Renal Problems Notes

Renal Problems

Objectives

  • Determine safe patient-centered nursing care using evidence-based practice for patients experiencing common elimination (renal) problems.
  • Identify development principles, prevention, and early detection of health problems and strategies to achieve optimal health for adult and older adult patients experiencing common elimination (renal) problems.
  • Differentiate medications prescribed for patients experiencing common elimination (renal) problems.
  • Examine caring and professional behaviors required when providing care for patients experiencing common elimination (renal) problems.
  • Examine effective verbal, non-verbal, written, and electronic communication required for the care of patients experiencing common elimination (renal) problems.
  • Use established practice standards and guidelines to ensure quality outcomes for patients experiencing common elimination (renal) problems.
  • Determine collaborative relationships needed to provide and improve care for patients experiencing common elimination (renal) problems.
  • Determine leadership skills required to provide care for patients experiencing common elimination (renal) problems.
  • Topics include: Cystitis/UTI, Urinary incontinence, Renal calculi, Pyelonephritis, Polycystic kidney disease, Acute Glomerulonephritis, Nephrosclerosis, Renovascular disease, Kidney trauma, Benign prostatic hypertrophy, Erectile dysfunction, Nephrostomy tube

Introduction

  • Kidneys:
    • Remove waste.
    • Help manage fluid and electrolyte balance.
    • Help regulate the acid/base balance of the body.
  • Patients with compromised renal function may present with a variety of clinical manifestations.
  • If the kidneys are not functioning properly and adequate treatment is not implemented in a timely manner, acute illness occurs, and death is inevitable.
  • Kidneys:
    • Remove waste from the body.
    • Regulate fluids, electrolytes, acid-base balance, and blood pressure.
  • Clinical manifestations and treatments depend on what is going on with the renal system.

Common Clinical Manifestations of Kidney Disorders

  • Changes in lab values:
    • UA (Urinalysis).
    • BUN (Blood Urea Nitrogen).
    • Creatinine.
    • Electrolytes such as Na+Na^+, K+K^+, Ca+Ca^+, PHOs+PHOs^+.
  • Edema, fluid overload.
  • Hypertension.
  • Changes in ABGs (Arterial Blood Gases).
  • Fatigue, Anorexia.
  • SOA/Crackles – Fluid overload.
  • Changes in lab values (electrolytes).

Labs

  • Urinalysis:
    • Check for Nitrates, White Cells, Red Cells, Hematuria, Proteinuria.
    • Culture and sensitivity in urine and blood for infection.
  • Glomerular filtration rate (GFR):
    • Indicates how well the kidneys are filtering.
    • Lower numbers indicate a problem.
    • Normal GFR: 90-120 mL/min/1.73 m2\rm{^2}.
  • Serum electrolyte levels:
    • Kidney regulates electrolytes - Sodium, Potassium, Phosphate, and Calcium.
  • Serum Creatinine:
    • Elevated numbers indicate a problem.
    • Normal:
      • Male: 0.6-1.2 mg/dL
      • Female: 0.5-1.1 mg/dL
  • Blood Urea Nitrogen (BUN):
    • Elevated indicates a problem.
    • Normal: Both Sexes: 10-20 mg/dL
  • ABGs:
    • For metabolic Acidosis or Alkalosis.
  • KUB/CT and Renal Scan:
    • X-ray of the Kidneys, ureters, and bladder.
    • CT & Renal scan to identify inflammation, abscesses, scarring, or structural issues within the urinary tract and kidneys.

Pyelonephritis

  • Severe Kidney Infection
  • Filtration, reabsorption, and secretion are affected, impairing and reducing kidney function.
Epidemiology
  • Young women most often affected by sexual activity.
  • Infants and the elderly are also at increased risk, reflecting anatomical changes and hormonal status.
Pathophysiology
  • Inflammation of the renal parenchyma and urinary collecting system.
  • Escherichia coli is the most common cause.
Clinical Manifestations

Acute Pyelonephritis
* Fever, Chills.
* Tachycardia and tachypnea.
* Flank, back, or loin pain.
* Tenderness at the costovertebral angle (CVA).
* Abdominal, often colicky, discomfort.
* Nausea and vomiting.
* General malaise or fatigue.
* Burning, urgency, frequency of urination.
* Nocturia.
* Recent cystitis or treatment for urinary tract infection (UTI).
Chronic Pyelonephritis
* Hypertension.
* Inability to conserve sodium.
* Decreased urine-concentrating ability, resulting in nocturia.
* Tendency to develop hyperkalemia and acidosis.

