410 Lectures

- Over 2 millions nephrons; As we age the cortical nephrons are

nonfunctionals and so we lose nephrons.
- ***KNOW THE PARTS OF A NEPHRON; The start is Bowman’s capsule
and that makes up the glomerulus (beginning stages of urine formed there-
filtration) this network of capillaries have a semipermeable membrane (in a
normal environment the membrane don’t allow protein), filtrate results from
filtration; filtrate is like serum w/ the exception of protein (watery clear part
of blood without RBC);
- Strept throat (the bacteria can cause a antibody response in the
glomerulus), Hypertension, UTI & Diabetes (damage membrane) sometimes
causes protein to get into the filtrate, once its in the filtrate it is lost in urine
and no longer in the body; (Pregnant women with proteinurea will have a
decrease amt of serum protein) All these things can damage the glomerulus
and Bowman’s capsule;
- What is the consequence of having low serum protein? Delivery of
medication, muscle and cell problems, slow healing, **Risk for delayed
healing rt to low serum protein from proteinurea;
Now Check for edema esp. in face w/ these patients (water was leaving the
cells, protein holds water in the intravascular compartment) Also, skin
integrity rt fluid in interstitial space; capillary refill will be sluggish, skin color
pale b/c less blood supply, mental status altered; Water is all in the intestinal
space, intravascular vol deficit w/ interstitial volume excess- fluid is in wrong
space all b/c protein is gone;
▪ Give this pt a hypertonic soln or give pt shot of protein (albumin); If it
works pt will have stronger pulse and bp and urine will increase, less
edema, better capillary refill
- Second part of nephron is PCT – proximal convulted tubule, (120 mL
per min forming filtrate) 90% of what is filtered is reabsorbed, surrounding
the PCT is an arteriole and the products move back into the blood; 90% of
whats filtered is reabsorbed;
▪ If the PCT is broken the urine volume will INCREASE! The volume in
our body will be low… decrease pulse, bp, cold clammy skin, etc. If
potassium cant be reabsorbed it will be low in the serum along with
other electrolytes
- The third is the Loop of Henle it concentrates urine (Loop Diuretics
work here and block the reabsorption of sodium, which water follows);
- The DCT is next, Distal convulated tubule, the primary role is
secretion; vesicles around DCT pick up any extra concentrated electrolytes
back into the nephron after they were reabsorbed;
▪ ADH has its effect on the DCT, water is reabsorbed and not secreted
into the urine;
- The fifth part is the collecting duct, it transfers the filtrate to the
renal pelvis. FINAL part of the tube and now the filtrate is called URINE;
- Urine then flows down the ureters to the bladder into the uretha to
EXCRET so the collecting ducts are for excretion;
- Question: Which pt is more likely to experience renal compromise
(decreased urine production)?
▪ A pt w/ blood pressure of 92/45 for 12 hr
▪ A pt w/ white blood cell count of 12,000 (5-10,000 – normal)
▪ A pt w/ 5 yr hx of DM
▪ A pt w/ hx of myocardial infection
- The ANSWER is A b/c this blood pressure has a mean arterial pressure
(MAP[KE1] ) of 62 mm hg. The kidney has a difficult time regulating GFR w/ a
MAP less then 65 mm Hg; If this was my pt from ER what would we see if
fluid vol overload, increased resp rate, nasal flaring, HOB elevated, pulse
oximeter, crackles in lung sound or rales, so primary for this pt would be
pulmonary; Next Cardiac mayb distended neck veins, puffy & edema, could
have pounding pulse w/ increased rate, will hear S3 (APEX is where this will
be heard)
- Filtration must have adequate blood flow and pressure, when pressure
falls vol of filtrate decreases and vol of urine decreases which can cause fluid
overload b/c all of it is retained. Prolonged hypotension can cause fluid
overload. Failure to filter is retention in the body, so electrolytes will go up,
like Potassium (meaning Cardiac should be evaluated when something is
wrong with filtration)
Bicarbonate Reabsorption
▪ • Secretion of hydrogen ions
▪ • Secretion of nonvolatile [acids that do not form a gas]
acids (phosphate, ammonia, urea, etc)
STORY - COPD pt have CO2 trapped and our levels increased which leads to
elevated carbonic acid; If this pt had healthy kidney it would recompensate
for it by holding onto bicarbonate and secrete other acids like ammonia but
when we have renal problems the kidney can’t do this and if it cant do that
the bicarb goes in the urine and the body has a low bicarb level This pt will
get bicarb tablets w/ pt having high resp rate b/c lungs tries to get rid of it;
** IF this was Pt is in fluid vol excess & have fluid in alveoli (resp rate goes
up); This pt will be sicker b/c they cant blow off the CO2; ( This pt would be
at risk for pneumonia, if a pt came in with or at risk for other respiratory
problems on top of renal problems & COPD they would be closer to nurse
station bc they are so prone to getting acidosis)
Make and reabsorb bicarb and secrete others like ammonia.
Renal Failure → Metabolic Acidosis
Regulation of Blood Pressure

