urine is formed by the kidney and flows through the other structures to be eliminated from the body.

1. KIDNEYS
Gross Anatomy
1. Shaped like a lima beans
2. Lies against posterior abdominal wall, behind the peritoneum at the level of the last thoracic and first lumbar
vertebrae; right kidney slightly lower than left.
3. External structure: hilum, renal capsule
4. Internal structure: cortex, medulla, pyramids, columns, papillae, calyces, pelvis.
Blood flow in the kidney
1. Kidney receives 20% of the cardiac output during rest; reduced to 2% to 4% during physical or emotional stress.
2. The normal blood flow through the kidneys is about 1200 mL/min.
3. Abdominal aorta gives rise to renal arteries, which enters the hilum of each kidney; eventually branches to
different arterioles, which enter glomerular capillary beds.
4. Efferent arterioles leave the glomerular capillary bed; eventually converge into progressively larger veins until
leaving the kidney.
Vascular system of nephron.
1. BOWMAN’S CAPSULE- contains the glumerulus and acts as a filter of urine
2. GLOMERULUS- a network of twisted capillaries that acts as a filter for the passage of protein-free and rbc-free
filtrate to the proximal convoluted tubules
2. URETERS
1. Tubes act as ducts channeling urine to the bladder via peristaltic waves that occur about one to five times per minute
they measure about 10” to 12” in adult.
3. URINARY BLADDER
1. A hollow, spherical, muscular organ in the pelvis that serves to store urine delivered by the ureters.
2. Bladder capacity ranges from 500 to 600 ml in a normal adult.
4. URETHRA
1. a small duct that channels urine outside the body from the bladder
Laboratory/Diagnostic Test
1. URINALYSIS
2. URINE CULTURE and SENSITIVITY- to identify the causative organism in UTI
3. RESIDUAL URINE – sterile technique
4. CREATININE CLEARANCE
 1. a 24-hour urine test commonly used to assess GFR
2. Determines how efficiently the kidneys clears creatinine from the blood.
Urine
a. Color – clear, light yellow, amber
b. Amount – 1,500 ml per day average
c. 0dor - aromatic
d. Specific gravity- 1.010-1.030
e. Urine osmolality- 300-900 mOsm/kg/24hr
f. pH – 5.5-6.5
g. Blood-none
h. Glucose- negative
i. Protein – less than 20
j. Rbc –less than 3
k. Wbc – 0-5
l. Bacteria- none
5. Intravenous Pyelography (IVP)
a. Test is used to evaluate: renal stones, masses ,hematuria, obstructive uropathy , congenital anomalies infection renal
function.
b. Series of radiologic films are obtained after
c. Injection of a radiopaque contrast medium.
Pre-procedure:
✓ Obtain consent
✓ Screening for potential allergies or sensitivity to contrast medium and iodine
✓ Bowel preparation is necessary
✓ NPO post-midnight
✓ Explanation that there may be a sensation of flushing and warmth, and unpleasant salty taste in the mouth or
nausea when the contrast dye is administered
✓ Antihistamines, steroids, and emergency cart must be readily available.
Post-procedure:
✓ Monitor hydration of renal after IVP to reduce the risk of renal failure in susceptible client.
✓ Promote fluids to promote renal clearance of the contrast dye.
✓ Monitor for dye reaction such as hives, nausea, or parotid swelling
CONTRAINDICATIONS:
✓ Contraindicated in patient with renal failure, uncontrolled DM, or multiple myeloma
✓ Contraindicated in patient receiving drug therapy for chronic bronchitis, or asthma, and in patient taking
metformin (glucophage)
✓ Patient with known iodine/contrast material allergy must have steroids/antihistamine preparation
6. Retrograde Pyelography
a. Injection of radio-opaque contrast material through ureteral catheters, which have been passed into ureters by means
of cystoscopic manipulation. The radio-opaque solution is introduced by syringe injection.
b. May be done when intravenous pyelography (IVP) is contraindicated or if IVP provides inadequate visualization of the
collecting system.
c. Contraindicated in patients with UTI.
7. Cystourethrogram
a. Visualization of urethra and bladder by X-ray after retrograde instillation of contrast material through a catheter.
b. An examination of only the bladder is a cystogram; of only the urethra is a urethrogram.
c. Used to identify injuries, vesicoureteral reflux, tumors, or structural abnormalities of the urethra or bladder; or to
evaluate emptying problems or incontinence (voiding cystourethrogram).
8. Renal Angiography
a. I.V. catheter is threaded through the femoral and iliac arteries into the aorta or renal artery.
b. Contrast material is injected to visualize the renal arterial supply.
c. Evaluates blood flow dynamics, demonstrates abnormal vasculature, and differentiates renal cysts from renal tumors.
d. May be done prior to renal transplant or to embolize a kidney before nephrectomy for renal tumor.
e. Clear liquids only after midnight before the examination; adequate hydration is essential.
f. Continue oral medications (special orders needed for diabetic patients).
g. I.V. required.
h. May not be done on the same day as other studies requiring barium or contrast material.
i. Maintain bed rest for 8 hours after the examination, with the leg kept straight on the side used for groin access.
j. Observe frequently for hematoma or bleeding at access site.
k. Keep sandbag at bedside for use if bleeding occurs.
9. Renal Scans
a. Radiopharmaceuticals (also called radiotracers or isotopes) are injected I.V.
b. Tc-DTPA, Tc99m-DMSA is used for anatomical or MAG3 visualization and evaluation of glomerular filtration.
c. Evaluates renal size, shape, position, and function or blood flow to the kidneys.
d. Studies are obtained with a scintillation camera placed posterior to the kidney with patient in a supine, prone, or sitting
position.
e. Patient should be well hydrated. Give several glasses of water or I.V. fluids as ordered before scan.
f. Furosemide (Lasix) or captopril (Capoten) may be administered in conjunction with the scan to determine their effects.
10. Ultrasound
a. A noninvasive technique.
b. Abnormalities, such as masses, malformations, or obstructions, can be identified; useful in differentiating between
solid and fluid-filled masses.
c. Uses high-frequency sound waves passed into the body and reflected back in varying frequencies based on the
composition of soft tissues.
d. Ultrasound examination of the bladder requires that the bladder be full.
11. Cystoscopy
a. Cystoscopy is a method of direct visualization of the urethra and bladder by means of a cystoscope that is inserted
through the urethra into the bladder.
b. To inspect bladder wall directly for tumor, stone, or ulcer and to inspect urethra for abnormalities or to assess degree
of prostatic obstruction.
c. To remove calculi from urethra, bladder, and ureter.
d. To diagnose and treat lesions of bladder, urethra, and prostate.
e. To perform endoscopic prostate surgeries including transurethral resection of the prostate (TURP)
12. Kidney Biopsy
✓ Performed by percutaneous needle biopsy through renal tissue with ultrasound guidance or by open biopsy through a
small flank incision.
✓ Useful in securing specimens for electron and immunofluorescent microscopy to determine diagnosis, treatment, and
prognosis of renal disease.
Pre-procedure
a. Obtain consent
b. NPO
c. Determine coagulation study
d. Obtain and record vital signs
e. Small gauge (21-25-gauge) are used in cytologic examination
f. Larger gauge (14-20) are used to obtain tissue cores for histophatologic examination.
g. Guided imaging such as MRI is used to help avoid large blood vessel.
h. The physician inserts the biopsy needle as the client inspires deeply and hold breathe.(12th rib)
Post-biopsy
a. Immediately after the biopsy, apply pressure to the puncture site for 20 minutes.
b. Apply sterile dressing
c. Pressure may be maintained by having the client lie on a sandbag placed against the biopsy site
d. Check puncture site for bleeding and monitor V/S
e. Force fluid to promote urination to prevent clot formation which can lead to urine obstruction.
DISORDERS OF THE GENITOURINARY SYSTEM
1. URINARY TRACT INFECTIONS (Cystitis, Urethritis)
✓ Presence of bacteria in the urine (10 bacteria/mL of urine or greater)
✓ Women are more susceptible to developing acute cystitis because of shorter length of urethra; anatomical proximity to
vagina, periurethral glands, and rectum (fecal contamination); and the mechanical effect of coitus.
✓ Poor voiding habits may result in incomplete bladder emptying, increasing the risk of recurrent infection.
✓ E. coli causes 86% of UTIs, other pathogens, such as Klebsiella species, Proteus species, and Staphylococcus
saprophyticus may cause UTI.
Clinical Manifestations
a. Dysuria, frequency, urgency, nocturia
b. Suprapubic pain and discomfort
c. Back pain
d. low-grade fever
e. Microscopic or gross hematuria
f. Generalized fatigue- most common in elderly
g. Change in cognitive functioning- - most common in elderly with dimentia
Diagnostic Evaluation
a. Urine dipstick may react positively for blood, white blood cells (WBCs), and nitrates indicating infection.
b. Urine microscopy shows RBCs and many WBCs per field without epithelial cells.
c. Urine culture is used to detect presence of bacteria and for antimicrobial sensitivity testing.
Medical Management
Antibiotic therapy - ciprofloxacin (Cipro), (Macrodantin), (Bactrim, Septra).
a. Adverse effects include nausea, diarrhea, drug-related rash, and vaginal candidiasis, crystalliuria
b. For severe discomfort with voiding, phenazopyridine (Pyridium).
c. Take antibiotic at bedtime after emptying bladder to ensure adequate concentration of drug overnight because low
rates of urine flow and infrequent bladder emptying predispose to multiplication of bacteria.
d. Assess for rash periodically during therapy. May cause Stevens-Johnson syndrome.
Nursing Management
a. Drink liberal amounts of water to lower bacterial concentrations in the urine.
b. Cleanse around the perineum and urethral meatus after each bowel movement, with front-to-back cleansing to
minimize fecal contamination of periurethral area.
c. Void immediately after sexual intercourse.
d. Avoid bladder irritants—coffee, tea, alcohol, cola drinks, and aspartame.
e. Avoid external irritants such as bubble baths, talcum powders, perfumed vaginal cleansers or deodorants.
2. ACUTE BACTERIAL PYELONEPHRITIS
➢ Inflammation of the renal pelvis & parenchyma, commonly caused by bacterial invasion
➢ Usually ascends from the lower urinary tract or following an invasive procedure of the urinary tract; can progress to
bacteremia or chronic pyelonephritis.