Diagnosis and Management
  • Diagnosed by history and physical exam. Labs
    • Urinalysis, urine culture-clean catch, blood culture.
    • Bacterial antigens and antibodies-for recurrent infections.
    • WBC, CBC, CRP, ESR, BUN, Creatinine, GFR.
      Imaging
    • X-ray of kidneys, KUB, CT - visualize anatomy, inflammation, fluid accumulation, abscess formation, and defects in kidneys and the urinary tract.
    • Antibody-coated bacteria in urine, testing for certain enzymes, radionuclide renal scans.
    • Hospitalization in case of bacteremia or hemodynamic instability.
    • Recurrent infections can lead to scarring, chronic kidney disease, or permanent damage.
Lab Results
  • UA = + for leukocyte esterase, nitrites, WBCs, and Bacteria.
    • May see RBCs and protein.
  • Urine Culture – show a specific bacteria.
  • CBC – increased WBCs.
  • Urine – cloudy, puss, foul-smelling.
Vital Signs
  • Fever, Tachycardia, tachypnea.
Patient Signs & Symptoms
  • Chills.
  • Flank, back, or loin pain.
  • Tenderness at the costovertebral angle (CVA).
  • Abdominal, often colicky, discomfort.
  • Nausea and vomiting.
  • General malaise or fatigue.
  • Burning, urgency, or frequency of urination.
  • Nocturia.
  • Recent cystitis or treatment for urinary tract infection (UTI).
Nonsurgical Management

Pain
1. Acetaminophen is preferred over NSAIDs because it does not interfere with kidney autoregulation of blood flow.
2. Will also help with fever.
3. Opioids.
4. Pyridium (Phenazopyridine) is a urinary analgesic that helps to relieve the symptoms associated with lower urinary tract ailments.
Antibiotics
1. Start with broad spectrum after drawing the culture.
2. Given via IV in a hospitalized patient.
3. Bactrim (Trimethoprim -Sulfamethoxazole) and Cipro (Ciprofloxacin) are most common used antibiotics with Bactrim as the first-line medication.
Other
* Cranberry juice can prevent bacteria from sticking to the urinary tract structures.
* Adequate calories, dietary consult.
* Fluid intake is recommended at 2 L/day, sufficient to result in dilute (pale yellow) urine, unless contraindicated.

Chronic Pyelonephritis
  • Results from repeated or continued urinary tract infection (UTI).
  • Most often, these infections are the result of a urinary tract defect like an obstruction that causes urine to reflux or move backward from the bladder into the kidneys.
  • Things like bladder stones and tumors can cause urine retention and reflux.
Cultural Considerations
  • More common in women.
  • In men after age 65, the rate of pyelonephritis increases greatly.
Care Focuses
  • Manage fever, pain, & comfort - Acetaminophen over NSAIDs. Pyridium is a urinary analgesic.
  • Infection - give antibiotics Bactrim, Cipro.
  • Proper Nutrition - Healthy diet & Fluids 2L/day.
  • Intake and output, Assess urine for color, odor, clarity, and sediments. Patient Education
    • Antibiotic education.
    • Signs and Symptoms of Complications.
Key Takeaway
  • Infection in the kidney.
  • Acute or chronic. Care Focuses
    • Pain relief.
    • Identifying the organism.
    • Administration of antibiotics and antihypertensive medications.
    • Restoring renal function.
    • In-depth patient teaching to prevent complications and further reoccurrence of disorder.

Glomerulonephritis

Types

Acute glomerulonephritis
* Inflammation of the glomerular capillaries approximately 10 days after an infection has occurred somewhere else in the body.
Chronic glomerulonephritis
* Develops over 20 years or longer.
* Recurrent glomerular inflammations causing renal destruction.