▪ • Production of Renin – regulates blood pressure

▪ Renin is produced when there is a decrease in blood pressure into the
kidney;
▪ • Structures within the DCT (macula densa cells – lie beside
renin producing cells) sense decrease perfusion/pressure --
release renin -- renin converts angiotensinogen (from liver)
into Angiotensin I which converts (in lung) into Angiotensin II
(increases afterload & stimulates release of Aldosterone (from
adrenal) to enhance sodium reabsorption (pg 202)
▪ • Renal Failure -> often hypertension
▪ CHF has less CO and less blood flow to kidney, with Renin in these
people the vessel are constricted which causes it to have even more
decrease in the CO, this is when we start meds like lisinopril (ACE
INHIBITOR) they block angiotension I to angiotension II which
ultimately causes less constriction. People who come in after
accidents taking this med is the most important.
▪ Aldactone – Potassium sparing diuretic; if you give this you are
blocking Aldosterone which is blocking sodium reabsorption meaning
Sodium is going to be urinated out & Potassium is reabsorbed; what
should they drink with aldactone? Water, OJ, apple, pineapple? Apple
juice, cranberry juice, water (NO TROPICAL JUICES b/c they are high in
potassium)
Red Blood Cell Synthesis
▪ Produces erythropoietin: when oxygen delivery to kidney
decreased, erythropoietin is released which stimulates the
bone marrow to release RBCs into the circulation
▪ Renal failure → chronic anemia
The renal failure pt will have problem making this and will exhibit anemia
hemoglobin less than 12; these pt have low oxygen; How would you
evaluate a Hemoglobin of 8 (perform ADL w/out shortness of breath, absence
of heart pain & arrhythmias, Confusion due to not enough blood to brain,
seizure)
Epogen, Procrit – if these are effective hemoglobin level goes up, no
confusion, etc.
Place these pt close to nursing station bc of low oxygen delivery to body due
to anemia!! Angina or arrhythmias from low o2 to heart; rest b/t activities;
diminished oxygen to body results in fatigue, SOB when carrying activities;
QUESTION: A pt with renal failure is complaining of dyspnea. The pt pulse
ox reading is 96% on room air. However, the pt is visibly distressed with a
respiratory rate of 32 breaths/min. A priority intervention would be:
A) Elevate HOB 90 degrees
B) Notify the respiratory therapist
C) Administer a resp nebulizing treatment
D) Administer Oxygen by NC
Answer: D high oxygen sat is an anemic pt that is showing signs of resp
distress may still be hypoxemic. Thus administering oxygen is necessary.
Conversion of Vitamin D (necessary for Ca++ absorption)
Ultraviolet light converts 7-dehydrocholesterol in skin to
cholecalciferol Kidney (& liver) hydroxylates this vitamin D into an
activated form
- Active Vit D is necessary for Ca absorption in the small intestine
- Renal Failure -> Low serum Calcium; Decrease in bone mass
(osteoporosis) due to PTH acting on bones to extract calcium out of bones.
These pt will take Vit D and calcium tablets; Calcium is best absorbed w/
food;
- Teach pt about bone breakage, fall precautions; (take away rugs,
extension cords, get safety in bathroom, lighting, etc) FALL RISK PT; use pull
sheet vs. pulling on arms; heart muscle may have problems if low serum
calcium; weak again risk for falls, peristalsis activity down and may get
constipation ALL B/C VIT D!!! Coagulation, delayed so they bleed easy; TUMS
is the cheapest source of Ca but must give with food, also antacid for acid
reflux drugs so take this on an empty stomach; Ca and P oppositely related,
Administer drug called PHOS-LOW when the Ca is low so this inhibits
Phosphorus absorption, Corn & Milk is high in Phosphorus, they can take the
phos-low so the phosphorus is inhibited so now they will just reabsorb Ca;
Basal-gal another phosphorus binding agent, block it from absorbing;
Tubules: Filtration, Reabsorption, Secretion, Excretion &
Regulation of Electrolytes
Glomerulus – Filtration
Proximal Tutble- reabsorption
Loop of Henele – concentration of urine
Distal tubule- secrete
Collecting Duct – excrete
▪ Calcium 9.0-10.5 mg/dl
▪ • Decrease in serum calcium stimulates secretion of PTH to
 increase reabsorption of calcium & excretion of phosphate;
mobilization of calcium from bone
▪ • ¯ Ca+ level from Vitamin D in Renal Fail.
▪ • A ¯ Ca+ level can also occur from: 1) Corticosteroids (¯
Ca+ absorption), 2) Diuretics Ca+ excretion, 3) diet
Signs and Symptoms of altered calcium levels
Consequences of altered calcium levels
Regulation of Electrolytes
▪ • Sodium – the major extracellular cation (norm =135-145
mEq/l)
▪ • Sodium reabsorption increases
l Decreased GFR, Aldosterone secretion, action of Atrial natriuretic
peptide
▪ • Sodium reabsorption decreases
l Increased GFR & excess ECF volume
l Secretion of ADH
l Loop-affecting diuretics
▪ • Potassium (norm = 3.5 - 5.5 mEq/L)
▪ • Major intracellular cation
▪ • Factors enhancing potassium excretion
l Increase in cellular potassium
l Metabolic/respiratory alkalosis
l High urine flow rates
l Aldosterone
l Loop Diuretics
Other Electrolytes of Concern
▪ • Phosphate
▪ • Magnesium
▪ • Need to know Signs and symptoms of electrolyte
alterations, consequences of electrolyte alterations, foods
