Nursing Management: Patients With Renal Disorders

Unit 7

Chapter 26

Wolters Kluwer

Learning Objectives

• At the end of this lesson, the student will be able to:

  • Discuss etiology, risk factors, pathophysiology, clinical manifestations, and prognosis of patients with:
  • Acute and Chronic Glomerulonephritis
  • Nephrotic Syndrome
  • Acute and Chronic Pyelonephritis
  • Polycystic Kidney Disease
  • Renal Cancer
  • Nephrolithiasis

• Summarize nursing management of the patient with kidney failure.

• Evaluate outcomes of care for the patient with kidney disorders.

• Identify causes of acute kidney injury and chronic renal failure.

• Describe renal replacement therapies.

Glomerular Diseases

• Group of kidney disorders affecting the glomeruli.
• May progress to chronic kidney disease (CKD) or renal failure.
• Clinical outcomes include:
  • Proteinuria
  • Hematuria
  • Hypertension
  • Edema

Common Glomerular Diseases

• Acute Glomerulonephritis
• Chronic Glomerulonephritis
• Nephrotic Syndrome
• Rapidly Progressive Glomerulonephritis (RPGN)
• Diabetic Nephropathy
• Lupus Nephritis

Acute Glomerulonephritis

• Definition: Inflammation of glomerular capillaries.
• Risk Factors:
  • Recent streptococcal throat or skin infection.
  • Exposure to nephrotoxic drugs or toxins.
  • Systemic lupus erythematosus (SLE).
  • Goodpasture syndrome.
  • Hepatitis.
  • Varicella zoster.

Clinical Manifestations

• Symptoms may include:
  • Hematuria (cola-colored urine).
  • Hypertension.
  • Edema (periorbital and peripheral).
  • Oliguria (reduced urine output).
  • Proteinuria.
  • Azotemia (elevated blood urea nitrogen and creatinine).
• Diagnosis:
  • Throat and skin lesion cultures, urinalysis, laboratory blood tests, and complement levels to assist in diagnosis.

Diagnosis

• Diagnostic tests for acute glomerulonephritis include:
  • Throat and skin lesion cultures.
  • Urinalysis.
  • Laboratory blood tests.
  • Complement levels.

Treatment

• Pharmacological interventions may involve:
  • Antihypertensives.
  • Immunosuppressants.
  • Diuretics.
  • Antibiotics.
  • Dialysis or transplantation if necessary.
  • Dietary restrictions focusing on sodium and protein intake.

Nursing Management

• Key nursing strategies include:
  • Monitoring fluid balance and daily weights.
  • Assessing urine output and characteristics.
  • Educating on dietary restrictions (low sodium, low protein).
  • Regular monitoring of blood pressure.
  • Providing psychological and emotional support.

Chronic Glomerulonephritis

• Risk Factors:
  • Repeated episodes of glomerular injury.
  • Uncontrolled hypertension.
  • Diabetes mellitus.
  • Autoimmune disorders.
  • Hyperlipidemia.
• Complication:
  • End-stage renal disease (ESRD).

Nephrotic Syndrome

• Definition: A renal or systemic disease that damages the glomeruli, leading to excessive protein loss in urine.
• Consequences:
  • Leads to hypoalbuminemia (low albumin), hyperlipidemia (high lipid levels), and edema.
• Affects both adults and children.

Risk Factors for Nephrotic Syndrome

• Includes:
  • Diabetic nephropathy.
  • Viral infections.
  • Autoimmune diseases.
  • Nephrotoxicity.

Manifestations and Assessment

• Common symptoms include:
  • Generalized edema.
  • Frothy urine (indicative of proteinuria).
  • Fatigue.
  • Weight gain.
  • Periorbital edema.
  • Dyspnea (difficulty breathing).

Medical Management of Nephrotic Syndrome

• Treatment options may include:
  • Corticosteroids.
  • Immunosuppressants.
  • ACE inhibitors/ARBs (angiotensin receptor blockers).
  • Diuretics.
  • Statins.
  • Anticoagulants.
  • Diet modification (including sodium and protein controls).

Nursing Management for Nephrotic Syndrome

• Key nursing responsibilities include:
  • Monitoring fluid balance and daily weight.
  • Assessing for edema and respiratory status.
  • Implementing a low-sodium, moderate-protein diet.
  • Infection prevention strategies.
  • Educating on medication adherence and providing emotional support.

Complications of Nephrotic Syndrome

• Possible complications include:
  • Thromboembolism (blood clots).
  • Acute kidney injury or progression to CKD.
  • Infections.
  • Malnutrition.