Acute Glomerulonephritis

Epidemiology
* 3rd leading cause of renal failure.
* Classified as acute or chronic.
* Caused by autoimmune disorders - Goodpasture’s syndrome or lupus, Streptococcus infection.
Pathophysiology
* Inflammation of the glomeruli triggered by an immunological mechanism.
Additional Pathophysiology Details
* More common in children, but can occur at any age.
* Most commonly caused following a streptococcus infection.
* Kidneys become enlarged, edematous, and congested.
* Related to the inflammatory process.
* Affects renal vessels, tubules, and glomeruli disrupting their normal functions.
* Antigen-antibody response to the infection leads to:
* Increased epithelial cells and leukocytosis causes thickening of glomerular membranes.
* Scarring of membrane and loss of filtration occurs.
* Decreased glomerular filtration rate (GFR).
Key Difference
* With Pyelonephritis, the infection is in the kidney.
* With Acute Glomerulonephritis, the infection is somewhere else, but it triggers the immune system to attack the kidney.

Clinical Manifestations

Renal
1. Proteinuria.
2. Hematuria - cloudy, cola-colored urine.
3. Oliguria - < 400 ml/day.
4. Decreased GFR.
5. Azotemia - increased urea nitrogen, uric acid, creatinine in blood.
6. Increased serum BUN and creatinine.
7. Hyperkalemia & Hypernatremia.
Cardiac
* Hypertension.
Lymphatic
* Periorbital edema & Edema - Facial, eyelids, hands.
* Anasarca (Severe generalized edema).
* Weight gain.
Gastrointestinal
* Anorexia.
Musculoskeletal
* Fatigue.
Respiratory
* SOA and crackles.

Lab and Diagnostics
  • Urinalysis - hematuria, proteinuria.
  • Glomerular filtration rate (GFR) - decreased.
  • Serum creatinine - elevated.
  • Blood urea nitrogen (BUN) - elevated.
  • Culture and sensitivity - throat, skin, blood to identify organism.
  • Serum electrolyte levels - Sodium- elevated, Potassium-elevated.
  • May do renal biopsy.
Care for the Patient with Glomerulonephritis
  • Manage nutrition & fluids.
  • Administer medications.
  • Monitor I's & O's, daily weights, urine quality.
  • Monitor for complications. Patient Education
    • Edema management.
    • Nutrition.
    • Medication management.
Medications
  • Antibiotics – to treat original infection
    • Penicillin
    • Erythromycin
    • Azithromycin
  • Loop diuretics – to decrease fluid and potassium
  • Antihypertensives – to lower blood pressure
  • Corticosteroids – reduce inflammation
  • Immunosuppressants – stop inappropriate immune response
Management
  • Monitor for fluid overload, pulmonary edema, and heart failure.
  • Increases in lab values.
  • Nausea, vomiting, fatigue, decreased urine output.
  • Dyspnea, crackles in lungs, pink-frothy sputum.
  • Decreased cardiac output.
  • Hypotension, tachycardia, tachypnea, dyspnea, and crackles in lungs.
  • Confusion, decreased LOC.
Acute Glomerulonephritis - Key Takeaway
  • Inflammation of the capillaries within the glomeruli.
  • Usually appears within 10 days of an infection.
  • Can be life-threatening if not treated promptly and correctly.
  • Common in children, but can occur at any age following an infection. Hallmarks
    • Periorbital edema
    • Cola-colored urine
    • Hematuria
    • Proteinuria
    • Oliguria
  • Goal is to treat and prevent complications.

Polycystic Kidney Disease (PKD)

