Disorders of the Kidneys and

Ureters
The most common urologic disorders
are infectious and inflammatory
conditions.
Those that affect the kidneys are
extremely dangerous because damage
to the nephrons can result in
permanent renal dysfunction.
PYELONEPHRITIS
Pyelonephritis

An acute or chronic bacterial infection of

the kidney and the lining of the collecting
system (kidney pelvis).
Acute phelonephritis presents with
moderate to severe symptoms that usually
last 1 to 2 weeks.
If the treatment of acute pyelonephritis is
not successful and the infection recurs, it
is termed chronic pyelonephritis.
Pathophysiology

Bacteria ascend to the kidney and

kidney pelvis by way of the bladder
and urethra.
Normal fecal flora such as E. coli, is
the most common bacteria that cause
acute pyelonephritis.
E. Coli accounts for about 85% of
infections.
Pathophysiology

In acute pyelonephritis, the inflammation

causes the kidneys to grossly enlarge.
Chronic pyelonephritis occurs after
recurrent episodes of acute pyelonephritis.
The kidneys develop irreversible
degenerative changes and become small and
atrophic.
Pathophysiology

If extensive numbers of nephrons are

destroyed, renal failure develops.
Renal dysfunction may not occur for
20 or more years after the onset of
the disease.
About 10 to 15% of clients with
chronic pyelonephritis require
dialysis.
Pyelonephritis S/S

Flank pain or tenderness

Chills, fever, and malaise
Frequency and burning on urination if there is
an accompanying cystitis (bladder inf)
Some with chronic are asymptomatic
Others have a low-grade fever and vague GI
complaints.
Polyuria and nocturia develop when the tubules
of the nephrons fail to reabsorb water
efficiently.
Medical Management

Tx includes relieving the fever and pain and

prescribing antimicrobial drugs such as
Septra or Cipro for 14 days.
Antispasmodics and anticholinergics such
as Ditropan & Pro-Banthine relax smooth
muscles of the ureters and bladder,
promote comfort, and increase bladder
capacity.
4 weeks of drug therapy is prescribed
Nursing Management

Obtain a complete medical, drug, &

allergy history.
V/S ( temp or BP)
Any s/s of fluid retention such as
peripheral edema and SOB.
Collect a clean-catch urine specimen
for urinalysis and urine culture.
Measure I & O
Nursing Management

Provide a liberal fluid intake of

approx. 2,000 to 3,000 mL to flush
the infectious microorganisms from
the urinary tract.
LAB TEST: BUN, creatinine, serum
electrolytes, and urine culture
Family Teaching

Suggest consuming acid-forming foods such

as meat, fish, poultry, eggs, grains, corn,
lentils, cranberries, prune, plums, and their
juices to prevent calcium and magnesium
phosphate stone formation.
Recommend avoiding alcohol and caffeine
products if bladder spasms are present or
until a clinical response to therapy is
verified.
GLOMERULONEPHRITIS:
ACUTE AND CHRONIC
Acute Glomerulonephritis

The term nephritis describes a group of

inflammatory but NONINFECTIOUS
disease characterized by wide-spread
kidney damage.
Glomerulonephritis is a type of nephritis
that occurs most frequently in children and
young adults; however, it can affect
individuals at any age.
Pathophysiology

Symptoms of acute glomerulonephritis

appear about 1 to 2 weeks after a group A
beta-hemolytic streptococci upper
respiratory infection.
The relationship between the infection &
acute glomerulonephritis is not clear;
microorganisms are not present in the
kidney when symptoms appear, but the
glomeruli are acutely inflamed.
Acute Glomerulonephritis S/S

About 50% are symptom free.