Clinical Manifestations
a. Fever, chills
b. Flank pain (with or without radiation to groin)
 c. Nausea, vomiting, anorexia, abdominal pain, diarrhea
d. Costovertebral angle(CVA) tenderness (unilateral or bilateral)
e. Urgency, frequency, and dysuria
Diagnostic Evaluation
a. Urinalysis (dipstick or microscopic) to identify leukocytes bacteria, and RBCs and WBCs in urine; white cell casts.
b. Urine culture to identify causative bacteria.
c. CBC shows elevated WBC count consisting of neutrophils and bands.
d. CT scan of abdomen—with contrast—is the imaging study of choice
e. Intravenous urography (IVU)
f. Renal ultrasound - to evaluate for urinary tract obstruction necessary.
g. Blood cultures may be drawn if indicated.
Medical Management
1. Antibiotic therapy
a. Penicillin plus aminoglycoside I.V.
b. Fluoroquinolone- 7 to 14 days is the usual length of treatment.
Nursing Interventions
a. Assess vital signs frequently, and monitor intake and output
b. Administer antiemetic medications to control nausea and vomiting.
c. Administer antipyretic medications as prescribed and according to temperature.
d. Monitor for effectiveness and adverse effects of antibiotic therapy
e. Report fever that persists beyond 72 hours after initiating antibiotic therapy
f. Use comfort measures, such as positioning, to locally relieve flank pain.
g. Hydration- 3L of fluids
3. CHRONIC BACTERIAL PHYELONEPHRITIS
✓ Repeated bouts of acute pyelonephritis.
✓ Complications of chronic pyelonephritis include end-stage renal disease, hypertension, formation of kidney stone.
Clinical Manifestations
a. Client usually unaware of the disease
b. May have bladder irritability
c. Chronic fatigue
d. Slight dull ache over the kidneys
e. Eventually develops hypertension, atrophy of the kidneys
f. Azotemia
Diagnostic Test
a. Intravenous pyelography(IVP)
b. BUN and creatinine measurement
c. Creatinine clearance test
Medical Management
✓ Long term use of antibiotic therapy
Nursing Management
a. 3 to 4 L of fluids per day is encouraged to dilute the urine
b. Take vital signs especially body temperature
c. Emptying the bladder regularly
d. Performing recommended perineal hygiene.
e. Taking antimicrobial medications exactly as prescribed.
4. UROLITHIASIS/ NEPHROLITHIASIS
✓ Presence of stones anywhere in the urinary tract.
✓ Frequent compositions of stones: calcium (phosphate), uric acid and cystine (rare) stones
✓ Most often occurs in men age 20-55 years; more common in the summer.
PREDISPOSING FACTORS
a. Sedentary lifestyles, immobility
b. Chronic dehydration, poor fluid intake
c. Genetic predisposition for urolithiasis or genetic disorders (cystinuria)
d. Chronic infection with urea-splitting bacteria (Proteus vulgaris)
e. Chronic obstruction with stasis of urine, foreign bodies within the urinary tract
f. Medications known to cause stones in some patients include antacids, acetazolamide (Diamox), vitamin D, laxatives,
and high doses of aspirin.
g. Causes of hypercalcemia (high serum calcium) and hypercalciuria (high urine calcium) may include the following:
a. Hyperparathyroidism
b. Renal tubular acidosis
 c. Cancers
d. Granulomatous diseases (eg, sarcoidosis, tuberculosis)
e. Excessive intake of vitamin D
f. Excessive intake of milk and alkali
g. Myeloproliferative diseases