high/low in these electrolytes; nursing implications
Changes in Kidneys Associated with Aging
▪ • Reduced renal blood flow causing kidney loss of cortical
tissue by 80 years of age
▪ • Thickened glomerular and tubular basement membranes,
reducing filtrating ability
▪ • Decreased tubule length with decreased glomerular
filtration rate
▪ • Nocturnal polyuria and risk for dehydration (volume
deficit)
Collecting duct is first to go and there is an inability to concentrate urine,
NOCTURIA, polyuria, sleep deprivation, slower thinking, emotional instability,
memory is altered;
- Consequences of changes:
Reduced ability to filter
Reduced ability to excrete waste products
Nephrons more vulnerable to damage from low or high BP/& or DM
Assessment Techniques
▪ • Family history and genetic risk assessment – DM, HTN,
Polycystic kidney disease
▪ • Demographic data and personal history- where you work,
chemicals that’s nephrotoxic, Fast food,
▪ • Diet history- High sodium intake from so much fast food;
diets high in protein trying to lose wt,
▪ • Socioeconomic status
▪ • Current health problems: DM HTN, etc. Meds toxic to
kidneys nonsteriodal anti-inflammatory (ibuprofen, Advil,
Motrin, Aspirin, all the general aches and pain w/ exception of
Tylenol) most arthritis drugs, ace inhibitors, loop diuretics,
antibiotics (REALLY NEPHROTOXIC),
Question: A pt with hx of renal disease is admitted with acute shoulder
pain. Which order should the nurse question?
1. Pan cultures for temp >38.5 c
2. Metoprolol (beta blocker) 50mg by mouth BID
3. Ibuprofen 600mg by mouth every 8 hr as needed for pain: nurse could
suggest Tylenol
4. Digoxin 0.125 mg daily
Answer C: these are nephrotoxic and should not be given to a renal patient
Physical Assessment
▪ • Inspection- discoloration (greater risk for bruising),
edema, color (pallor- look at mucous membranes), uremia
(yellow skin color)
▪ • Auscultation – lungs crackles, S3 in heart, listen for renal
bruit abnormal blood flow b/c renal artery stenosis esp. HTN pt
(high sound so listen with diaphragm on midclavicular line
around belly button);
▪ • Palpation- kidneys can be palpable but its advanced
practice;
▪ • Percussion- check for inflammation of kidney, rule out
CVA tenderness;
▪ • Assessment of the urethra – visual, look for blood, mucus
or pus
- BODY WT for fluid balance!!!!!
Urinalysis
▪ • Color, odor, and turbidity – can be very dilute or
concentrated
▪ • Specific gravity varies w/ hydration
▪ • pH
▪ • Glucose **
▪ • Ketone bodies **
▪ • Protein ** (look at glomerulus)
▪ • Leukoesterase ** (UTI)
Nitrates** UTI
▪ • Cells, casts, crystals, and bacteria ** (don’t worry about
these as much)
Normal urine shouldn’t have the ***
- WBC 18,000 orders urine for Culture: Clean Catch urine sample: clean
front to back, void, catch; from Foley, clamp for while to build up urine,
cleanse port, attach syringe to aspirate urine.
- 24 Hour urine is a direct reflection of glomeruler filtration;
Blood Tests
▪ • Serum creatinine – Renal is only thing that would make
this high;
▪ o Normal value is 0.8-1.5;
▪ § # is as important as trend, normal it should stay same, if it
alters then something is wrong in kidneys
▪ • Blood urea nitrogen- Tells about protein metabolism:
Renal, hydration, GI, dietary protein intake
▪ o State of hydration affects BUN; (Dehydration can elevate
BUN)
▪ o May indicate GI bleeding (Elevate BUN)
▪ • Ratio of blood urea nitrogen to serum creatinine ~ 10:1
-GFR Rate: Greater than 65 normal. Should be around 120;
- 24 hours for creatinine clearance: How many mL of blood should have
creatinine filtered off; it should be 120 mL; get big 3L jug with preservative so
the metabolic activity stops when you put uine in there so put it on ice; tell pt
to empty bladder (if they cant go make sure they tell you next time) If she
empties at 10 don’t collect that first sample but start then and collect all
urine after emptying collected; You must start over if for some reason you
miss one void, or if there is contamination of sample (poop); If not in hospital
keep ice in cooler, use Foleys only if absolutely necessary;
- 24 hr direct reflection of GFR: if normal is 120 but report is 40, GF is
impaired. This tells you they have 30% fx left, if they cant filter serum levels
of electrolytes and things go up & Substances stay in blood (K+ cardiac
problems)
- If filtration is significantly impaired, meds will stay in body; STORY: dr.
orders digoxin (increase contractility ad CO, before hand ou must check HR
b/c this slows HR… used for tachycardia and atrial arrhythmia… visal defects
(halos) indicate dig tox, seeing yellow lights, N/V) If creatinine clearance is
30mL/min tell dr he may want to decrease dose bc this is high value (not
filtering well)
Other Urine Tests
▪ • Creatinine clearance—best indication of overall kidney
function norm ~ 120 ml/min
l Nursing Implications 24 hr urine (described above), bucket and ice
▪ • Urine electrolytes – Usually nephrologist consulted bc
they aren’t making enough urine
▪ • Urine drug screens – observe pt void then you directly
take to lab (chain of command)
▪ • Serum Osmolarity - Urine and plasma ( plasma norm
~290) & urine osmolarity
Have pt empty bladder, start at that time and go to the other 24hr container;