  • Genetic disorder characterized by the growth of numerous cysts in the kidneys.
  • As the cysts fill with fluid, nephrons are destroyed.
  • Cysts cause the kidney to no longer function correctly and enlarge the kidney resulting in kidney failure, also known as “end-stage renal disease” (ESRD).
  • Patients have high blood pressure due to kidney ischemia from the enlarged cysts.
  • Early detection and management of HTN are key. Control of HTN is the top priority.
Epidemiology
  • One of the most common genetic disorders.
  • 2 forms of PKD are childhood and adult.
Pathophysiology
  • Genetic disorder that manifests in the cortex and medulla of both kidneys.
  • Appears as large, thin-walled, fluid-filled cysts.
  • Ranging from millimeters to centimeters in diameter.
  • As the vessels are compressed and blood flow to kidneys is decreased, the renin-angiotensin system is active that raises the blood pressure.
Clinical Manifestations
  • No early signs, hypertension is the first symptom.
  • Hematuria, lower back pain, headaches, or abdominal pain.
Management
  • Diagnosis on the basis of clinical signs and history.
  • Laboratory and diagnostic tests.
  • Hemodialysis or peritoneal dialysis.
  • Renal transplant.
Additional Clinical Manifestations
  • Hypertension.
  • Nocturia – early manifestation.
  • Hematuria or cloudy urine – especially when cyst rupture – suspect infection if cloudy or foul smelling.
  • Proteinuria.
  • Kidney stones.
  • Sodium wasting and inability to concentrate urine in the early stage.
    • This means they may see an increase in dilute urine production in the early stages.
    • However, as the disease progresses and the kidneys become more damaged, urine production will slow down and possibly even cease.
  • Abdominal or flank pain – often the first clinical manifestation
    • Described as dull, aching pain (Pressure due to distension) or sharp/intermittent (when rupture or stones).
Management Details
  • Definitive diagnosis is determined by abdominal ultrasound, magnetic resonance imaging (MRI), IV pyelogram (IVP), or computerized axial tomography (CAT) scan.
  • Diagnostic imaging can reveal other complications related to PKD such as cysts on the liver and other abdominal organs. Labs
    • Urinalysis - will show proteinuria and hematuria.
    • WBC
    • BUN
    • Creatine
    • Sodium
      Diagnostic Testing
    • Renal Ultrasound
    • CT
    • MRI
    • Genetic testing
Care for the Patient with PKD
  • Supportive care.
  • Controlling hypertension - teach patients about side effects of HTN such as headache, dizziness, blurred vision, SOB, nosebleed, anxiety.
  • Preventing UTI - clean front to back, drink plenty of fluids.
  • Control Pain - Acetaminophen and Opioids but avoid aspirin-containing drugs, NSAIDS.
  • Low Protein diet.
  • Sodium Restriction - dietary salt of 2g/day.
  • Adequate Fluid (sugar-free) intake - 2-3 L daily in food and beverages.
  • Needle aspiration of cysts due to excessive pain.
  • Medications for pain, HTN, fluid retention.
Nursing Care
  • Administer medications - Ace inhibitors to reach BP < 130/80.
    • Teach patients on the side effects of Ace inhibitors such as low BP, persistent dry cough, hyperkalemia.
    • Hold drug if BP < 100, orthostatic hypotension.
  • Monitor blood pressure.
  • Daily weights.
  • Measure abdominal Girth.
  • Monitor bowel movements.
  • I's & O’s.
  • Monitor urine output (<2500 mL/24 hr.).
Patient Teaching
  • Measure and record BP daily. Notify PCP if high.
  • Take temperature if fever, notify PCP.
  • Weight daily at the same time of the day and with the same clothing. Notify if you have sudden weight gain.
  • Limit salt intake to help control HTN.
  • Notify PCP if urine smells foul or has hematuria.
  • Notify provider if you have a headache that does not go away or visual disturbance because these are the symptoms of stroke or bleeding in the brain.
  • Monitor bowel movements to prevent constipation, high-fiber food, fluids.
Cultural Considerations
  • Equal chance regardless of sex since not linked to sex chromosomes.
  • If patient inherits disease, cysts will develop by age 30.
  • 50% of people with PKD will progress to chronic kidney disease by age of 50.
Specific Patient Teaching Points
  • Monitoring daily BP
  • Decrease salt
  • Monitor infections, take temp
  • Perform Daily weight
  • Monitor urine - odor, hematuria
  • Monitor bowel
  • Safety with night “walking” for Nocturia
PKD - Key Takeaway
  • Polycystic kidney disease (PKD) is an inherited disorder
  • Goals are providing supportive care and managing pain
  • Patients require intense teaching to control the effects of this disorder and to prevent complications
  • Can progress to renal failure, dialysis, kidney transplant.

Kidney Trauma

  • Penetrating wounds or blunt injuries to the back, flank, or abdomen.
  • Iatrogenic (from urologic procedures).
  • Extracorporeal shock wave lithotripsy.
  • Kidney biopsy.
  • Percutaneous renal procedures.
  • Blunt trauma accounts for most kidney injuries.
Clinical Manifestations

Renal
* Ureteral or renal pelvic injury causes abdominal pain.
* Hypotension
* Blood around urethra
Cardiovascular
* Tachycardia
Musculoskeletal
* Abdomen, chest, and lower back (flank) for bruising, asymmetry, or penetrating wounds