Renal (Kidney) Failure

• Definition: Inability to remove metabolic waste, can be acute or chronic.
• Consequences include:
  • Azotemia (increased nitrogen waste in blood).
  • Metabolic derangements.
  • Acid-base imbalances.
  • Electrolyte imbalances.

Acute Renal Failure

• Definition: Sudden loss of kidney function, with a decrease in GFR resulting in decreased urine output.
• Classification:
  • Prerenal (caused by factors outside the kidney).
  • Intrinsic (renal, due to damage to kidney tissue).
  • Postrenal (due to obstruction of urine flow).

Clinical Manifestations of Acute Renal Failure

• Oliguria (decreased urine output) or anuria (absence of urine output).
• Electrolyte imbalances (e.g., hyperkalemia).
• Fluid overload.
• Uremic symptoms (nausea, fatigue).
• Increased BUN (blood urea nitrogen) and creatinine levels.
• Acidemia (acidosis due to retention of acids).

Complications of Acute Renal Failure

• Include:
  • Metabolic acidosis.
  • Hyperkalemia, leading to risk of arrhythmias.
  • Pulmonary edema.
  • Progression to chronic kidney disease.

Management of Acute Renal Failure

• Focus on:
  • Treating the underlying cause.
  • Fluid management.
  • Correcting electrolyte imbalances.
  • Avoiding nephrotoxic drugs.
  • Dialysis if the condition is severe.

Nursing Management in Acute Renal Failure

• Important nursing actions:
  • Monitoring fluid balance.
  • Keeping track of vital signs and hemodynamic status.
  • Assessing for electrolyte imbalances.
  • Implementing dietary modifications.
  • Providing patient education.
  • Considering gerontological factors in patient management.

Chronic Renal Failure (CRF) and End-Stage Renal Disease (ESRD)

• CRF: Progressive, irreversible deterioration in renal function.
• ESRD: Final stage of CRF.

Risk Factors for CRF

• Key risk factors include:
  • Diabetes.
  • Hypertension.
  • Glomerulonephritis.
  • Family history of kidney disease.
  • Polycystic kidney disease.
  • Pyelonephritis.
  • Increasing age.

Systemic Clinical Manifestations

• Affect multiple systems, including:
  • Neurologic: confusion, irritation.
  • Cardiovascular: hypertension, edema.
  • Gastrointestinal: nausea, vomiting.
  • Immunologic: increased infection risk.
  • Hematologic: anemia.
  • Genitourinary: urinary changes.
  • Dermatologic: dryness, pruritus.
  • Musculoskeletal: pain, weakness.
  • Reproductive: infertility.

Other Manifestations of CRF

• May include:
  • Sodium and water retention leading to edema.
  • Electrolyte imbalances (e.g., increased potassium).
  • Acidosis.
  • Coagulopathies.

Diagnostic Evaluation – Renal Failure

• Diagnostic tests may include:
  • Laboratory blood tests.
  • Urinalysis.
  • Imaging studies.
  • eGFR (estimated glomerular filtration rate) calculation.
  • Kidney biopsy (if required for diagnosis).

Nursing Priorities for Renal Failure

• Key nursing focuses:
  • Vital signs monitoring.
  • Fall precautions.
  • Maintaining fluid balance and daily weights.
  • Infection prevention strategies.
  • Assessing for complications in renal function.
  • Providing patient education and psychological support.

Management of Chronic Renal Failure (CRF)

• Strategies include:
  • Control underlying cause (e.g., managing diabetes, hypertension).
  • Diet modification as necessary.
  • Pharmacologic agents to manage symptoms.
  • Treat complications effectively.

Management of End-Stage Renal Disease (ESRD)

• Treatment options include:
  • Renal replacement therapy (RRT).
  • Hemodialysis.
  • Peritoneal dialysis.
  • Continuous renal replacement therapies (CRRTs).
  • Kidney transplantation as a long-term solution.

Hemodialysis

• Definition: Most common method of dialysis.
• Administration:
  • Performed three times per week for 3–5 hours each session.
  • Requires vascular access for blood filtration.

Vascular Access for Hemodialysis

• Access methods include:
  • Cephalic vein, radial artery, creating an internal arteriovenous fistula.
  • Internal jugular vein for catheter-based access.
  • Catheter for short-term access.
  • Graft options, such as synthetic tube grafts.

Complications of Hemodialysis

• Expected complications can include:
  • Hypotension during sessions.
  • Muscle cramps.
  • Headaches.
  • Vascular access infections.
  • Disequilibrium syndrome (an imbalance of electrolytes).