If filtration is reduced to 30% of normal; Substances are staying in the blood..

medications will stay in body, etc. Digoxin – check hr, it increases
contractiility and output; Give digoxin to control a irregular rhythm; (Digoxin
toxic – see visual halos, n/v, yellow lights);
Question: What to do first, Laxic or collect sample of urine? Sample of urine
b/c a lasix increases urine output by blocking reabsorption of sodium;
Urine Culture
Front back cleaning, etc. look over clean catch; remember to stop the
drainage (DON’T GET SAMPLE FROM BAG) clamp Foley to build it up then take
it from the port after CLEANSING;
Other Diagnostic Tests
▪ • Bedside sonography/bladder scanners – want to know how
much urine is in bladder; looking for post void residual usually;
not invasive or painful;
▪ • Computed tomography (CT scan) – doesn’t matter if fecal
is there b/c it slices and can get the picture. VERY SHORT, 5-
10 min. Looks like a doughnut table that goes through the
 hole, (hold your breath now breathe) usually they need to
inject contrast dye (dye is nephrotoxic- ask if they are allergic
to iodine or shellfish (shrimp lobsters, etc), if the pt was
allergic then the Dr. would order a antihistamine and a steroid
and epinephrine should be on hand just in case things got out
of hand. Metformin + contrast dye = renal failure, so STOP the
metformin 48hr before and after the test, make sure you get
some other diabetic med like insulin; Muco-Mist given orally
48hr before and after contrast medium may protect kidneys,
this med is also a mucolytic which loosens pulmonary
secretions and is the antidote for acetaminophen;
▪ • Kidney, ureter, and bladder x-rays (KUB) (come in to ER
abdominal x-ray must have bowel preparation to be helpful)
▪ • Renal Ultrasound – noninvasive, quick, painless, need
fluids so NPO isn’t necessary, looks at the structures, NO DYE!
▪ • Intravenous pyelography (IVP) iv injection of contrast
medium but with x-ray no CT; If bowel is full same as KUB must
do NPO, bowel prep, allergy, nephrotoxicity;
l Bowel preparation
l Allergy information
l Fluids