Clinical Manifestations
a. Abdominal pain or flank pain
b. Renal colic severe pain in the kidney area radiating down the flank to the pubic area
c. Hematuria, frequency, urgency, nausea and vomiting
d. History of prior associated health problems gout, hyperparathyroidism, immobility, dehydration, UTI
e. Diaphoresis, pallor, grimacing
f. Pyuria if infection is present
Diagnostic Test
a. Intravenous Pyelography (IVP)/KUB
b. Ultrasound
c. 24-hour urine test for calcium, uric acid, creatinine, sodium, pH.
d. Stone analysis
Medical Management
1. Relieve pain
a. Opioid analgesic , Nonsteroidal anti-inflammatory drugs (NSAIDs)
b. Hot baths or moist heat to the flank areas.
2. Interventional Procedures
a. Ureteroscopy
b. Endourologic (percutaneous)
c. Chemolysis- (eg, alkylating agents, acidifying agents) for the purpose of dissolving the stone.
d. Extracorporeal shock wave lithotripsy (ESWL)

NURSING CARE
POST ESWL
a. Strain all urine through gauze to detect stones
and crush all clots.
b. Send stone to the laboratory for chemical
analysis.
c. Force fluids (3000 – 4000 ml/day).
d. Encourage ambulation to prevent stasis.
e. Monitor I & O.

Nursing Management
a. Give prescribed NSAID or opioid analgesic (usually I.V. or I.M.)
b. Administer Allopurinol (Zyloprim) as ordered
c. Monitor vital signs especially respiratory rate
d. Administer antiemetics (I.M. or rectal suppository) as indicated for nausea.
e. Prevention of urinary stasis by:
 ✓ Increasing fluid intake especially in hot weather and during illness
✓ Encourage client to ambulate.
✓ Voiding whenever the urge is felt and at least twice during the night.
f. Diet modification

CALCIUM STONES OXALATE STONE CYSTINE STONES (rare)

-Low calcium diet (400 mg - Avoid excess intake of URIC ACID STONES
daily) achieved by eliminating foods/fluids high in oxalate - Uric acid is a metabolic
-Low methionine
milk/dairy products - Tea product of purines
-Provide acid-ash diet to - Chocolate -Reduce foods high in purine
acidify urine - Rhubarb -Liver -Methionine is the essential
- Cranberry or prune juice - Spinach - Brains amino acid from which the
- Meat -Maintain alkaline-ash diet -Kidneys non-essential amino acid
- Eggs to alkalinize urine - Venison cystine is formed
- Poultry - Milk -Shellfish
- Fish - Vegetables -Meat soups
-Gravies -Limit protein foods
- Grapes - Fruits except prunes,
- Whole grains -Legumes Meat, milk, eggs, cheese
cranberries and plums
- Take vitamin A & C, Folic - Whole grains
acid supplements and -Maintain alkaline-ash diet -Maintain Alkaline-ash diet -Maintain alkaline-ash diet
Riboflavin
Maintain acid-ash diet
-

5. Acute renal failure (ARF)

✓ Is a rapid loss of renal function due to damage to the kidneys.
✓ It is frequently associated with an increase in BUN and creatinine, oliguria (less than 500 mL urine/24 hours),
hyperkalemia, and sodium retention.
✓ Due to conditions that reduce blood flow to the kidney and impair kidney function:
a. Hypovolemia
b. Hypotension
c. Reduced cardiac output and heart failure
d. Obstruction of the kidney or lower urinary tract by tumor, blood clot, or kidney stone;
e. Bilateral obstruction of the renal arteries or veins.

