Renal Disorders, Dialysis, and Basic Concepts

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KIDNEYS

Play role in:

Maintaining fluid balance Maintaining acid/base balance Producing erythropoiten Secreting renin

Renin

angiotensin cycle

Activating vitamin D Regulating ADH Eliminating metabolic wastes

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Obj. 1: Identify pathophysiology, clinical manifestations and interventions for renal disorders

Congenital Disorders

PKD (polycystic kidney disease)

Obstructive disorders
Hydronephrosis Hydroureter Urethral stricture Pyelonephritis Renal absess, renal tuberculosis

Infectious disorders

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Immunologic disorders Acute Glomerulonephritis Rapid progressive glomerulonephritis Chronic glomerulonephritis Nephrotic syndrome Immunologic interstitial disorder Degenerative disorders Nephrosclerosis Renovascular disease Diabetic neuropathy Tumors Cysts benign
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Congenital: Polycystic Kidney Disease

Hereditary disorder Two types: childhood and adult In adults usually manifested by age 40 years Grapelike cysts in place of normal kidney tissue Cysts enlarge, compress functional renal tissue, and result in renal failure Signs and symptoms

Dull, aching abdominal, lower back or flank pain, or colicky pain that begins abruptly

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Polycystic Kidney Disease

Medical treatment
Supportive treatment is recommended to preserve kidney function, treat UTI, and control hypertension Infections treated promptly with antibiotics Dialysis, nephrectomy, and transplantation once end-stage renal disease develops

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Obstructive: Hydronephrosis

Patho

Dilatation of renal pelvis and calyces

S/S

Flank pain, anuria, sepsis

Interventions

Nephrostomy tube and stents

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Urethral stricture

Patho

Usually due to injury

s/s

Pain, decreased urine stream and output Dilate stricture; similar to hydronephrosis

Interventions

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Infectious:

Pyelonephritis

Inflammation of the renal pelvis Acute pyelonephritis most often caused by ascending bacterial infection, but it may be blood borne Chronic pyelonephritis often the result of reflux of urine from inadequate closure of the ureterovesical junction during voiding

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Pyelonephritis

Signs and symptoms

Acute pyelonephritis
High

fever, chills, nausea, vomiting, and dysuria; severe pain or a constant dull ache occurs in the flank area irritation, chronic fatigue, and slight aching over one or both kidneys

Chronic pyelonephritis
Bladder

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Pyelonephritis

Medical treatment
Antibiotics, urinary tract antiseptics, analgesics, and antispasmodics Drink at least eight 8-ounce glasses of fluids daily Intravenous fluids may be ordered if nausea and vomiting Dietary salt and protein restriction for patient with chronic disease

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Pyelonephritis

Assessment

Related signs and symptoms, history of urinary tract disorders, predisposing factors, and effects of the infection on daily activities Acute Pain Activity Intolerance Deficient Fluid Volume and Imbalanced Nutrition Ineffective Management of Therapeutic Regimen

Interventions

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Infectious: Renal Absess

Patho
Complications of UTI; tissue necrosis leads to scarringwall off infection Strept is usual cause

s/s fever, flank pain, dysuria Interventions

antibiotics
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Infectious: renal tuberculosis

Patho
Spread by hematogenesis route from pulmonary disease Usually bilateral

s/s few, males more than females; dormant for years; pain in pelvis Interventions INH
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Immunologic : Acute Glomerulonephritis

Pathophysiology

Immunologic disease: inflammation of the capillary loops in the glomeruli Urine becomes tea colored as output decreases Peripheral and periorbital edema As glomerular filtration decreases, mild to severe hypertension occurs and hypervolemia results Patient assessment and laboratory tests

Signs and symptoms

Medical diagnosis

Urinalysis, BUN, creatinine, and albumin Renal ultrasound, renal biopsy, or both

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Acute Glomerulonephritis

Medical treatment
Diuretics, antihypertensive medications, and antibiotics Bed rest; activity restriction Fluids, sodium, potassium, and protein may be restricted If renal failure develops, dialysis is necessary

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Acute Glomerulonephritis

Assessment

Signs and symptoms, recent infections, and changes in urine

Nursing Diagnosis
Excess Fluid Volume Activity Intolerance Self-Care Deficit Anxiety

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Immunologic: Rapid Progressive glomerulonephritis