Urodynamic Studies
▪ • Studies that examine the process of voiding include:
l Cystometrography – how strong is urinary stream
l Urethral pressure profile
l Electromyography
l Urine stream test

Cystography and Cystourethrography-

Instilling dye into bladder via urethral catheter
▪ • Monitoring for infection
▪ • Encouraging fluid intake
▪ • Monitoring for changes in urine output and for
development of infection from catheter placement
Retrograde Procedures
▪ • Retrograde procedures go against the normal flow of
urine.
▪ • Procedure identifies obstruction or structural
abnormalities with the instillation of dye into lower urinary
 tract.
▪ • Monitor for infection. High risk than normal;
▪ • Follow-up care is the same as for a cystoscopic
examination.
Dye not absorbed it’s a topical, not nephrotoxic;
Cystoscopy/Cystourethroscopy=“Cysto” see all way up ureters
l Procedure is invasive.
l Consent is required.
l Postprocedure care includes monitoring for airway patency, vital
signs, and urine output.
l Monitor for bleeding and infection.
l Encourage client to take oral fluids.
▪ • Conscious sedations – morphine, fintanyl, versaid – quick
onset, short acting! Need a driver they can’t drive themselves
home; Invasive and inserting larger than typical cath, size 26
usually) – quick onset, short acting but leave loopy- risk for
FALLS;
Renal Arteriography (Angiography)-injection of dye in renal artery to show
blood flow into kidney
▪ • Possible bowel preparation;
▪ • Light meal evening before, then NPO
▪ • Injection of radiopaque dye into renal arteries, √ allergies
▪ • Assessment for bleeding
▪ • Monitoring of vital signs
▪ • FLUIDS
▪ • Absolute bedrest for 4 to 6 hours
▪ • Serum creatinine may be measured for several days to
assess effects of test/dye
▪ Remember all the allergies, etc.
▪ Large cath inserted in femoral artery and gone up the renal artery
inject dye, check for hemmorage (big cath in big artery) First when pt
back do vital signs and check insertion site and palpate site blood will
go back; Hr will increase and bp decrease with pallor, weak pulse –
HEMMORAHGE; if pt is bleed & surrounding tissue is hard –
indurations; Interventions to prevent bleeding pt must remain at bed
rest supine with leg straight hob elevated not more than 30degrees;
force fluids, etc.;

▪ Question: An expected outcome for the pt who has undergone a renal

arteriogram is
▪ A) maintaining bedrest for 12 hr
▪ B) Maintaining the leg in a straight position for 12 hours
▪ C) Discouraging ankle flexing and wt shifting
▪ D) measuring serum creatinine for several days
Answer: D
When creatinine gets around a 7 creatinine they are exhibiting uremia
symptoms; Diaylsis is usually instituted around this time (Pt could have a 3
creatinine but could still need dialysis due to other factors like electrolytes)
- *** (STORYTIME) Compartmental syndrome – (upper arms in football
players) swelling in tissue (impairs arterial circulation, below arm impaired,
death of muscle protein finally, dead muscle releases rhabdomyolysis, this
rhabdo causes renal failure, so those football players were at risk for ARF; ;;;
89 yr old brother caregiver for 91 yr old sister, 89yr old put sis to bed buddle
up and put her to bed but he feel and remained in floor overnight eventually
found but since it was winter with no heat he laid in a cold environment for a
long amount of time and he became hypothermic severe rhadomyolsis,
etc.;;;;
Renography
▪ • Small amount of radioactive material, a radionuclide,
used; not radioactive, no safe precautions needed;
▪ • Procedure via intravenous infection
▪ • Follow-up care:
l Small amount of radioactive material may be excreted = force
fluids
l Maintain standard precautions.
l Client should avoid changing posture rapidly and avoid falling.
5 P’s Pain, Pulse Pallor, Paresthesia, Paralysis (Look at pictures on
Blackboard)
Percutaneous Renal Biopsy
▪ • Clotting studies
▪ • Preprocedure care
▪ • Follow-up care
l Assessment for bleeding for 24 hours
l Strict bedrest
l Monitoring for hematuria
Increase Comfort measures after procedure
Insertion of long needle thru skin (back) and poke and pull out a piece of
tissue (bleeding is a complication) place pt on back or sandback to put
pressure on kidney biopsy; vitals to assess for hemorrhaging; strict bedrest,
watch urine for blood b/c if so the kidney is bleeding;
Question: A priority assessment of a pt who had kidney biopsy include:
A) assess for compliance w/ strict bedrest
B) assess for signs of hypovolemia
C) Monitor for hematuria
D) assess for pain;
Answer: B; at risk for bleeding ad hemorrhage