Pharmacologic Management for Renal Disorders

• Treatment options may involve:
  • Antihypertensive therapy.
  • Erythropoiesis-stimulating agents (ESAs) for anemia.
  • Phosphate binders to manage electrolytes.
  • Vitamin D supplementation.
  • Potassium binders.
  • Sodium bicarbonate to treat acidosis.
  • Antibiotics and antiplatelet therapy.
  • Diuretics as required.

Nutritional Therapy for Renal Patients

• Key nutritional strategies:
  • Sodium restriction.
  • Potassium restriction.
  • Phosphate restriction to prevent complications.
  • Fluid restriction as necessary.
  • Adequate protein intake.
  • Calcium and vitamin D supplementation for bone health.
  • Iron supplements to address deficiency.

Peritoneal Dialysis

• Definition: A method to remove toxic substances and metabolic wastes from the body.
• Benefits:
  • Promotes patient independence due to flexible scheduling.
  • Allows for treatments in comfort of home.
• Types:
  • Continuous ambulatory PD (CAPD).
  • Automated PD (APD).

Complications of Peritoneal Dialysis

• Possible complications may include:
  • Peritonitis (infection of the peritoneal cavity).
  • Poor drainage or dialysate leakage.
  • Bleeding at the catheter site.
  • Catheter site infections.
  • Hernias due to increased intra-abdominal pressure.
  • Hyperglycemia due to glucose absorption from dialysate.

Continuous Renal Replacement Therapy (CRRT)

• Usage: Primarily utilized for critically ill patients with acute kidney injury (AKI).
• Mechanism: Slow, continuous removal of fluid and solutes to mitigate complications.
• Types Include:
  • Continuous Veno-Venous Hemofiltration (CVVH).
  • Continuous Veno-Venous Hemodialysis (CVVHD).
  • Continuous Veno-Venous Hemodiafiltration (CVVHDF).
  • Slow Continuous Ultrafiltration (SCUF).

Nursing Priorities in Renal Replacement Therapy (RRT)

• Critical nursing focuses include:
  • Monitoring fluid balance and vital signs continuously.
  • Care of vascular access or PD catheter.
  • Implementing infection prevention strategies.
  • Patient education on diet, fluid intake, and medications.
  • Providing emotional and psychological support.

Kidney Transplantation

• Definition: Surgical placement of a donor kidney as a treatment for ESRD.
• Lifetime Requirement: Patients must adhere to lifelong immunosuppressive therapy to avoid rejection.

Medical and Nursing Management Preoperatively for Transplant

• Includes:
  • Complete history and physical examination of the donor/recipient.
  • Administration of immunosuppressant medications to prevent rejection.
  • Screening for infections to ensure donor safety.
  • Blood typing and HLA (human leukocyte antigen) matching.
  • Blood crossmatching for compatibility.
  • Comprehensive medical and psychological evaluations.
  • Performing renal function tests.

Post-Operative Priorities for Kidney Transplant

• Focus on:
  • Monitoring urine output and evaluating renal function post-surgery.
  • Managing fluid and electrolyte balance.
  • Infection prevention protocols.
  • Assessing for surgical complications.
  • Administering prescribed medications, particularly immunosuppressants.
  • Early mobilization to aid in recovery.
  • Patient education and continued care after discharge.

Polycystic Kidney Disease (PKD)

• Definition: A common genetic disorder leading to fluid-filled cyst formation that progressively damages renal tissue.
• Types of PKD:
  • Autosomal Dominant PKD (ADPKD).
  • Autosomal Recessive PKD (ARPKD).
• Consequences include:
  • Hypertension and impaired filtration.
  • Risk of chronic kidney disease and end-stage renal disease.

Clinical Features of PKD

• Symptoms include:
  • Flank pain due to cyst stretching.
  • Hematuria (blood in urine).
  • Recurrent urinary tract infections (UTIs).
  • Hypertension.
  • Kidney stones from cyst growth.
  • Progressive renal failure as the disease advances.

Diagnosis and Complications of PKD

• Evaluation Methods:
  • Imaging studies such as ultrasound or CT scans.
  • Genetic testing for confirmation.
  • Laboratory tests to monitor renal function.
• Complications Include:
  • Hypertension requiring management.
  • Chronic kidney disease leading to ESRD.
  • Risk of cyst infection or rupture.
  • Kidney stones.
  • Rupture of intracranial aneurysms associated with PKD.