Categories of Acute Renal Failure

A. Prerenal Failure- is the result of impaired blood flow that leads to hypoperfusion of the kidney and a decrease in the GFR.
1. Volume depletion resulting from:
✓ Hemorrhage
✓ Renal losses (diuretics, osmotic diuresis)
✓ Gastrointestinal losses (vomiting, diarrhea, nasogastric suction)
2. Impaired cardiac efficiency resulting from:
✓ Myocardial infarction
✓ Heart failure
✓ Dysrhythmias
✓ Cardiogenic shock
3. Vasodilation resulting from:
✓ Sepsis
 ✓ Anaphylaxis
✓ Antihypertensive medications or other medications that cause vasodilation
B. Intrarenal Failure
1. Prolonged renal ischemia resulting from:
✓ Pigment nephropathy (associated with the breakdown of blood cells containing pigments that in turn occlude
kidney structures)
✓ Myoglobinuria (trauma, crush injuries, burns)
✓ Hemoglobinuria (transfusion reaction, hemolytic anemia)
2. Nephrotoxic agents such as:
✓ Aminoglycoside antibiotics (gentamicin, tobramycin)
✓ Radiopaque contrast agents
✓ Heavy metals (lead, mercury)
✓ Solvents and chemicals (ethylene glycol, carbon tetrachloride, arsenic)
✓ Nonsteroidal anti-inflammatory drugs (NSAIDs)
✓ Angiotensin-converting enzyme inhibitors(ACE inhibitors)
3. Infectious processes such as:
✓ Acute pyelonephritis
✓ Acute glomerulonephritis
C. Postrenal Failure
1. Urinary tract obstruction, including:
✓ Calculi (stones)
✓ Tumors
✓ Benign prostatic hyperplasia
✓ Strictures
✓ Blood clots
Phases of Acute Renal Failure
1. Initiation
✓ Begins with the initial insult and ends when oliguria develops.
2. Oliguria
✓ Period is accompanied by an increase in the serum concentration of (urea, creatinine, uric acid, organic acids, and
the intracellular cations [potassium and magnesium]).
✓ The minimum amount of urine needed to rid the body of normal metabolic waste products is 400 mL.
✓ In this phase uremic symptoms first appear and life-threatening conditions such as hyperkalemia develop.
3. Diuresis
✓ Begins when the 24-hour urine volume exceeds 500 mL and ends when the BUN and serum creatinine levels stop
rising.
4. Recovery
✓ Usually lasts several months to 1 year.
✓ Probably some scar tissue remains, but the functional loss is not always clinically significant.
Clinical Manifestations
1. Prerenal—decreased tissue turgor, dryness of mucous membranes, weight loss, hypotension, oliguria or anuria, flat
neck veins, tachycardia
2. Postrenal—obstruction to urine flow, obstructive symptoms of BPH, possible nephrolithiasis
3. Intrarenal—edema
4. Changes in urine volume and serum concentrations of BUN, creatinine, potassium.
Diagnostic Evaluation
1. Urinalysis—reveals proteinuria, hematuria, casts
2. Creatinine and BUN levels
3. Urine chemistry examinations to distinguish various forms of acute renal failure; decreased sodium
4. Renal ultrasonography/ MRI/CT scan—for estimate of renal size and to exclude a treatable obstructive uropathy
Medical Management
1. Eliminating the underlying cause; avoiding fluid excesses.
2. Maintenance of fluid balance.
3. Restore and maintain BP.
4. Drugs
✓ Mannitol, furosemide- for edema
✓ Kayexalate- for hyperkalemia
✓ Phosphate-binding agents –Amphohel, Alternagel
5. Dialysis
Nursing Management
1. Monitoring Fluid and Electrolyte Balance
✓ Hyperkalemia is the most immediate life-threatening
✓ Watch for ECG changes—tall, tented T waves; depressed ST segment; wide QRS complex.
✓ IV medications should be administered in the smallest volume possible.
✓ Limited oral fluid intake
2. Daily weight monitoring
3. Monitor urine output, edema, distention of the jugular veins, alterations in heart sounds and breath sounds, difficulty
in breathing.
4. Bed rest
5. Prevent skin breakdown
✓ Bathing the patient with cool water
✓ Frequent turning
✓ Keeping the skin clean and well moisturized
✓ Fingernails trimmed
6. Accurate daily weights, as well as I&O records
7. Promoting Pulmonary Function- assisted to turn, cough, and take deep breaths frequently to prevent atelectasis
and respiratory tract infection.
6. CHRONIC RENAL FAILURE (End-Stage Renal Disease)
✓ is a progressive deterioration of renal function, which ends fatally in uremia (an excess of urea and other nitrogenous
wastes in the blood)
Causes
1. Hypertension, prolonged and severe
2. Diabetes mellitus
3. Glomerulopathies (from lupus or other disorders)
4. Interstitial nephritis
5. Hereditary renal disease, polycystic disease
6. Obstructive uropathy
7. Developmental or congenital disorder