Patho

Rapid, causes damage to small structures that filter waste Edema, blood in urine, abd pain, joint pain

s/s

Interventions corticosteroids, plasmaphoresis, watch for kidney failure

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Immunologic: chronic glomerulonephritis

Patho Due to repeated episodes of acute glomerulonephritis, hyperlipidemia, hypertensive nephrosclerosis and chronic tubulointerstitial injury s/s Progressive; acute nosebleed, stroke or seizure; malnourished, edema, diminished DTR, mucous membranes pale, gallop rhythm, distended neck veins Interventions Fluid and elec- imbalance (labs);emotional support; anxiety high; teaching client about treatment plan and need for follow up.
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Immunologic: nephrotic syndrome

Patho

Cluster of findings: Increase protein, decrease albumin, edema, high serum cholesterol; serious damage to the glomerular capillary membrane; occurs with intrinsic renal disease; disorder of childhood; caused by DM, lupus, Multiple myeloma Edema: periorbital, lower extremity, abdomen (ascites); patients have irritability, HA and malaise Early stages: similar to acute glomerulonephritis Late stages: Chronic Renal Failure
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s/s

Interventions

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Degenerative: nephrosclerosis

Patho:

Malignant: associated with malignant hypertension

Young adults, men>women; progress is rapid

Benign: associated with athersclerosis and hypertension

Older adults

s/s

Rare early in the disease; renal insufficiency occurs late in the disease Aggressive antihypertensives; ACE inhibitors
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Interventions

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Degenerative: renovascular disease

Patho 3-16% of arteries become blocked and shrinkage of the kidney occurs leading to HTN and reduced blood flow causing release of excess renin and reinitiates the cycle. s/s HTN above 180/100 and resistent to 2 or more meds Interventions Lipid management, Smoking cessation, antiplatelet therapy, weight reduction, ACE-I, Endovascular therapy (stents) Monitor VS, monitor insertion site, etc.
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Degenerative: Diabetic nephropathy

Patho Characterized by a period of hyperfiltrationand increased GFR to proteinuria and decreased GFR with increase in creatinine s/s Asymptomatic, found on routine lab screen with microalbuminuria, BP starts increasing, neurogenic bladder, infection, Interventions ACE-I/ARB, monitor BP, monitor UO, monitor Lab values, dialysis, transplant, monitor Wt, Monitor A1C, Sodium Restriction
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Tumors: Renal Cancer

80% of malignancies: adenocarcinomas; primarily affect men 55-60 years of age Less common squamous cell carcinomas of the renal pelvis affect men and women equally Tumor may be large before it is detected. Renal malignancies metastasize to the liver, lungs, long bones, and the other kidney Early symptoms: anemia, weakness, and weight loss; painless, gross hematuria classic sign, but usually occurs in the advanced stage. A dull ache in the flank area also is a late symptom

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Renal Cancer

Medical diagnosis

Excretory urography, IVP, retrograde pyelography, ultrasound, arteriography, computed tomography, magnetic resonance imaging, and renal biopsy

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Renal Cancer

Medical treatment
Radical nephrectomy In general, renal tumors are not responsive to radiation or chemotherapy; radiation is sometimes used as a palliative measure for inoperable cancer Biotherapy with alpha-interferon and interleukin-2 for metastatic disease

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Renal Cancer

Assessment
Weakness, fatigue, and changes in the urine Patients emotional state, usual coping strategies, and support systems

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Renal Cancer

Preoperative Care
Ineffective Coping related to potentially fatal disease Deficient Knowledge of tests, procedures, and effects of nephrectomy

Postoperative Care
Monitor vital signs; record intake and output Routinely check drains and tubes Monitor dressings for drainage Auscultate breath sounds and bowel sounds

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Renal Cancer

Interventions
Acute Pain Risk for Deficient Fluid Volume Ineffective Breathing Pattern Risk for Injury Risk for Infection Ineffective Coping Deficient Knowledge

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Obj. 2. Acute Renal Failure

Causes
Prerenal failure: decreased blood flow to glomeruli Intrarenal failure: nephrotoxic agents, kidney infections, occlusion of intrarenal arteries, hypertension, diabetes mellitus, or direct trauma to the kidney Postrenal failure: obstructions beyond the kidneys that cause urine to back up