Occasionally the onset is sudden with
pronounced symptoms such as fever,
nausea, malaise, headache, generalized
edema, or periorbital edema, puffiness
around the eyes.
In some instances, the disorder is
discovered during a routine physical
examination.
Acute Glomerulonephritis S/S

More often, the client or family

notices that the person’s face is pale
and puffy and that slight ankle edema
occurs in the evening.
Many other vague symptoms
Diagnostic Findings

Gross or microscopic hematuria gives

the urine a dark, smoky, or frankly
bloody appearance.
Medical Management

No specific treatment exists for acute

glomerulonephritis and treatment is guided
by the symptoms and their underlying
abnormality.
Treatment may consist of bed rest, a
sodium-restricted diet (if edema or HTN is
present), and antimicrobial drugs to
prevent a superimposed infection in the
already inflamed kidney.
Medical Management

The client is not considered cured

until the urine is free of protein and
red blood cells for 6 months.
Return to full activity usually is not
permitted until the urine is free of
protein for 1 month.
Nursing Management

Maintain bed rest when the blood pressure is

elevated and edema is present
Collect daily urine specimens to assist with
evaluating the client’s response to TX.
Assess the BP q 4 hours or prn
Encourage adequate fluid intake and measure
I & O.
Encourage carbohydrate intake to prevent
the catabolism of body protein stores (may
be restricted in sodium and protein)
Chronic Glomerulonephritis

A slowly progressive disease characterized

by inflammation of the glomeruli that
causes irreversible damage to the kidney
nephrons.
Some live for years with only occasional
symptomatic episodes or none at all, or the
disease may be rapidly fatal unless renal
failure is treated with dialysis.
Pathophysiology

The chronic inflammation leads to

ever-increasing bands of scar tissue
that replace nephrons, the vital
functioning units of the kidney.
Decreased glomerular filtration can
eventually lead to renal failure.
Chronic glomerulonephritis accounts
for approx. 40% of people on dialysis.
Chronic Glomerulonephritis S/S

Some experience no symptoms of this

disorder until renal damage is severe.
Generalized edema known as ANASARCA is
a common finding.
Anasarca is due to the shift of fluid from
the intravascular space to interstitial and
intracellular fluid locations.
The fluid shift is due to depletion of serum
proteins, albumin in particular, which is lost
in the urine.
S/S

Clients remain markedly edematous for

months or years.
The client may feel relatively well, but the
kidney continues to excrete albumin.
The fluid burden and subsequent renal
failure contribute to fatigue, headache,
hypertension, dyspnea, and visual
disturbances.
Diagnostic Findings

Azotemia, accumulation of nitrogen waste

products in the blood, is evidenced by
elevated BUN, serum creatinine, and uric
acid levels.
The urine contains protein (albumin),
sediment, cast (deposits of minerals that
break loose from the walls of the tubules),
and red and white blood cells.
Medical Management

Treatment is nonspecific and symptomatic

Management goals include (1) controlling
HTN with medications and sodium
restriction (2) correcting fluid and
electrolyte imbalance, (3) reducing edema
with diuretic therapy (4) preventing
congestive heart failure (5) eliminating
urinary tract infections with antimicrobials.
May necessitate dialysis or kidney
transplantation
Nursing Management
Fluid Volume Excess
Weigh daily at the same time on the same
scale while wearing similar clothing.
Measure I & O
Monitor BP, HR, lung and heart sounds each
shift
Assess for pitting edema, tight rings or
shoes, clothes that do not fit comfortably
Educate on low sodium restriction
Administer prescribed diuretics
Nursing Management
Fatigue & Activity Intolerance
Avoid clustering nursing tasks and physical
activities
Provide periods of rest and promote
uninterrupted sleep at night
Eliminate any activities of daily living that
are not necessary.
Assist the client with activities when
evidence of tachycardia or dyspnea is
present.
POLYCYSTIC DISEASE
Polycystic Disease

A congenital kidney disorder that has a

familial tendency.
2 forms: the infantile and adult forms
1. The infantile form is rare. It may cause
fetal death (before delivery), early neonatal
death, or renal failure during childhood.
2. The adult form has its onset between 30
to 50 years of age and insidiously
progresses to renal insufficiency.
Polycystic Disease

Once renal failure

develops, polycystic
disease is usually
fatal within 4 years,
unless the client
receives dialysis
treatment or organ
transplant.
Pathophysiology

Adult polycystic kidney disease is the

result of autosomal dominant
inheritance.
This means that the gene for the
disease is passed from an affected
parent to his or her children.
Each child has a 50:50 chance of
acquiring the defective gene
Pathophysiology