Treatment for PKD

• Management strategies may include:
  • Controlling hypertension with medications.
  • Pain management methods.
  • Prompt treatment of UTIs to prevent complications.
  • Tolvaptan, a medication that slows cyst growth.
  • Dialysis or kidney transplantation in advanced stages.
  • Implementation of lifestyle changes to promote kidney health.

Nursing Management for PKD

• Key nursing roles involve:
  • Monitoring blood pressure and renal function regularly.
  • Educating patients on medication adherence to manage symptoms.
  • Advising on lifestyle modifications to support kidney health.
  • Providing psychosocial support to cope with chronic illness.

Renal Cell Carcinoma (RCC)

• Definition: A malignancy originating in the kidney.
• Prevalence: Accounts for approximately 3% of adult cancers, with a higher incidence in men than women.

Types of Renal Cancers

• Various types include:
  • Renal cell carcinoma (RCC), the most common.
  • Transitional cell carcinoma (originating in the renal pelvis).
  • Wilms’ Tumor (pediatric type).
  • Sarcomas (rare types of kidney cancer).

Clinical Manifestations of Renal Cancers

• May present as:
  • Classic triad symptoms such as hematuria, flank pain, and a palpable mass.
  • Weight loss.
  • Fatigue.
  • Fever.
  • Paraneoplastic syndromes (systemic effects of cancer).

Diagnostic Evaluation for Renal Cancer

• Evaluation of renal cancers may involve:
  • Imaging studies such as CT scans or MRIs.
  • Laboratory tests for tumor markers.
  • Urinalysis to detect blood or cancer cells.
  • Biopsy is rarely used due to associated risks.

Staging of Renal Cancer

• Stages include:
  • Stage I: Tumor ≤ 7 cm, confined to the kidney.
  • Stage II: Tumor > 7 cm, confined to the kidney.
  • Stage III: Tumor extends into major veins or adrenal gland, without distant spread.
  • Stage IV: Tumor spreads beyond Gerota’s fascia or has distant metastases.

Management of Renal Cell Carcinoma

• Treatment options include:
  • Surgical treatment options such as radical nephrectomy or partial nephrectomy.
  • Targeted therapy focusing on specific cancer mechanisms.
  • Immunotherapy as a method to enhance body’s immune response against cancer.
  • Radiotherapy and chemotherapy as adjunctive treatments.

Nursing and Supportive Care for Renal Cancer

• Key nursing interventions:
  • Pain management strategies post-surgery.
  • Regular monitoring of renal function post-treatment.
  • Providing psychological support for the patient and family.
  • Education focusing on lifestyle modification and smoking cessation.
  • Post-operative care including wound monitoring and infection prevention.

Nursing Management: Patients With Urinary Disorders

Unit 7

Chapter 27

Wolters Kluwer

Pyelonephritis

• Definition: Bacterial infection of the kidney and renal pelvis, can be classified as acute or chronic.
• Etiology: Often results from ascending urinary tract infections (UTIs) and is more common in women.
• Progression: Ignored, it may lead to chronic kidney disease or kidney failure.

Etiology and Risk Factors for Pyelonephritis

• Common causes include:
  • Escherichia coli (most prevalent pathogen).
  • Klebsiella, Proteus, and Enterococcus species.
• Risk factors involve:
  • Female gender.
  • Pregnancy due to anatomical changes.
  • Urinary tract obstruction (stones, tumors).
  • Diabetes mellitus as a systemic condition.
  • Catheterization or other invasive procedures.
  • Immunosuppression conditions.

Pathophysiology of Pyelonephritis

• Mechanism:
  • Bacteria ascend from the bladder through the ureters to the kidneys.
  • Resulting inflammation causes infiltration with neutrophils in acute cases.
  • Chronic cases can lead to renal scarring and fibrosis.

Clinical Manifestations of Pyelonephritis

• Symptoms can include:
  • Costovertebral (flank) tenderness.
  • Fever and chills indicating systemic infection.
  • Dysuria (painful urination), frequency, urgency.
  • Nausea and vomiting due to systemic infection effects.
  • Fatigue and malaise.
  • Anorexia and headache.
  • Elevated white blood cell count (leukocytosis).
  • Sepsis with shock in severe cases.
  • Possible bacteremia.

Diagnosis of Pyelonephritis

• Diagnostic process may include:
  • Urinalysis (presence of WBCs, bacteria).
  • Urine culture to isolate pathogens.
  • Blood tests to evaluate kidney function and infection markers.
  • Imaging studies such as ultrasound or CT scans if obstruction is suspected.

