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 endstage renal disease develops Obstructive: Hydronephrosis Urethral stricture
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
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
Infectious: Renal Absess Patho Complications of UTI; tissue necrosis leads to scarring wall off infection Strept is usual cause s/s fever, flank pain, dysuria Interventions antibiotics
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
Immunologic : Acute Glomerulonephritis Pathophysiology Immunologic disease: inflammation of the capillary loops in the glomeruli Signs and symptoms Urine becomes tea colored as output decreases Peripheral and periorbital edema
As glomerular filtration decreases, mild to severe hypertension occurs and hypervolemia results Medical diagnosis Patient assessment and laboratory tests Urinalysis, BUN, creatinine, and albumin Renal ultrasound, renal biopsy, or both Acute Glomerulonephritis Assessment
Signs and symptoms, recent infections, and changes in urine Nursing Diagnosis Excess Fluid Volume Activity Intolerance
Self-Care Deficit Anxiety Immunologic: Rapid Progressive glomerulonephritis Patho Rapid, causes damage to small structures that filter waste s/s Edema, blood in urine, abd pain, joint pain
Interventions corticosteroids, plasmaphoresis, watch for kidney failure Immunologic: chronic glomerulonephritis Patho Due to repeated episodes of acute glomerulonephritis, hyperlipidemia, hypertensive nephrosclerosis and chronic tubulointerstitial injury
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 s/s Edema: periorbital, lower extremity, abdomen (ascites); patients have irritability, HA and malaise
Interventions Early stages: similar to acute glomerulonephritis Late stages: Chronic Renal Failure Degenerative: nephrosclerosis Patho: Malignant: associated with malignant hypertension Young adults, men>women; progress is rapid
Benign: associated with atherosclerosis and hypertension Older adults s/s Rare early in the disease; renal insufficiency occurs late in the disease Interventions Aggressive antihypertensives; ACE inhibitors 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. 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 Tumors: Renal Cancer 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
Medical diagnosis Excretory urography, IVP, retrograde pyelography, ultrasound, arteriography, computed tomography, magnetic resonance imaging, and renal biopsy 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 Renal Cancer Nursing Diagnoses
Acute Pain Risk for Deficient Fluid Volume Ineffective Breathing Pattern Risk for Injury Risk for Infection Ineffective Coping Deficient Knowledge 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 Acute Renal Failure: Stages Onset stage Short (1-3 days); increasing BUN and serum creatinine
with normal to decreased urine output Oliguric stage 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 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 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 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) 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
function Cardiovascular system (CHF and dysrhythmias) 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
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 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 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 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 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
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 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 antibodieswould 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 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 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 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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