E. coli: medicine for that is gentamycin but this is nephrotoxic and ototoxic;
ARF- SUDDEN ONSET, reversible, ESRD/HD end stage renal disease;
Question: A pt w/ ESKD has serum lab analysis: K+ 5.9 mEq/L, Na+ 152
mEq/L, creatinine 6.2mg/dL, BUN 60 mg/dL. A priority intervention would be:
A) Assess heart rate and rhythm.
B) Contact the Dr
C) Prepare the pt for dialysis therapy
D) Evaluate pt resp stat E) Weigh Pt
Answer: A: Potassium is very high!!
K+ is the most lethal problem with the labs so check cardiac.
Interventions for Clients with Acute & Chronic Renal Failure Chapter
71
Acute Renal Failure= ARF SUDDEN ONSET!!!
▪ • Pathophysiology- rapid decline in function
▪ • Types of acute renal failure include:
– Prerenal (cause = decreased perfusion)
– Intrarenal =Intrinsic = ATN (cause = meds, bacteria, NSAIDs, &
pre/post renal)
– Postrenal (cause = obstruction to urine flow)
30 urine per hr if not red flags should be up that something is wrong with
renal
Intervention: bolus with fluids; diuretic; dopamine to improve blood flow;
acute tubular necrosis –
Phases of ARF
▪ • Phases include:
– Onset – precipitating event (First thing lost by kidney is lost to
concentrate urine);
– Diuretic (non-oliguirc) non-oliguirc is that they are excreting water
just not the metabolic wastes
– Oliguric /anuria Less than 30ml hour/no urine; RISK FOR FLUID
OVERLOAD, hyperkalemia (no more OJ); Kayexlate orally or rectally –
it’s a Na, high sodium on one side and Potassium goes into Gut
which is good but we don’t want that much Sodium in body so we
mix it with a hypoosmolar that’s a sugar to even it out because
water will be pulled in and sodium will follow, pt K+ will go down
and the pt will poop a lot; Insulin pushes sugar in the cell and K
goes with the sugar so by giving insulin potassium will follow, give
reg insulin IV if you do this an the pt does not need insulin with their
sugar level you can give 50% dextrose with it;
– Recovery
▪ • Acute syndrome may be reversible with prompt
intervention.
Assessment
▪ • History – precipitating event
▪ • Clinical manifestations- depends on phase/type (could be
hypo/hypervolemia); Increasing K, P, Mg and decreasing Ca &
GFR
▪ • Laboratory assessment ↑Creatinine, BUN, K+, Phos, Mg+
+; ↓Cr Clearance, Ca++
▪ • Radiographic assessment
▪ • Other diagnostic assessments such as renal biopsy
Interventions:
▪ • Prerenal
– Fluid bolus
– Diuretics
▪ • Intrinsic=Intrarenal
– Low dose Dopamine (~3 mcg/kg/min)
– Monitor fluid volume status
– Calcium Channel Blockers (improve renal blood flow)
– Monitor for medication toxicities; dose adjustments
▪ • Postrenal
– Remove/bypass obstruction to urine flow
Medication Considerations
▪ • Cardioglycides = digoxin toxicity = ↓ dose
▪ • Vitamins and minerals-may need B9 & iron – boost all the
blood
▪ • Biologic response modifiers= Epogen (Erythropoietin)
▪ • Phosphate binders= Amphojel to ↓ phos absorption, TUMS
to ↑Ca++
▪ • Stool softeners and laxatives
▪ • Diuretics
▪ • Calcium channel blockers & HBP control; dilate renal
 artery;
DON’T TAKE ANYTHING WITH OTHER STUFF IN IT!! Fleets phosphate
or milk mag, etc, they cant excrete these;
K+ management
Treatment
▪ • Diet therapy
– Protein intake – according to client needs
– Watch foods high/low in electrolytes of concern
– Watch fluid intake
– If elemental or TPN needed – special Renal Formula

▪ • Dialysis therapies
– If needed for fluid, electrolyte, azotemia control
– Hemodialysis
– Peritoneal dialysis
– ‘Continuous Renal Replacement Therapy’ (for fluid overload)
Posthospital Care
▪ • If renal failure is resolving, follow-up care may be required.
▪ • There may be permanent renal damage and the need for
chronic dialysis or even transplantation.
▪ • Temporary dialysis is appropriate for some clients.
▪ • May take ~ 1 year to resolve