Labs & Diagnostics
  • Urinalysis- shows hemoglobin or RBCs from tissue damage.
  • Hemoglobin and Hematocrit- decreases with blood loss.
  • CT Scan
  • Abdominal x-ray- KUB
Care for a Patient with Kidney Trauma
  • Support ABCs
  • Manage bleeding
  • Manage pain
  • Surgical repair
Assessment Findings
  • Assess abdomen, chest, and lower back
    • Grey-Turner’s sign
    • Cullen’s sign
  • Assess abdominal girth
  • Percuss abdomen for distention
  • Inspect urethra for blood
  • Inspect urine for amount and hematuria
Patient Teaching
  • Check the pattern and frequency of urination.
  • Color, clarity, and amount appear normal.
  • Seek medical attention if:
    • Anything appears abnormal
    • If bladder distention or inadequate bladder emptying occurs
    • Any chills, fever, lethargy, or cloudy, foul-smelling urine
      Prevention
    • Wear seatbelt
    • Wear appropriate protective sports equipment.
    • Avoid contact sports if only have one kidney.

Nephrosclerosis

  • Degenerative disorder resulting from changes in kidney blood vessels.
  • Nephron blood vessels thicken, resulting in narrowed lumens and decreased kidney blood flow.
  • Occurs with all types of HTN, atherosclerosis, and DM.
  • Rarely seen when BP < 160/110.
  • Can progress to ESRD.
  • Genetic component.
Caring for a Patient with Nephrosclerosis

Labs
* Elevated BUN & Creatinine
* Elevated Urine Albumin
* Elevated Potassium
Treatment
* Control BP and reduce albuminuria.
* ACE inhibitors are very useful in reducing HTN and preserving kidney function.
* Diuretics can help maintain fluid and electrolyte balance.
* Monitor K+K^+ values to prevent hyperkalemia.

Renal Vascular Disease

  • Process affecting renal arteries that may severely narrow the lumen and greatly reduce blood flow to kidney tissues.
  • Clients may have a sudden onset of HTN. Clients with HTN but no family history may potentially have RAS.
  • RAS from atherosclerosis or blood vessel hyperplasia is the main cause of renovascular disease.
Diagnostics
  • MRA, Renal U/S, Radionuclide imaging, or renal arteriography.
Pharmacologic Treatment
  • HTN medications, ACEi, help preserve renal function.
Procedural Treatment
  • Stent placement with or without balloon angioplasty.
Surgical Treatment
  • Renal artery bypass surgery

Nephrostomy

  • Drainage tube placed within the kidney pelvis.
  • Extends to the outside of the body or through the ureter into the bladder.
  • The word Nephrostomy comes from nephro which means kidney and ostomy which means a hole.
Nursing Care
  • Assess insertion site.
  • Observe for postoperative hemorrhage.
  • Assess dressing for an increase in bloody drainage.
  • Dressing changes should be conducted very carefully as to not dislodge tube.
  • Ensure that the tube is secured to the patient.
  • Obtain VS as prescribed. Teach the patient to splint area with turning, coughing, and deep breathing.
  • Medicate for pain and monitor effectiveness.
Repositioning
  • Usually prefer to have patient placed on the affected side.
  • Fluids may be restricted immediately after tube placement, then gradually increased.
  • If tube placement is lost: Notify healthcare provider immediately.
Care Considerations
  • Never clamp or irrigate a nephrostomy tube without a prescription from a healthcare provider. Remember it is placed directly into the kidney, and you do not want to introduce any infections.
  • Ensure that the tube remains patent.
  • Observe output for amount, color, clarity, and presence of blood.
  • If no output or output less than 30 mL/hour, notify healthcare provider.
  • Make sure you are teaching your nursing assistants to measure urine output accurately and carefully and to:
  • Use aseptic technique to prevent infection.
  • Repositioning depends on the healthcare provider, usually preferring to have the patient placed on the affected side.
  • Fluids may be restricted immediately after tube placement, then gradually increased.
  • If tube placement is lost, notify the healthcare provider immediately.
Patient Teaching - Notify the Provider if:
  • Dressing changes until the site is healed.
  • Keep drain site dry.
  • May shower, but cover area with plastic.
  • Avoid tub bathing or swimming while the catheter is in place.
  • Drink at least 2000 mL of water each day.
  • Sudden decrease in urine output.
  • Presence of blood in drainage bag.
  • Presence of blood around insertion site.
  • Fever and chills.
  • Nausea and vomiting.
  • Urine becomes cloudy or foul smelling.
  • Complaints of back pain.
  • Catheter leaks, becomes dislodged, or broken.