RENAL

DISORDERS
NCMB 312 LEC

DR. POTENCIANA A.
MAROMA
 LEARNING OBJECTIVES:
 Describe the diagnostic studies used to determine
upper and lower urinary tract function.
 Differentiate between the causes of chronic kidney
disease and acute and chronic renal failure.
 Compare and contrast the pathophysiology, clinical
manifestations, medical management, and nursing
management for patients with renal disorders.
 Describe the nursing management of patients with
acute and chronic renal failure.
 Compare and contrast the renal replacement
therapies including hemodialysis, peritoneal dialysis,
and kidney transplantation.
 Pyelonephritis

 Acute or chronic bacterial infection of the kidney and the

lining of the collecting system (kidney pelvis)
 Acute pyelonephritis
 Moderate to severe symptoms that usually
last 1-2 weeks
 If treatment is unsuccessful & infection
recurs  chronic pyelonephritis
Pathophysiology:

 Bacteria ascend to the

kidney and kidney
pelvis by way of the
bladder and urethra
 E. coli (85%), K. pneumoniae,
P. mirabilis, Strep. Fecalis, P
aeruginosa, S. aureus
Pathophysiology:
 Inflammation (kidneys grossly enlarge)
 Pathophysiology:
Risk factors:
 Instrumentation of the urethra & bladder
(catheterization, cystoscopy, urologic
surgery)
 Inability to empty the bladder, Pregnancy
 Urinary stasis, Urinary obstruction
(tumors, strictures,calculi, prostatic
hypertrophy)
 Pathophysiology:

Risk factors:

 DM, other renal disease (polycystic kidney

disease), neurogenic bladder (stroke,
multiple sclerosis, spinal cord injury)
 Women with increased sexual activity,
failure to void after intercourse, history of
recent UTI, infection with HIV
 Assessment findings:
 Signs & symptoms:
 Flank pain & tenderness
 Chills
 Fever
 Malaise
 Urinary frequency with burning sensation
(bladder infection)
 Some are asymptomatic (chronic)
 Polyuria & nocturia (when tubules of the
nephrons fail to reabsorb water efficiently)
 Assessment findings:
Diagnostic findings:
 Urinalysis – PYURIA
 Urine culture – identifies the causative organism
 Ultrasound, CT scan – determines obstruction in the
urinary tract
 Cystoscopy, IV pyelogram (not done in acute cases) or
retrograde pyelogram – demonstrate obstruction or
damage to structures of the urinary tract
 KUB x-ray – reveal calculi, cysts, tumors
 Serum creatinine & BUN – impaired renal function
 Medical Management:

 Relieving fever & pain

 Antimicrobial drugs
 Trimethoprim-sulfamethoxazole (TMP-SMZ, Septra), Gentamicin w/ or
w/out ampicillin, Cephalosporin, Ciprofloxacin
 Antispasmodics & anticholinergics
 relax smooth muscles of the ureters & bladder, promote comfort &
increase bladder capacity
 Oxybutynin (Ditropan), propantheline (Pro-Banthine)
 Nursing Management:

 Obtain complete medical, drug & allergy histories

 Assess VS (T°, BP)
 Physical exam
 determine the location of discomfort & any signs of fluid
retention (peripheral edema, shortness of breath)
 Observe & document the characteristics of the client’s
urine
 Encourage liberal fluid intake if not contraindicated (3-4L)
 Administer prescribed medications
 Nursing Management:

 Evaluates laboratory test results

 BUN, Creatinine, serum electrolytes, urine culture to determine client
response to therapy
 Provide health teaching:
 Provide information about the disease
 Medications
 Increase fluid intake
 Acid forming diet (meat, fish, poultry, eggs, corn, cranberries, prunes)
– to prevent Ca++ & MgPO4 stone formation
 Glomerulonephritis

 Occurs most frequently in children

(boys 6-7y/o) & young adults
 Most client recover spontaneously
or with minimal therapy without
sequelae
 Some develop chronic
glomerulonephritis
 Pathophysiology:

 Most believe that the inflammatory response is from

Antigen-Antibody stimulation in the

glomerular capillary membrane
 Assessment findings:
 Signs & symptoms:
 50% are asymptomatic
 Sudden onset with pronounced symptoms
 fever, nausea, malaise, headache, generalized edema, periorbital
edema, puffiness around the eyes
 Pain or tenderness over the kidney area
 Mild to moderate hypertension
 Poor appetite, irritability, shortness of breath
 Hematuria, convulsions (due to hypertension), CHF, oliguria (UO
100-400ml/day), anuria (<100 ml/24hr)
Medical Management:
 No specific treatment exist: guided by the symptoms & the
underlying abnormality.
 Bed rest
 Na+ - restricted diet (edema, HPN)
 Diuretics, antihypertensive drugs
 Antimicrobials (penicillin)
 Vitamins to improve general resistance
 Oral iron supplements (anemia)
 Corticosteroids & immunosuppressive agents
 Nursing Management:

 Monitor VS (BP q4°), collects daily urine specimens to evaluate

client response to treatment
 Maintain bed rest especially if BP & edema is present
 Ensure adequate fluid intake & measure I&O
 Diet: Na & CHON restricted; adequate CHO intake (prevents
catabolism of body CHON stores)
 Provide health teaching
 Nephrotic Syndrome

A condition of increased glomerular

permeability that allows larger
molecules to pass through the
membrane into the urine and be
removed from the blood
Most common cause: Immune or
inflammatory process
Nephrotic Syndrome
 Treatment: depends on the cause
 Immunologic – steroids
 ACE inhibitors – decreases proteinuria
 Cholesterol-lowering drugs
 Heparin – lower proteinuria & renal insufficiency
 GFR is normal – complete CHON diet
 GFR is decreased – low CHON diet
 Mild diuretics & Na restriction – edema & HPN
 Assess hydration: vascular dehydration
Urolithiasis
 Presence of calculus/calculi
(stone) in the urinary tract
 Nephrolithiasis (kidney)
 Ureterolithiasis (ureter)
Urolithiasis
Predisposing factors:
 Calciuria, hyperparathyroidism, calcium-based
antacids, excessive vit.D intake
 Dehydration
 UTI esp. if cause by P. mirabilis (makes urine alkaline &
Ca++ ppt.)
 Obstructive d/o (enlarged prostate)
 Gout (UA crystallizes)
 Osteoporosis
 Prolonged immobility (sluggish emptying of urine)
 Assessment Findings:
Signs & Symptoms:
 Sudden, sharp, severe flank PAIN that travels to the
suprapubic region & external genitalia (Renal colic,
painful spasm)
 Severity of pain causes nausea, vomiting, shock
 Chills, fever, hypotension (if infection develops)
 Urinary retention, dysuria (obstruction)
 Assessment Findings:

Diagnostic findings:
 Urinalysis
 Gross or microscopic hematuria
 pH conducive to stone formation
 SG, mineral crystals, casts
 Leukocyte (infection)
 Radiography (KUB)
 IVP
 Ultrasonography
                             

                                                  
                                                  
                      

Urinary crystals. (A) Calcium oxalate crystals (arrows;

100 X); (B) uric acid crystals (100 X); (C) triple
phosphate crystals with amorphous phosphates (400
X); (D) cystine crystals (100 X).
Urinary casts. (A) Hyaline cast (200 X); (B)
erythrocyte cast (100 X); (C) leukocyte cast
(100 X); (D) granular cast (100 X).
 Medical Management:

 Small calculi
 Passed naturally with no specific interventions
 Pain is tolerable if the stone is 5mm or less in diameter and moving
 Vigorous hydration
 Analgesics (opioids and NSAIDs)
 Antimicrobials
 Larger calculi
 ESWL (extracorporeal shock wave lithotripsy)
 Laser lithotripsy
MANAGEMENT
 Surgical Management:

 Indicated for large or complicated by obstruction, ongoing UTI,

kidney damage or constant bleeding
 Percutaneous nephrolithotomy
 Ureterolithotomy
 Pyelolithotomy
 nephrolithotomy
 Nursing Process
 Assessment:
 History
 Pain intensity & location, N&V
 Vital signs
 Urine (strain)
 Diagnosis, Planning, Interventions
 3 main goals
Improve urinary output
Relive pain
Prevent infection
 Renal Failure
 Inability of the nephrons in the kidneys to maintain F&E,
Acid-Base balance, excrete nitrogen waste products &
perform regulatory function
 2 types:
 ACUTE renal failure
 sudden, rapid decrease in renal function
 Reversible with early, aggressive treatment
 CHRONIC renal failure
 Progressive (months to years) & irreversible
damage to the nephrons
 Acute Renal Failure

 Causes:

Prerenal
Intrarenal
Postrenal
 Acute Renal Failure

Prerenal
 Hypovolemic shock
 Cardiogenic shock 2° to CHF
 Septic shock
 Anaphylaxis
 Dehydration
 Renal artery thrombosis or
stenosis
 Cardiac arrest
 Lethal dysrhythmias
 Acute Renal Failure

Intrarerenal
 Ischemia
 Nephrotoxicity 2° to drugs
(aminoglycosides)
 Acute & Chronic
glomerulonephritis
 Polycystic disease
 Untreated pre&post renal
disorders
Acute Renal Failure

Postrerenal
 Ureteral calculi
 Prostatic hypertrophy
 Ureteral stricture
 Ureteral or bladder tumor
 Acute Renal Failure

 Four phases:

Initiation phase
Oliguric phase
Diuretic phase
Recovery phase
 Acute Renal Failure
 Initiation phase
 Begins with the onset of the
contributing event
Reduced blood flow  ATN

ATN (acute tubular necrosis)

Death of cells in the collecting
tubules
 Acute Renal Failure

 Oliguric phase (less UO)

 Begins within 48hr after the initial cellular insult (10-14 days or
longer)
 FVE develops (edema, HPN, cardiopulmonary complications)
 AZOTEMIA (accumulation of urea & nitrogenous waste in the blood) 
neurologic changes, seizures, coma, death
 Low urine SG, hyperkalemia, metabolic acidosis, UREMIA
develops
Acute Renal Failure
 Diuretic phase

 Diuresis begins as the nephrons recover

 water content of urine but excretion of
wastes & electrolytes continues to be
impaired
 BUN, creatinine, K, phosphate
 Acute Renal Failure
 Recovery phase

 Normal glomerular
filtration & tubular
function is
restored (1 or more
years)
Chronic Renal Failure
 Kidneys are extensively damaged
 3 stages;
 Reduced renal reserve
 40 to 75% loss of nephrons function

 Renal insufficiency
 75 to 90%
 Kidney loses ability to concentrate urine (polyuria, nocturia), anemia
develops

 ESRD
 <10% of nephrons are functional
 Regular course of dialysis is needed or kidney transplantation
 Chronic Renal Failure

 Assessment findings:
 Elevated BP, weight gain, UO decreased
 Puffy face appearance
 Pale skin
 GIT ulceration & bleeding
 Vague symptoms (lethargy, headache, anorexia, dry mouth)
 Pruritus, dry, scaly skin
 Urine breath odor, muscle cramps, bone pain or tenderness &
spontaneous fractures can develop
  mental processes (confusion, depression, seizures, coma)
Chronic Renal Failure
 Diagnostic findings:
 BUN, creatinine, K, Mg, Phosphorus
 RBC count, Hct/Hgb, pH, SG
 IVP – reveals renal dysfunction
 Percutaneous renal biopsy shows destruction of nephrons
 Radiography & ultrasonography demonstrate structural defects
in the KUB
 Renal angiography identifies obstructions in blood vessels
Medical Management
 Prevention of ARF is an important consideration
 Risk for dehydration- adequately hydrate the client
 Treat shock & hypotension as quickly as possible
(replacement of fluids & blood)
 Treat infection promptly
 Continuous renal function monitoring
 Dopamine (Intropin), hemodialysis, peritoneal dialysis
 Diet; low CHON, high calories, low Na, low K
 Kayexalate, IV infusion of insulin & glucose for
hyperkalemia
 Na bicarbonate for acid-base imbalance
 Medical management of CRF
is similar to that for ARF,
except the period of
treatment is lifelong (unless a
kidney transplantation is performed)
 Chronic anemia
 Epoetin alfa (Epogen) is administered rather than blood transfusion
Surgical Management
 Nursing Management

 Excess fluid volume r/t impaired renal function

 Weight
 Output
 Assess lung sounds, RR, effort, heart sounds, jugular vein
 Monitor lab studies
 Administers prescribed diuretics & anti HPN
 Prepare client for dialysis
 Nursing Management

 Imbalanced nutrition: risk for less than body requirements r/t

anorexia
 Monitor & record clients dietary intake
 Provide frequent small feedings
 Encourage client to be involved with food choices & times for
meals
 Explains restrictions & provide list of nutritional needs &
acceptable food choices
Hemodialysis
 Nausea & Vomiting