Chronic Renal Insufficiency Failure ESRD

▪ • Progressive, irreversible kidney injury; kidney function
does not recover
Changes in Chronic Renal Failure → ESRD
▪ • Metabolic – azotemia -> uremia – causes HTN, creatinine is a
irritant (infects mucous membranes and linings of all organs)
the <3 has the worst effect;
– Urea and creatinine (around 7)
▪ • Electrolytes
– Sodium (hyponatremia/hypernatremia)
– Potassium (hyperkalemia)
▪ • Acid-base balance
▪ • Metabolic acidosis
▪ • Calcium and phosphorus
▪ • Hyperphosphatemia/hypocalcemia
Clinical Manifestations
▪ • Neurologic: lethargy - coma
▪ • Cardiovascular: HBP, CHF, P E, dysrhythmias; “rub”; high
hyperlipidemia; uremic pericarditis
▪ • Respiratory: tachypnea, pleurisy
▪ • Hematologic: anemia, bruising; Low WBC & Platelets;
▪ • Gastrointestinal: bleeding, ulceration, hiccups,
▪ • Urinary: decreased output
▪ • Skin: yellow/gray discoloration, pruritus, frost, ecchymoses
▪ • Sexuality: infertility, dryness, impotence
Proton pump inhibiter (protonix); lining should be resonance but if there is
fluid it will be dull;
Hemodialysis – there is a blood that flows to dialyzer, and the hemodialyzer
(where the filtering takes place); Blood flows back to body;
Give heparin and get PTT’s done;
▪ If a heparin pt has dialysis and needs a thorascentis do the thora first
before the heparin; so give protamin sulfate to reverse the heparin;
heparin stays active 6hr; if air or dialysate got in the airway it would
shut down;
Vascular Access
▪ • Arteriovenous fistula, or arteriovenous graft for long-term
permanent access
▪ • Hemodialysis catheter, dual or triple lumen, or
arteriovenous shunt for temporary access
▪ • Precautions: no restrictive clothing, tourniquets, NO BP,
IV, or blood draw
▪ • Complications: clotting (= loss of access= no HD), infection
▪ • Listen for bruit, palpate for thrill; Assess any vascular
assess devices- listen for bruit, (sounds like a little air gun)
Hemodialysis Nursing Care
▪ • Postdialysis care:
– Monitor for complications such as hypotension, headache, nausea,
malaise, vomiting, dizziness, and muscle cramps (disequilibrium
syndrome).
– Monitor vital signs and weight.
– Avoid invasive procedures 4 to 6 hours after dialysis.
– Continually monitor for hemorrhage.
– Administer meds that were held prior to dialysis: HBP, dialyzable
antibiotics, digoxin, etc
There is an unequal another of creatinine in the CSF and serum (eventually
they will diffuse and be equal) BAD CSF problems. SS above.
HOLD MEDS PRIOR TO DIALYSIS OTHERWISE THEY WILL GO OUT!!
Peritoneal Dialysis
▪ • Procedure involves special catheter placed into the
abdominal cavity for infusion of dialysate.
▪ • Types of peritoneal dialysis:
– Continuous ambulatory peritoneal
– Automated peritoneal
– Intermittent peritoneal
– Continuous-cycle peritoneal
PD more closely mimics the kidney it just doesn’t make Vit D and
erythropoietin;
Complications
▪ • Peritonitis
▪ • Pain
▪ • Exit site and tunnel infections
▪ • Poor dialysate flow
▪ • Dialysate leakage
▪ • Other complications
Nursing Care During Peritoneal Dialysis
▪ • Before treating: evaluate baseline vital signs, weight, and
laboratory tests.
▪ • Continually monitor the client for respiratory distress, pain,
and discomfort.
▪ • Monitor prescribed dwell time and initiate outflow.
▪ • Observe the outflow amount and pattern of fluid.
Complications of Hemodialysis