As the name implies, this disorder is

characterized by the formation of multiple
bilateral kidney cysts. Fig 64-4 pg 1130.
The cysts interfere with kidney function
and eventually lead to renal failure.
The fluid-filled cysts cause enormous
enlargement of the kidneys from normal
fist size to as much as the size of a
football.
Pathophysiology

As the cysts enlarge, they compress the

renal blood vessels and cause chronic
hypertension.
Bleeding into cysts causes flank pain
Polycystic Disease S/S

Hypertension is present in approx 75% of

affected individuals at the time of
diagnosis.
Other symptoms, such as pain from
retroperitoneal bleeding, lumbar
discomfort, and abdominal tenderness, are
due to the size and effects of the cysts.
Colic (acute spasmodic pain) is experienced
when there is ureteral passage of clots or
calculi.
Medical Management

Has no cure, but some interventions

reduce the rate of progression.
HTN --- antihypertensive drugs,
diuretic med and sodium restriction
UTI—promptly with antibiotics
Low RBC count—iron supplements,
injections of erythropoietin (Epogen)
or blood transfusions
Medical Management

NEPHROTOXIC MEDICATIONS, SUCH

AS NONSTEROIDAL ANTI-
INFLAMMATORY DRUGS AND
CEPHALOSPORIN ANTIBIOTICS, ARE
AVOIDED AT ALL COSTS.
Dialysis substitutes for kidney function
when renal failure occurs and while the
client awaits an organ transplant
Nursing Management

Assess V/S especially BP

Observe the urine for signs of
bleeding or infection
Measure I & O
Report any decrease in or absence of
urine output.
OBSTRUCTIVE DISORDERS:
KIDNEY STONES/RENAL
CALCULI AND URETHRAL
STONES
Obstructive Disorders

KIDNEY AND URETRERAL STONES:

A stone (calculus) is a precipitate of
mineral salts that ordinarily remain
dissolved in urine.
About 80% of renal calculi in the US are
composed of calcium oxalate.
Stones may be smooth, jagged, or staghorn
shaped
Kidney & Ureteral Stones

Calculi can occur anywhere in the urinary tract

from the kidney pelvis and beyond.
When a stone forms, the condition is called
urolithiasis.
Nephrolithiasis refers to the presence of a
kidney stone, the size of which may range form
microscopic to several centimeters in diameter.
Ureterolithiaisis is a stone within the ureter.
Ureteral stones are usually small –some may be
no larger than a grain of sand.
Pathophysiology

Predisposing factors:
Calciuria, excessive calcium in the urine
(hyperparathyroid dx, calcium-based
antacids, and excessive intake of vitamin D)
Dehydration
Osteoporosis in which bone is demineralized
Obstructive disorders (enlarged prostate)
Immobility
UTI
Pathophysiology

Calculi traumatize the walls of the urinary

tract and irritate the cellular lining,
causing pain as violent contractions of the
ureter develop to pass the stone along.
But the ureteral spasms may just as easily
hold a stone in place.
If a stone totally or partially obstructs the
passage of urine beyond its location,
pressure increases in the area above the
stone.
S/S

Small stones may pass unnoticed

However, sudden, sharp, severe flank
pain that travels to the suprapubic region
and external genitalia is the classic
symptom of urinary calculi.
The pain comes in waves that radiate to
the inguinal ring, the inner aspect of the
thigh, and to the testicle or tip of the
penis in men , or the urinary meatus or
labia in women.
Flank/
Costovertebral Angle (CVA)
Medical Management

Small calculi are passed naturally with no

specific interventions.
If the stone is 5 mm or less in diameter,
moving, the pain is tolerable, and no
obstruction is present, the client is
managed medically with vigorous hydration,
analgesics, antimicrobial therapy, and drugs
that dissolve calculi or eventually alter
conditions that promote their formation
Medical Management

For larger stones, extracorporeal shock

wave lithotripsy (ESWL), a procedure that
uses 800 to 2,400 shock waves aimed from
outside the body toward dense stones may
be used
The stones are shattered into smaller
particles that are passed from the urinary
tract
Medical Management

ESWL is administered with the client in a

water bath or surrounded by a soft cushion
while under light anesthesia or sedation.
Stones can also be pulverized with laser
lithotripsy.--- to do so, a fine wire, through
which the laser beam passes, is inserted
into the ureter by means of a cystoscope.
Repeated bursts of the laser reduces the
stone to a fine powder, which is then
passed in the urine.
ESWL
Medical Management