Complications of Pyelonephritis

• Potential complications include:
  • Renal abscess formation.
  • Sepsis potentially leading to systemic infection.
  • Chronic pyelonephritis resulting in renal scarring.
  • Hypertension from kidney damage.
  • Advanced renal failure in severe or untreated cases.

Medical Management of Pyelonephritis

• For uncomplicated acute pyelonephritis:
  • Antibiotics for infection control.
  • Analgesics for pain management and antipyretics for fever reduction.
  • IV fluids for hydration support.
• In complicated cases, surgical intervention may be required (e.g., drainage of abscesses).

Nursing Priorities in Pyelonephritis

• Essential nursing focus:
  • Monitoring vital signs for signs of infection or instability.
  • Ensuring adequate hydration through IV or oral fluids.
  • Monitoring urine output and its characteristics.
  • Administering medications as prescribed (antibiotics, analgesics).
  • Minimizing prolonged catheterization to reduce infection risk.
  • Patient education on understanding the disease and signs of complications.

Chronic Pyelonephritis

• Definition: A chronic, recurrent infection leading to kidney scarring and deformation.
• Impact: Causes progressive renal dysfunction and can lead to chronic kidney disease.

Clinical Features of Chronic Pyelonephritis

• Often presents insidiously:
  • Flank pain or discomfort.
  • Hypertension due to renal damage.
  • Polyuria and nocturia (increased urination at night).
  • Symptoms of chronic kidney disease in later stages.

Complications of Chronic Pyelonephritis

• Risks include:
  • Hypertension management difficulties.
  • Recurrence of infections.
  • Urolithiasis (kidney stones) leading to obstruction.
  • Ongoing renal scarring and eventual chronic kidney disease leading to ESRD.

Management of Chronic Pyelonephritis

• Management strategies involve:
  • Use of antibiotics and treating underlying causes.
  • Control of hypertension.
  • Supportive care to manage symptoms.
  • Addressing end-stage renal disease when it arises.

Urolithiasis and Nephrolithiasis

• Definition: Presence of renal stones (calculi) in the urinary tract and kidneys.
• Terms:
  • Urolithiasis: stones in the urinary tract.
  • Nephrolithiasis: stones specifically in the kidneys.
  • Ureterolithiasis: stones located in the ureters.

Risk Factors for Urolithiasis

• Key risk factors include:
  • Genetic predisposition (family history).
  • Seasonal factors, particularly spring and summer.
  • Increasing age.
  • Excessive intake of vitamin D can affect calcium metabolism.
  • Obesity increases overall risk.
  • Certain supplements and medications may contribute.

Clinical Manifestations of Urolithiasis

• Signs and symptoms depend on obstruction presence:
  • Fever and chills may occur if accompanied by infection.
  • Pyuria (presence of pus in urine).
  • Costovertebral pain (especially renal colic).
  • Hematuria (blood in urine).
  • Urinary retention due to blockage.

Medical Interventions for Urolithiasis

• Treatment strategies may involve:
  • Pain management (e.g., NSAIDs).
  • Increased fluid intake promotes stone passage.
  • Ureteroscopy for stone removal if necessary.
  • Extracorporeal shock wave lithotripsy (ESWL) to break up stones.
  • Endourological (percutaneous) approaches, such as percutaneous nephrolithotomy.

Nursing Priorities in Urolithiasis

• Key actions for nursing care:
  • Effective pain management strategies.
  • Ensuring adequate hydration to facilitate stone passage.
  • Urinary strain and observation for passed stones.
  • Monitoring for potential complications, such as infections.
  • Providing patient education regarding dietary changes and prevention.
  • Pre- and post-procedural care for surgical interventions.

Nutritional Therapy for Urolithiasis

• Patient education for stone prevention includes:
  • Change of lifestyle and dietary habits.
  • Maintaining adequate fluid intake.
  • Implementing dietary restrictions based on the type of stone (calcium, oxalate, uric acid).

Note on Procedures

Ureteroscopy with Stone Removal

• Description:

- Utilizes optical instruments to access and remove kidney stones.

Electromagnetic Shock Wave Lithotripsy (ESWL)

• Description:

- A non-invasive method to break stones into smaller fragments using shock waves.

Percutaneous Nephrolithotomy (PCNL)

• Description:

- An invasive procedure to remove larger stones through a small incision in the back.

Nursing Interventions for Urolithiasis

• Focus on:
  • Pain relief management.
  • Managing potential complications from urinary obstruction.
  • Coordinating continuity of care during recovery and follow-up.