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Acute Renal Failure: Stages

Onset stage

Short (1-3 days); increasing BUN and serum creatinine with normal to decreased urine output The urine output decreases to 400 mL/day or less Serum values for BUN, creatinine, potassium, and phosphorus increase Serum calcium and bicarbonate decrease Follows onset stage and continues for up to 14 days

Oliguric stage

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Acute Renal Failure: Stages

Diuretic stage
Urine

output exceeds 400 mL/day; may rise above 4 L/day Kidneys excrete BUN, creatinine, potassium, and phosphorus and retain calcium and bicarbonate

Recovery stage
As

renal tissue recovers, serum electrolytes, BUN, and creatinine return to normal This stage lasts 1 to 12 months
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Acute Renal Failure

Medical treatment
Fluid and dietary restrictions, restoration of electrolyte balance, and dialysis Drug therapy Diet Fluids Hemodialysis and peritoneal dialysis Continuous renal replacement therapy

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Acute Renal Failure

Assessment
Monitoring fluid status is critical Signs and symptoms of electrolyte imbalances Signs and symptoms related to immobility: pressure sores, impaired circulation, constipation, and atelectasis Fears, anxiety, coping strategies, sources of support

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Acute Renal Failure

Nursing Diagnosis
Excess Fluid Volume Decreased Cardiac Output Anxiety Disuse Syndrome Deficient Knowledge

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Chronic Renal Failure

Progressive nephron destruction of both kidneys Creatinine clearance: important measure of renal function

<15 mL/min, dialysis or transplantation necessary

Uremia: when kidneys unable to maintain fluid and electrolyte or acid-base balance

Also called end-stage renal disease

Causes: hypertension, diabetes mellitus, and atherosclerosis

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Obj. 3: ARF & CRF: Risk Factors

ARF:

Hypovolemia; hypotension; reduced cardiac output; obstruction of the kidney; obstruction of the renal arteries or veins

CRF:

DM; hypertension;polycystic kidney disease, vascular disorders, infections, meds, environmental agents (lead, mercury, chromium)
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Chronic Renal Disease (ESRD): Signs and Symptoms

Azotemia Hyperkalemia Hypocalcemia Metabolic acidosis Fluid balance (hypernatremia and hypervolemia) Insulin resistance Anemia Suppressed immunologic function Cardiovascular system (CHF and dysrhythmias)

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Chronic Renal Disease: Signs and Symptoms

Neurologic system (mental status changes) Integumentary system (accumulation of waste products) GI system (irritation, nausea, vomiting, a metallic taste in the mouth, and bleeding) Musculoskeletal system (renal osteodystrophy) Reproductive system (sex hormones decline and libido is diminished) Endocrine function (hyperparathyroidism) Emotional and psychological effects

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Chronic Renal Disease: Medical Treatment

IV glucose and insulin, calcium carbonate, calcium acetate, or sodium polystyrene sulfonate to treat hyperkalemia Calcium, active vitamin D, and phosphate binders to treat hypocalcemia Fluid restriction and diuretics to treat hypervolemia Diuretics, beta blockers, calcium channel blockers, and ACE inhibitors for hypertension Iron supplements, folic acid, and synthetic erythropoietin to treat anemia Hypertonic glucose to treat disequilibrium syndrome High-carbohydrate, low-protein diet to prevent excess urea

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Sodium polysterene sulfonate (exchange resin kayexalate) is prescribed. The action of the medication is that it releases sodium ions in exchange for primarily potassium ions

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Obj. 4: Compare/Contrast Dialysis types

Passage of molecules through semipermeable membrane into special solution called dialysate solution Dialysis operates like the kidney Small molecules (urea, creatinine, and electrolytes) pass out of the blood, across a membrane, and into a solution The goals of dialysis

Remove end products of protein metabolism from the blood Maintain safe concentrations of serum electrolytes Correct acidosis and replenish the bodys bicarbonate buffer system Remove excess fluid from the blood

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Hemodialysis

Blood is removed and circulated through an artificial kidney to remove excess fluid, electrolytes, wastes Dialyzed blood then returned to the patient Requires vascular access

By catheter, cannula, graft, or fistula Subclavian or femoral catheters for temporary access for dialysis during acute renal failure while a graft or fistula matures (dilates and toughens) or for patients on peritoneal dialysis who need immediate access for hemodialysis