Other stone removal procedures are

performed with ureteroscopic approaches in
which the endoscope is inserted from the
urethra into the upper urinary tract under
anesthesia to grasp, crush, and remove stones
from the kidney pelvis or ureter.
Afterward, a catheter or ureteral stent, a
slender supportive device, is left in place for
3 days to splint the ureter or divert the urine
past any possible tear in the ureteral wall
Medical Management

If the stone cannot be removed, a

ureteral catheter is left in place for
24 hours to dilate the ureter in the
hope that the stone will pass through
it or that it will be pulled into the
bladder when the catheter is
removed.
Surgical Management

A nephrostomy tube, is a catheter that is

inserted through the skin into the renal
pelvis to manage any obstruction to urine
flow above the bladder.
The tube is kept in place with a suture
through he skin.
Unlike the bladder, the kidney pelvis can
only hold APPROX. 5 TO 8 ML of urine.
Surgical Management

If urinary drainage through the tube is

impaired for even a short time from a
blood clot or kinking or compression of the
tubing, hydronephrosis and damage to
surgically repaired tissue can result.
The client will complain of pain if the renal
pelvis becomes distended with urine.
URETHRAL STRICTURE
Urethral Stricture

A stricture is a narrowing of a lumen; in this

case the ureter is narrowed
The recurrent inflammation and infection cause
scar tissue to accumulate within the ureter.
Other conditions that can interfere with urine
passing through the ureter are congenital
anomalies or conditions that mechanically
compress the ureter such as pregnancy and
tumors within the abdomen or upper urinary
tract.
S/S

Flank pain or discomfort and

tenderness at the costovertebral
angle (CVA) due to enlargement of
the renal pelvis often develop.
CVA where the last rib joins the
vertebra
Medical Management
The ureter can be stretched by inserting a dilator
called a filiform or urethral sound, a curved metal
rod, followed by others that are sequentially
larger.
If the obstruction persists, the MD performs a
ureteroplasty, removal of the narrowed section of
ureter and reconnection of the patent portions.
A ureteral stent is placed in the ureter to provide
support to the walls of the ureter, relive the
obstruction, and maintain the flow of urine
through the ureter and into the bladder.
Nursing Management

If a ureteral catheter is inserted

preoperatively, measure the urine output
from the catheter hourly.
Immediately report if there is no urine
output from the ureteral catheter.
On return from surgery, all urinary
drainage tubes and catheters are
connected to a closed drainage system or
to the type of drainage ordered by the
physician.
Nursing Management

The main complication associated with

ureteral surgery is failure of the ureter to
transport urine from the kidney to the
bladder.
Contact the MD if signs of shock appear,
urinary output from the ureteral catheter
is decreased or absent, or if the client
complains of significant abdominal pain,
which may indicate leakage of urine into
the peritoneal cavity.
Nursing Management