Clinical Manifestations
1. GFR decreases (due to nonfunctioning glomeruli) Normal GFR 90- 120 gfr/min
2. Creatinine clearance- decreases
3. BUN/ Creatinine – increased
4. HPN
5. Metabolic acidosis
6. Anemia
7. Electrolytes- increased except calcium
 Neurologic Cardiovascular Pulmonary Integumentary
• Weakness and • Hypertension • Crackles • Gray-bronze skin color
fatigue • Pitting edema • Thick, tenacious sputum • Dry, flaky skin
• Confusion (feet,hands, • Depressed cough reflex • Pruritus
• Inability to sacrum) • Pleuritic pain • Ecchymosis
concentrate • Periorbital edema • Shortness of breath • Purpura
• Disorientation • Pericardial friction rub • Tachypnea • Thin, brittle nails
• Tremors • Engorged neck veins • Kussmaul-type • Coarse, thinning hair
• Seizures • Pericarditis respirations
• Asterixis • Pericardial effusion • Uremic pneumonitis
• Restlessness of legs • Pericardial tamponade
• Burning of soles of • Hyperkalemia Hematologic
feet
Reproductive • Hyperlipidemia • Anemia
•• Behavior
Amenorrhea changes • Thrombocytopenia
• Testicular atrophy Musculoskeletal
• Infertility • Muscle cramps
• Decreased libido • Loss of muscle strength
• Renal osteodystrophy
• Bone pain
• Bone fractures
• Foot drop

Diagnostic Evaluation
1. Complete blood count (CBC)—anemia (a characteristic sign)
2. Elevated serum creatinine, BUN, phosphorus
3. Decreased serum calcium, bicarbonate, and proteins, especially albumin
4. ABG levels—low blood pH, low carbon dioxide, low bicarbonate
5. 24-hour urine for creatinine, protein, creatinine clearance
Medical Management
A. Pharmacologic Therapy
1. Calcium and Phosphorus Binders- Calcium carbonate (Os-Cal) or calcium acetate (PhosLo)
2. Antihypertensive and Cardiovascular Agents- digoxin (Lanoxin) or dobutamine (Dobutrex), ACE-inhibitor
3. Antiseizure Agents- IV diazepam (Valium) or phenytoin (Dilantin)
4. Erythropoietin- (Epogen) for hematocrit less than 30%)
B. Nutritional Therapy
1. Careful regulation of protein intake, fluid intake to balance fluid losses, sodium intake to balance sodium losses, and
some restriction of potassium.
2. Allowed protein must be of high biologic value (dairy products, eggs, meats)
3. Offer high-carbohydrate feedings
C. Dialysis
D. Kidney transplantation
Nursing Management
1. Monitoring Fluid and Electrolyte Balance
✓ Hyperkalemia is the most immediate life-threatening
✓ Watch for ECG changes—tall, tented T waves; depressed ST segment; wide QRS complex.
✓ IV medications should be administered in the smallest volume possible.
✓ Limited oral fluid intake
2. Daily weight monitoring
3. Monitor urine output, edema, distention of the jugular veins, alterations in heart sounds and breath sounds, difficulty in
breathing.
4. Bed rest
5. Prevent skin breakdown
✓ Bathing the patient with cool water
✓ Frequent turning
✓ Keeping the skin clean and well moisturized
✓ Fingernails trimmed
6. Seizure precautions
7. Assist client in dialysis
DIALYSIS
✓ Removal by artificial means of metabolic wastes, excess electrolytes and excess fluid from clients with renal failure.
✓ Acute dialysis is indicated when there is a high and increasing level of serum potassium, fluid overload, or impending
pulmonary edema, increasing acidosis, pericarditis, and severe confusion.
✓ To remove medications or toxins (poisoning or medication overdose) from the blood or for edema that does not
respond to other treatment, hepatic coma, hyperkalemia, hypercalcemia, hypertension, and uremia
PURPOSE:
a. Remove the end products of protein metabolism from blood.
b. Maintain safe levels of electrolytes.
c. Correct acidosis and replenish the blood bicarbonate system.
d. Remove excess fluid from the blood.
A. HEMODIALYSIS
✓ Shunting of blood from the client’s vascular system through an artificial dialyzing system and return of dialyzed blood
to the client’s circulation.
✓ Dialysis coil acts as the semi-permeable membrane.
1. 3 principles- diffusion, osmosis, ultrafiltration
2. A dialyzer (also referred to as an artificial kidney) serves as a synthetic semipermeable membrane, replacing the renal
glomeruli and tubules as the filter for the impaired kidneys.
3. The anticoagulant heparin is administered to keep blood from clotting in the dialysis circuit.
Vascular Access
1. Vascular Access Devices
✓ Is achieved by inserting a double-lumen, non-cuffed, large-bore catheter into the subclavian, internal jugular, or
femoral vein by the physician.
✓ Complications- hematoma, pneumothorax, infection, thrombosis of the subclavian vein
✓ Safe for longer-term use.

2. Arteriovenous Fistula
✓ Permanent access is an arteriovenous fistula (AVF) that is created surgically (usually in the forearm) by joining
(anastomosing) an artery to a vein, either side to side or end to side
✓ The arterial segment of the fistula is used for arterial flow to the dialyzer and the venous segment for reinfusion of
the dialyzed blood.
✓ This access will need time, (2 to 3 months) to “mature” before it can be used.
✓ This access has the longest useful life and thus is the best option for vascular access for the chronic hemodialysis
patient.