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Obj. 7: Identify vascular access devices

Arteriovenous fistula: is formed by creating a surgical incision and anastomosing a vein and an artery usually in the forearm
Arteriovenous graft: a Gortex tube is surgically implanted into to the forearm with the vein and artery

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Obj. 5: Nursing Care

Hemodialysis (during and post care)

Aseptic technique Do not cannulate new sites Watch for pseudoaneurysms Do not obtain blood pressure/ iv access on AV fistula site Teach client how to develop fistula thru exercise like squeezing a ball Monitor weight and vitals Monitor meds and diet before and after Monitor labs before

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Chronic Renal Disease: Dialysis

Peritoneal dialysis

Uses the patients own peritoneum as a semipermeable dialyzing membrane Fluid instilled into peritoneal cavity Waste products drawn into the fluid, which is then drained from the peritoneal cavity May be temporary or permanent

Temporary: catheter inserted into the peritoneal cavity through the abdominal wall Long-term: catheter is implanted into the peritoneal cavity

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Chronic Renal Disease: Dialysis

Peritoneal dialysis
Advantages over hemodialysis: less anemia, reduced cost, fewer dietary and fluid restrictions, independence, closer to normal kidney function Disadvantages: risk of peritonitis (the major complication) and catheter site infection, hyperglycemia, elevated serum lipids, and body image disturbance Three phases: inflow, dwell, and drain

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Chronic Renal Disease

Assessment

Frequent monitoring for changes important Fluid balance evaluated closely Accurate intake and output records Signs and symptoms of fluid volume excess that can lead to cardiac failure: increasing edema, dyspnea, tachycardia, bounding pulse, rising blood pressure Signs and symptoms of electrolyte imbalances Appetite, usual daily intake, weight gain or loss pattern, and prescribed diet

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Chronic Kidney Disease

Nursing Diagnosis

Excess Fluid Volume Imbalanced Nutrition: Less Than Body Requirements Disturbed Sensory Perception Ineffective Coping Situational Low Self-Esteem Risk for Infection Risk for Injury Constipation Diarrhea Sexual Dysfunction Self-Care Deficit

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Renal Transplantation

Kidney donation

Healthy kidney from live donor (a relative) or cadaver Tissues must match or recipient will reject new kidney Matching based on ABO blood groups and human leukocyte antigens Crossmatching reveals any cytotoxic preformed antibodies would certainly result in organ rejection Kidney donors must be at least 18 years of age, free of systemic disease or infection, have no history of cancer or renal disease, have normal renal function, and be without major medical problems

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Renal Transplantation

Preoperative nursing care

Patient must be prepared mentally and physically Recipient and live donor have complete diagnostic workups to rule out other medical problems and evaluate function of the urinary tract Recipient given medications to bring blood pressure within normal limits Immunosuppressants: to control the bodys response to foreign tissue

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Renal Transplantation

Interventions
Encourage patient to discuss concerns Factual information helps the patient cope by reducing the fear of the unknown When patients are active participants in their care, they feel less helpless and less anxious Preoperative teaching begins when the patient is identified as a candidate for transplantation

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Renal Transplantation

Surgical procedure

Donor kidney removed from live donor in OR; taken to adjacent room where the recipient has been prepared Cadaver kidney removed under sterile conditions and transported to the hospital where recipient is waiting Donor kidney placed in recipients abdomen and anastomosed (attached) to bladder and blood vessels Acute tubular necrosis, rejection, renal artery stenosis, hematomas, abscesses, and leakage of ureteral or vascular anastomoses

Complications

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Renal Transplantation

Postoperative nursing care

Assessment
Fluid

intake, urine output, weight changes, and vital signs

Interventions
Impaired

Urinary Elimination Deficient Fluid Volume Risk for Infection Ineffective Management of Therapeutic Regimen Anxiety

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The Kidney Donor

Physical care of the donor similar to that for a nephrectomy Nephrectomy may be conventional or laparoscopic Pain worse with conventional approach; provide good pain control Conventional approach: patient hospitalized 4 to 7 days and return to work in 6 to 8 weeks Laparoscopic approach: donor hospitalized 2 to 4 days and can return to work in 4 to 6 weeks Donor usually feels good about the experience If kidney fails, donor may be disappointed; be sensitive

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ANY QUESTIONS???
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