Notify the MD if signs of a urinary tract

infection develop, such as fever and chills
or if the urine is cloudy or has a foul odor.
TUMOR OF THE KIDNEY
 Tumors of the Kidney
• A hypernephroma (renal adenocarcinoma)
is the most common malignant tumor of
the kidney in adults.
• Squamous cells tumors are second.
• May be associated with carcinogenic
effects of long-term cigarette smoking,
environmental toxin (asbestos) or volatile
solvents (gasoline)
• Because the kidneys are deeply protected
in the body, tumors can become quite large
before causing symptoms.
 S/S
• The classic triad of renal cancer is
PAINLESS hematuria, flank pain,
and the presence of a palpable
mass.
• Additional symptoms include weight
loss, malaise, and unexplained fever.
• Later, there is colic-like discomfort
during the passage of blood clots
 Medical Management
• Nephrectomy, including removal of
the surrounding perinephric fat, is the
treatment for a malignant renal
tumor.
• Surgery, chemotherapy, and
radiation done
• If extensive metastases are found,
only palliative treatment is given.
RENAL FAILURE:
ACUTE AND
CHRONIC
 Renal Failure
• The inability of the nephrons
within the kidneys to maintain
fluid, electrolyte, and acid-base
balance, excrete nitrogen waste
products, and perform regulatory
functions such as maintaining
calcification of bones and
producing erythropoietin.
 Renal Failure
• There are two types of renal failure:
• 1. Acute renal failure (ARF) is
characterized by sudden and rapid
decrease in renal function. ARF is
potentially reversible with early,
aggressive treatment of its contributing
etiology.
• 2. Chronic renal failure: (CRF) is
characterized by progressive and
irreversible damage to the nephrons. It
may take months to years for CRF to
develop.
 Acute Renal Failure
• Acute renal failure progresses
through 4 phases:
• 1. Initiation phase
• 2. Oliguric phase
• 3. Diuretic phase
• 4. Recovery phase
 Acute Renal Failure
• 1. Initiation Phase: begins with the
onset of the contributing event.
• It is accompanied by a reduction in blood
flow to the nephrons to the point at
which there is acute tubular necrosis
(ATN)
• ATN refers to the death of cells within the
collecting tubules of the nephrons where
reabsorption of water, electrolytes, and
excretion of protein wastes and excess
metabolic substances occurs.
 Acute Renal Failure
• 2. Oliguric Phase: associated with
the excretion of less that adequate
urinary volumes.
• This phase begins within 48 hours
after the initial cellular insult and may
last for 10 to 14 days or longer.
• Fluid volume excess develops, which
leads to edema, HTN< and
cardiopulmonary complications.
 Acute Renal Failure
• Azotemia, marked accumulation of urea
and other nitrogenous wastes such as
creatinine and uric acid in the blood,
creates a potential for neurologic changes
such as seizures, coma, and death.
• Some clients excrete urinary volumes
greater than 500 mL/day. However, the
urine has a very low specific gravity
because it lacks normal amounts of
excreted substances such as excess
potassium and hydrogen ions, to maintain
homeostasis.
 Acute Renal Failure
• Consequently, hyperkalemia,
metabolic acidosis, and uremia, a
toxic state caused by the
accumulation of nitrogen wastes,
develop regardless of the
excreted water volume.
 Acute Renal Failure
• Diuretic Phase: diuresis begins as the
nephrons recover.
• Despite an increase in the water
content of urine, the excretion of
wastes and electrolytes continues to
be impaired.
• The BUN, creatinine, potassium, and
phosphate levels remain elevated in
the blood.
 Acute Renal Failure
• Recovery Phase: it may take one
or more years of recovery while
normal glomerular filtration and
tubular function are restored.
• Some clients recover completely;
others develop varying degrees
of permanent renal dysfunction.
Chronic Renal Failure
 Chronic Renal Failure
• In CRF, the kidneys are so extensively
damaged that they do not adequately
remove protein by-products and
electrolytes from the blood and do not
maintain acid-base balance.
• End-stage renal disease (ESRD) is the
term given for the point at which a
regular course of dialysis or kidney
transplantation is necessary to
maintain life.
 Chronic Renal Failure
• Actual electrolyte imbalances include
hyperkalemia, hyperphosphatemia,
hypermagnesemia, and hypocalcemia.
• The skin becomes the excretory organ
for the substances the kidney usually
clears from the body.
• A precipitate, referred to as uremic
frost, may form on the skin.
 Chronic Renal Failure
• Assessment: S/S—In both ARF &
CRF, the client has an elevated
blood pressure and weight gain.
• Urine output is generally
decreased.
• Facial features appear puffy due to
fluid retention
• The skin is pale; ulceration and
bleeding of the GI tract may occur.
 Chronic Renal Failure
• The oral mucous membranes
bleed, and blood may be found in
the feces.
• Vague symptoms of lethargy, HA,
anorexia, and dry mouth.
• The client’s breath and body may
have an odor characteristic of
urine.
 Medical Management
• Dialysis
• Fluid and dietary restrictions that
include:
• Low protein
• High calories
• Low sodium
• Low potassium
 Medical Management
• Kayexalate—an ion-exchange resin, is
prescribed for oral or rectal
administration to remove excess
potassium when hyperkalemia occurs.
• An IV infusion of glucose and insulin
also facilitates movement of
potassium within the cell.
• Instead of blood transfusions to
correct chronic anemia, Epogen is
administered to stimulate bone
marrow production of RBC’s
 Surgical Management
• Some are candidates for a kidney
transplant
• One healthy kidney can perform the work
of two
• Any potential donor with a history of HTN,
malignant disease, or DM is excluded form
donation.
• When a transplant is performed, the donor
kidney is inserted through an abdominal
incision and the nonfunctioning kidneys
are left in place unless the client is
extremely hypertensive.
 Surgical Management
• The blood vessels from the donor
kidney are sutured to the iliac
artery and vein and the ureter is
implanted in the bladder
Dialysis