Arteriovenous Fistula
 3. Arteriovenous Graft
✓ An arteriovenous graft can be created by subcutaneously interposing a biologic, semibiologic, or synthetic graft
material between an artery and vein.
✓ Patients with compromised vascular systems (eg, from diabetes) will require a graft because their native vessels
are not suitable for creation of an AV Fistula.

AV Graft

NURSING CARE:
(BEFORE and DURING HEMODIALYSIS)
1. Have client void.
2. Chart client’s weight.
3. Assess vital signs before and every 30 minutes during procedure.
4. Withhold antihypertensives, sedatives, and vasodilators - to prevent hypotensive episode (unless ordered otherwise).
5. Ensure bed rest with frequent position changes for comfort.
6. Inform client that headache and nausea may occur.
7. Monitor closely for signs of bleeding since blood has been heparinized for procedure.
8. The bruit, or “thrill,” over the venous access site must be evaluated at least every 8 hours. Absence of a palpable thrill
or audible bruit may indicate blockage or clotting in the vascular access.
Complications of Hemodialysis
a. HYPOVOLEMIC SHOCK- May occur as a result of rapid removal or ultrafiltration of fluid from the intravascular
compartment.
b. DIALYSIS DISEQUILIBRIUM SYNDROME
✓ Urea is removed more rapidly from the blood than from the brain.
✓ Assess for nausea, vomiting, elevated BP, disorientation, leg cramps, and peripheral paresthesias.
2. PERITONEAL DIALYSIS
a. Introduction of a specially prepared dialysate solution into the abdominal cavity, where the peritoneum acts as a semi-
permeable membrane between the dialysate and blood into the abdominal vessels.
b. Sterile dialysate fluid is introduced into the peritoneal cavity through an abdominal catheter at intervals.
c. Diffusion and osmosis occur as waste products move from an area of higher concentration (the blood stream) to an
area of lesser concentration (the dialysate fluid) through a semipermeable membrane (the peritoneum).
d. Ultrafiltration (water removal) occurs in PD through an osmotic gradient created by using a dialysate fluid with a higher
glucose concentration.
e. PD usually takes 36 to 48 hours to achieve what hemodialysis accomplishes in 6 to 8 hours.
NURSING CARE
1. Chart client’s weight.
2. Assess V/S before, q15 min during first exchange and every hour thereafter.
3. Assemble specially prepared dialysate solution with added medications.
4. Have client void.
5. Warm dialysate solution to body temperature.
6. Assist physician with trocar insertion.
Inflow: Allow dialysate to flow unrestricted into peritoneal cavity. 10-20 minutes
Dwell: Allow fluid to remain in peritoneal cavity for prescribed period. 30-45 minutes
Drain: Unclamp outflow tube and allow to flow by gravity
7. Observe characteristics of dialysate outflow.
a. CLEAR PALE YELLOW- normal
b. CLOUDY- infection, peritonitis
c. BROWNISH- bowel perforation
d. BLOODY - common during first few exchanges, abnormal if continuous
Complications
1. Peritonitis
2. Leakage- reduce factors that might delay healing, such as undue abdominal muscle activity and straining during bowel
movement.
3. Bleeding
3. CONTINUOUS AMBULATORY PERITONEAL DIALYSIS
✓ A permanent indwelling catheter is implanted into the peritoneum
✓ The dialysate bag is raised to shoulder level and infused by gravity into the peritoneal cavity (approximately 10 minutes
for a 2-L volume).
✓ The typical dwell time is 4 to 6 hours.
✓ At the end of the dwell time, the dialysate fluid is drained from the peritoneal cavity by gravity.
✓ Drainage of 2 L plus ultrafiltration takes about 10 to 20 minutes if the catheter is functioning optimally.
✓ The patient performs exchanges four or five times a day, 24 hours a day, 7 days a week, at intervals scheduled
throughout the day.

Complications
1. Infectious peritonitis, exit-site and tunnel infections.
2. Noninfectious catheter malfunction, obstruction, dialysate leak.
3. Peritoneal–pleural communication, hernia formation.
4. GI bloating, distention, nausea.
5. Hypervolemia, hypovolemia.
6. Bleeding at catheter site.
7. Bloody effluent secondary to internal bleeding. In female patients, this may occur during menstruation.
8. Obstruction may occur if omentum becomes wrapped around the catheter or the catheter becomes caught in a loop of
bowel.
NURSING CARE
1. Dialysate leak
2. Exit site infection
3. Bacterial/Fungal contamination
4. Obstruction
5. Adherence to high-protein (if indicated), well-balanced diet.
 6. Importance of periodic blood chemistries.
7. Daily weight monitoring
KIDNEY TRANSPLANTATION
1. Kidney transplantation involves transplanting a kidney from a living donor or deceased donor to a recipient who no
longer has renal function.
2. A living donor is a person who is alive at the time of donation and may or may not be related to the recipient. (with
compatible ABO and human leukocyte antigens).
3. A deceased or cadaveric transplant comes from someone who has died and donated his or her organs.
4. Contraindications to become donor:
1. Malignancy
2. Active or chronic infection
3. Severe irreversible extrarenal disease (eg, inoperable cardiac disease, chronic
Lung disease, severe peripheral vascular disease)
4. Active autoimmune disease (eg, HIV, hepatitis B and C)
5. Morbid obesity (body mass index greater than 35)

6. The patient must be free of infection at the time of renal transplantation, because after surgery medications to
prevent transplant rejection will be prescribed. These medications suppress the immune response, leaving the
patient immunosuppressed and at risk for infection.
7. The client will receive anti-rejection drug such as Sandimmune, Imuran, Cytoxan, Prednisone, Antilymhpocytic
globulin to prevent organ rejection.
8. Assesses the patient for signs and symptoms of transplant rejection: oliguria, edema, fever, increasing blood
pressure, weight gain, and swelling or tenderness over the transplanted kidney or graft.
7. ACUTE GLOMERULONEPHRITIS
✓ Refers to a group of kidney diseases in which there is an inflammatory reaction in the glomeruli. It is not an infection of
the kidney, but rather the result of the immune mechanisms of the body.