 Nausea:
 a feeling of discomfort in the epigastrium with a conscious desire
to vomit; occurs in association with & prior to vomiting
 Vomiting:
 forceful ejection of stomach contents from the upper GI tract
(Emetic center in medulla is stimulated (e.g., by local irritation of
intestine or stomach or disturbance of equilibrium), causing the
vomiting reflex)
 Nausea & Vomiting

 Contributing factors:
 GI disease
 CNS disorders (meningitis, CNS lesions)
 Circulatory problems (CHF)
 Metabolic disorders (uremia)
 Side effects of certain drugs (chemotherapy, antibiotics)
 Pain
 Psychic trauma
 Response to motion
 Nausea & Vomiting

 Assessment findings
 Weakness, fatigue, pallor, possible lethargy
 Dry mucous membrane and poor skin turgor/ mobility (if
prolonged with dehydration)
 Serum sodium, calcium, potassium decreased
 BUN elevated (if severe vomiting and dehydration)
 Nausea & Vomiting

Nursing interventions
 Maintain NPO until client able to tolerate oral, intake
 administer medications as ordered and monitor
effects/side effects
 Notify physician if vomiting pattern changes
 Maintain F & E balance
 Administer, IV fluids as ordered, keep accurate record of l&O
 Record amount/frequency of vomitus
 Assess skin tone/turgor for degree of hydration
 Monitor laboratory/electrolyte values
 Test NG tube drainage or vomitus for blood, bile; monitor pH
 Nausea & Vomiting

Nursing interventions
 Provide measures for maximum comfort
 Institute frequent mouth care with tepid water/saline
mouthwashes
 Remove encrustations around nares
 Keep head of bed elevated and avoid sudden changes in position
 Eliminate noxious stimuli from environment
 Keep emesis basin clean
 Maintain quiet environment and avoid unnecessary procedures
 Nausea & Vomiting

Nursing interventions
 When vomiting subsides;
 provide clear fluids (ginger ale, warm tea) in small amounts
 gradually introduce solid foods (toast, crackers),
 and progress to bland foods (baked potato), in small amounts
 Nausea & Vomiting

Nursing interventions
 Provide client teaching and D/C planning concerning
 Avoidance of situations, foods, or liquids that precipitate nausea
and vomiting
 Need for planned, uninterrupted rest periods
 Medication regimen, including side effects
 Signs of dehydration
 Need for daily weights with frequent anthropometric
measurement
 Diarrhea

Increase in peristaltic
motility, producing watery or
loosely formed stools
Diarrhea is a symptom of
other pathologic processes
 Diarrhea
 Causes:
 Chronic bowel disorders, Malabsorption problems
 Intestinal infections, Biliary tract disorders
 Hyperthyroidism, Saline laxatives
 Magnesium-based antacids
 Stress, Antibiotics, Neoplasms
 Highly seasoned foods
 Diarrhea
 Assessment findings

 Abdominal cramps/distension, foul-

smelling watery stools, increased
peristalsis
 Anorexia, thirst, tenesmus, anxiety
 Decreased potassium and sodium if severe
 Diarrhea
Nursing interventions

1. Administerantidiarrheals
 diphenoxylate with atropine (Lomotil),
paregoric, loperamide (Imodium),
Kaopectate as ordered; monitor effects.
 Diarrhea
Nursing interventions
2. Control fluid/food intake.

 Avoid milk and milk products

 Provide liquids with gradual introduction
of bland, high-protein, high-calorie, low-
fat, low-bulk foods
 Diarrhea
Nursing interventions

3. Monitor and maintain fluid and

electrolyte status; record
number, characteristics, and
amount of each stool.
 Diarrhea
Nursing interventions

4. Prevent anal excoriation.

 Cleanse rectal area after each bowel movement
with soap and water and pat dry
 Apply ointment or Desitin to promote healing
 Use a local anesthetic as needed
 Diarrhea
Nursing interventions
5. Provide client teaching and discharge planning
concerning
 Medication regimen
 Adherence to prescribed diet and
avoidance of foods that are known
to produce diarrhea
 Importance of perineal hygiene and
care and daily assessment of skin
changes
 Diarrhea
Nursing interventions
5. Provide client teaching and discharge planning concerning
 Importance of good handwashing
techniques after each stool
 Need to report worsening of
symptoms (abdominal cramps,
frequency & amount of stool)
 Need to assess daily weights with
frequent anthropometric
measurements
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