A procedure for cleaning and filtering

the blood.
It provides a substitute for kidney
function when the kidneys are unable
to remove the nitrogenous waste
products and maintain adequate fluid,
electrolyte, and acid-base balance.
Dialysis

During dialysis the client’s blood is filtered

by diffusion and osmosis.
Substances such as urea, creatinine,and
dangerously high levels of potassium, and
water move FROM the blood through the
semipermeable membrane TO the
dialysate, the solution used during dialysis
that has a composition similar to normal
human plasma.
Dialysis

Dialysis is performed by hemodialysis

and peritoneal dialysis.
Either technique can be performed at
home or in a dialysis center.
Each type of dialysis has advantages
and disadvantages. Table 64-5 pg.
1148
Arteriovenous Fistula

A surgical anastomosis (connection)

of an artery and vein lying in close
proximity. Fig 64-13 pg 1149
The vessels usually joined are the
cephalic vein and the radial artery or
the cephalic vein and brachial artery.
They require from 1 to 4 months to
mature before being used.
Arteriovenous Fistula

At the time of dialysis, two venipunctures

are performed at either end of the fistula
The distal venipuncture is used to remove
blood that is transported to the machine.
The proximal needle puncture is used to
return the dialyzed blood.
When dialysis is completed, the needles are
removed and pressure dressings are applied
for several hours.
Arteriovenous Fistula

Blood samples are taken before and after

dialysis.
The client’s predialysis and postdialysis
weights are compared. Sometimes as much
as 10 lb of fluid is removed.
BUN, creatinine, sodium, potassium,
chlorides, and HCT are used as indicators
of efficiency of dialysis.l
Arteriovenous Graft

A type of vascular access method that uses

a tube of synthetic material to connect a
vein and artery in the upper or lower arm
Fig 64-13 pg 1149.
The graft pulsates with blood flow
AV grafts can be used 14 days after their
insertion.
Although the graft reseals after each
needle puncture, the expected life of the
graft is 3 to 5 years with repeated use.
Nursing Management

Assess & record vital signs before and

after hemodialysis.
Weigh the client and obtain blood for lab’s
To prepare for vascular access:
Palpate for a THRILL (vibration) over the
vascular access. Listen for a BRUIT, a loud
sound caused by turbulent blood flow. IF
ABSENT, POSTPONE FURTHER USE
AND REPORT FINDINGS.
Nursing Management

After dialysis is completed, do not

administer injections for 2 to 4 hours.
This allows time for the metabolism and
excretion of heparin, which is
administered during dialysis, to reach safe
levels.
Before discharging the client, observe for
disequilibrium syndrome.
Nursing Management

Disequilibrium Syndrome: a neurologic

condition believed to be caused by cerebral
edema.
The shift in cerebral fluid volume occurs
when the concentrations of solutes within
the blood are lowered rapidly during dialysis
Decreasing solute concentration lowers the
plasma osmolality.
WATER THEN FLOODS THE BRAIN
TISSUE!!!
Nursing Management

This syndrome is characterized by HA,

disorientation, restlessness, blurred vision,
confusion, and seizures.
The symptoms are self-limiting and
disappear within several hours after
dialysis as fluid and solute concentrations
equalize.
The syndrome can be prevented by slowing
the dialysis process to allow time for
gradual equilibration of water.
Nursing Management

Client Teaching: Avoid carrying heavy

items in the arm with the fistula or graft
Do not sleep on the vascular access arm
Do not permit venipunctures, injections,
or blood pressures in the arm with the
vascular access.
Assess for a thrill or bruit daily!!
THANK YOU….