Pathophysiology
↓
Antigen (group A beta-hemolytic streptococcus) immune complexes lodge in the glomeruli.
↓
Producing thickening of glomerular basement membrane; the renal vasculature, interstitium, tubular epithelium.
↓
These affect vascular tone and permeability.
↓
Resulting in tissue Injury eventual scarring.
↓
Loss of filtering surface
↓
Lead to renal failure.
Clinical Manifestations
1. History of infection: pharyngitis or impetigo from group A streptococcus, such viral infections as Epstein Barr and
hepatitis B
2. Tea-colored urine, oliguria
3. Puffiness of face, edema of extremities
4. Fatigue and anorexia, possible headache
5. Hypertension (mild, moderate, or severe)
6. Anemia from loss of RBCs into the urine
Diagnostic Evaluation
1. Urinalysis for hematuria
2. 24-hour urine for protein (increased) and creatinine clearance (reduced)
3. BUN and serum creatinine levels
4. Antistreptolysin (ASO) titer
5. Kidney biopsy
Medical Management
1. Medications- antihypertensives, diuretics, drugs for hyperkalemia, H2 blockers, phosphate-binding agents, antibiotic
therapy.
2. Fluid intake is restricted.
3. Potassium and sodium intake is restricted.
4. Dietary protein is restricted, carbohydrates are increased
Nursing Management
1. Carefully monitor fluid balance.
2. Monitor for signs and symptoms of heart failure.
3. Assess urine specimen for blood, protein, color, and amount.
4. Administer medications, as ordered, and evaluate patient’s response
5. Observe for hypertensive encephalopathy and any evidence of seizure activity.
8. NEPHROTIC SYNDROME
✓ Is a type of renal failure characterized by increased glomerular permeability and is manifested by massive proteinuria.
✓ Seen in any condition that seriously damages the glomerular capillary membrane:
a. Chronic glomerulonephritis
b. Diabetes mellitus with intercapillary glomerulosclerosis
d. Systemic lupus erythematosus
e. Renal vein thrombosis
f. Secondary to malignancy (older adults)
Clinical Manifestations
1. Proteinuria
2. Hypoalbuminemia
3. Hyperlipidemia
4. Dependent edema- ascites
5. Irritability, headache, and malaise.
Diagnostic Evaluation
1. Urinary analysis for proteinuria- proteinuria (predominately albumin) exceeding 3.5 g/day is the hallmark of the
diagnosis of nephrotic syndrome. Foamy urine present
2. Protein electrophoresis and immune electrophoresis.
3. 24-hour urine for protein (increased) and creatinine clearance (decreased).
4. Serum chemistry
Medical Management
1. Diuretics for edema
2. ACE inhibitors to reduce proteinuria
3. Corticosteroids or immunosuppressive agents to decrease proteinuria
4. Anti-hyperlipedemic agent
5. General management of edema
✓ Sodium and fluid restriction; liberal potassium
✓ Infusion of salt-poor albumin
✓ Dietary protein supplements
6. Diet low in saturated fats
Nursing Management
1. Monitor daily weight, intake and output, and urine specific gravity.
2. Monitor CVP (if indicated), vital signs, orthostatic BP, and heart rate to detect hypovolemia.
3. Monitor serum BUN and creatinine to assess renal function.
4. Administer diuretics or immunosuppressive agents, as prescribed, and evaluate patient’s response.
5. Infuse I.V. albumin as ordered.
6. Encourage bed rest for a few days to help mobilize edema; however, some ambulation is necessary to reduce risk of
thromboembolic complications.
7. Enforce mild to moderate sodium and fluid restriction if edema is severe; provide a high-protein diet.
9. BENIGN PROSTATIC HYPERPLASIA
✓ BPH is enlargement of the prostate that constricts the urethra, causing urinary symptoms.
✓ BPH generally occurs when men have elevated estrogen levels and when prostate tissue becomes more sensitive to
estrogens and less responsive to DHT (Dihydrotestosterone).
Risk factors
1. Elevated estrogen in men
2. Smoking
3. Heavy alcohol consumption
4. Obesity, reduced activity level
5. hypertension, heart disease, diabetes
6. Western diet (high in animal fat and protein and refined carbohydrates, low in fiber).

Clinical Manifestations
1. Obstructive symptoms—hesitancy, diminution in size and force of urinary stream, terminal dribbling, sensation of
incomplete emptying of the bladder, urinary retention.
2. Irritative voiding symptoms—urgency, frequency, nocturia
 3. Generalized symptoms - fatigue, anorexia, nausea, vomiting, and pelvic discomfort.
Diagnostic Evaluation
1. Rectal examination—smooth, firm, symmetric or asymmetric enlargement of the prostate
2. Urinalysis—to rule out hematuria and infection
3. Serum creatinine and BUN—to evaluate renal function
4. Serum PSA—to rule out cancer, but may also be elevated in BPH
5. Urodynamics—measures peak urine flow rate, voiding effectively contract
6. Measurement of post-void residual urine; by ultrasound or catheterization
7. Cystourethroscopy—to inspect urethra and bladder and evaluate prostatic size
8. Uroflow—demonstrates voiding pattern
Medical Management
A. Pharmacologic Therapy
1. Alpha adrenergic blockers- doxazosin (Cardura), tamsulosin (Flomax), terazosin (Hytrin), and alfuzosin (Uroxatral)—
relax smooth muscle of bladder base and prostate to facilitate voiding.
2. 5-alpha-reductase inhibitors- Proscar , Propecia (finasteride); dutasteride (Avodart).
✓ An enzyme that converts testosterone into dihydrotestosterone (DHT) in the prostate gland, resulting in a
decreased serum DHT level.
✓ Antiandrogen effect on prostatic cells, reverses or prevents hyperplasia.
✓ Women should not handle drug because it can be absorbed through skin and is pregnancy category X.
B. Surgical Treatment
1. Transurethral microwave heat treatment (TUMT) - minimally invasive therapy
2. Transurethral needle ablation (TUNA) by radiofrequency energy and the UroLume stent.
3. Transurethral resection of the prostate (TURP)
Nursing Management
1. Administer medications, as ordered
2. Provide privacy and time for patient to void.
3. Finasteride and dutasteride—hepatic dysfunction, impotence, interference with PSA testing, presence in semen with
potential adverse effect on fetus of pregnant woman.
4. Assess for and teach patient to report hematuria, signs of infection.
9. URINARY INCONTINENCE
✓ Involuntary loss of urine from the bladder.
✓ Urinary incontinence is commonly regarded as a condition that occurs in older multiparous women, it can occur in
young nulliparous women, especially during vigorous high-impact activity. Age, gender, and number of vaginal
deliveries are established risk factors that explain, in part, the increased incidence in women.
Types of Urinary Incontinence
1. Stress incontinence
a. Is the involuntary loss of urine through an intact urethra as a result of sneezing, coughing, or changing
position.
b. It predominantly affects women who have had vaginal deliveries.
c. In men, stress incontinence is often experienced after a radical prostatectomy.
2. Urge incontinence
a. Is the involuntary loss of urine associated with a strong urge to void that cannot be suppressed.
b. The patient is aware of the need to void but is unable to reach a toilet in time.
c. An uninhibited detrusor contraction is the precipitating factor.
d. This can occur in a patient with neurologic dysfunction that impairs inhibition of bladder contraction or in a patient
without overt neurologic dysfunction.
3. Functional incontinence
a. Refers to those instances in which lower urinary tract function is intact but other factors, such as severe cognitive
impairment (eg, Alzheimer’s dementia), make it difficult for the patient to identify the need to void or physical impairments
make it difficult or impossible for the patient to reach the toilet in time for voiding.
4. Iatrogenic incontinence
a. Refers to the involuntary loss of urine due to extrinsic medical factors, predominantly medications.
b. One such example is the use of alpha-adrenergic agents to decrease blood pressure.
c. As soon as the medication is discontinued, the apparent incontinence resolves.
5. Mixed urinary incontinence
a. Which encompasses several types of urinary incontinence, is involuntary leakage associated with urgency and also
with exertion, effort, sneezing, or coughing.
Risk Factors for Urinary Incontinence
✓ Pregnancy: vaginal delivery, episiotomy
✓ Menopause
 ✓ Genitourinary surgery
✓ Pelvic muscle weakness
✓ Incompetent urethra due to trauma or sphincter relaxation
✓ Immobility
✓ High-impact exercise
✓ Diabetes mellitus
✓ Stroke
✓ Age-related changes in the urinary tract
✓ Morbid obesity
✓ Cognitive disturbances: dementia, Parkinson’s disease
✓ Medications: diuretics, sedatives, hypnotics, opioids
✓ Caregiver or toilet unavailable

Medical Management
1. Behavioral Therapy
a. First choice to decrease or eliminate urinary incontinence.
b. Pelvic floor muscle exercises (sometimes called Kegel exercises) represent the cornerstone of behavioral intervention
for addressing symptoms of stress, urge, and mixed incontinence.
c. Other behavioral treatments include use of a voiding diary, biofeedback, verbal instruction (prompted voiding), and
physical therapy.
2. Pharmacologic Therapy
a. Anticholinergic agents- inhibit bladder contraction and are considered first-line medications for urge incontinence.
b. Pseudoephedrine sulfate (Sudafed)- alpha-adrenergic receptors, causing urinary retention
c. Tricyclic antidepressant medications (eg, amitriptyline [Endep], amoxapine [Asendin])- decreases bladder contractions,
increase bladder neck resistance.
d. Hormone therapy (eg, estrogen)
Surgical Management
a. Men-lifting and stabilizing the bladder or urethra.
b. Wemen- anterior vaginal repair, retropubic suspension, or needle suspension to reposition the urethra.
c. Periurethral bulking is a semipermanent procedure in which small amounts of artificial collagen are placed within
the walls of the urethra to enhance the closing pressure of the urethra.
Strategies to Promote Bladder Continent
1. Increase awareness of the amount and timing of all fluid intake.
2. Avoid taking diuretics after 4 PM.
3. Avoid bladder irritants, such as caffeine, alcohol, and aspartame (NutraSweet).
4. Take steps to avoid constipation: Drink adequate fluids, eat a well-balanced diet high in fiber, exercise regularly, and take
stool softeners if recommended.
5. Void regularly, five to eight times a day (about every 2 to 3 hours):
✓ First thing in the morning
✓ Before each meal
✓ Before retiring to bed
✓ Once during the night if necessary
6. Perform all pelvic floor muscle exercises as prescribed, every day.
7. Stop smoking (smokers usually cough frequently, which increases incontinence)