▪ • Dialysis disequilibrium syndrome

▪ • Infectious disease
▪ • Hepatitis B and C infections & HIV exposure—poses some
risk for clients undergoing dialysis & staff
Cost, time
Renal Transplantation
▪ • Candidate selection criteria
▪ • Donors
▪ • Preoperative care
▪ • Immunologic studies
▪ • Surgical team
▪ • Operative procedure
Postoperative Care
▪ • Urologic management
▪ • Assessment of urine output hourly for 48 hours.
▪ • Complications include:
– Rejection
▪ • S/S: increased Temp, BP, pain, UO, Cr/BUN, weight
– Acute tubular necrosis
– Thrombosis
– Renal artery stenosis
– Other complications
– Immunosuppressive drug therapy
–Psychosocial preparation
Cystitis & Infections of Lower Urinary Tract (Chapter 69)
▪ • Inflammation of the bladder
Most commonly caused by bacteria (or viruses, fungi, or parasites ) from the
rectum/vagina moving into the external urethra to the bladder, ureter, &
even to the kidney (pyelonephritis)
E. Coli is the most common bacteria
Catheter related infections common during hospital stay
▪ • HIGH RISK: UROSEPSIS with high mortality
UTI – Urinary tract infection – inflammation of lower urinary system (FOLEY
CATH is highest in hospital) Women are more likely to get it because urethra
is shorter & Perneal area so close; Men get it due to enlarged prostate b/c it
obstructs urine; (Empty bladder q 3 hr)
Cystitis – visible vessels, lots of tiny red dots, hemorrhagic area from
infection;
Most common sign is: FREQUENCY: PAIN (burning);
Incidence and Prevalence of Cystitis
▪ • 2nd most common reason to visit to HCP
▪ • ASSESSMENT
– Frequent urge to urinate
– Dysuria
– Urgency
▪ • UA needed to test for leukocyte esterase (+ in UTI), also
WBCs, RBCs (WBC URINE CLOUDLY) (SMOKY or pink/red if RBC
in urine)
For older adults in the hospital, the 1st sign is altered mental status.
Type of organism confirmed by urine culture
↑serum WBCs with ↑ in ‘bands’ (adolescent WBC)
When we are faced with an infection bone marrow will release adolescent
aged WBC to help the “tired already in circulation” WBC; should not have
these “bands” unless we are sick; LOOK AT TYPE OF WBC (are they in
the correct proportion) Bandemia
E. coli is the most common type of bacteria found as a cause of
UTI;
CYSTO to R/O abnormalities
Pharmacological Therapy
▪ •Urinary antiseptics: Macrobid, Macrodantin (nitrofurodantin); Pt will
frequent recurring UTI may have a low dose daily; this decreases
bacteria growth
▪ •Antibiotics: Septra, Cipro, Levaquin, Amoxil, Duricef
▪ •Analgesics: Pyridium (overcounter med) Orange color urine; will
diminish burning but doesn’t address cause; drink LOTS of liquids;
▪ •Antispasmodics: Anaspaz (b/c the bladder is irritated so it needs
something to diminish the spasm)
▪ •Antimicrobials: Bactrim/Septra, Cipro/Levaquin, Amoxil, Duricef
▪ •Antifungal agents: Nizoral
Long-term antibiotic therapy for chronic, recurring infections
▪ •Intravaginal Estrogen for postmenopausal women (general dryness as
women age) cream or tablets
QUESTION: What is an expected outcome for the older adult male pt
with a history of asthma who is being treated w/ nitrofurntin
(Macrobid)?
1. A. Orange-colored urine
2. B. Constipation
3. C. Blurred vision
4. D. Flu-like symptoms;
Answer: D - monitor these symptoms in older pt taking
nitrofurantoin and those with pulmonary disease;
Nonpharmacological Management
▪ • Urinary elimination after sex & before bedtime
Urinate q 3-4hr
▪ • Diet therapy: all food groups, ↑ calorie RT ↑ increase in
metabolism caused by the infection; ↑ intake 2-3 L/day of
fluids, possible intake of cranberry juice; d/c caffeine; Vit C
foods/fluids
▪ •Other pain relief measures, such as warm sitz baths but not
vigorous cleaning of perineum or douching
▪ • Cotton undies/no tight jeans
▪ •Daily perineal cleansing (but not vigorous cleaning, douching or
 bubble baths)
Question: 21 yr old male complaining of burning and difficulty with
urination. Priority question in obtaining info about pt chief complaint would
be:
1. How long have you had these symptoms?
2. Do you have low back pain?
3. Are you sexually active?
4. Have you had fever in past 24 hr
Answer: C Most common cause of urethritis in men is STD: Ureaplasma,
Chlamydia or Trichomonas vaginalis!!
Can lead to pylenephritis & Urosepsis ; Altered mental status
(decreased blood flow to brain)
Urinary Incontinence
▪ • Impacts > 13 million in USA. Mostly ♀
▪ • Not a normal result of aging, but does ↑ with age
▪ • Five types of incontinence include:
– Stress – little when coughing, sneezing, vomiting;
– Urge – Cant make it to the bathroom
– Mixed
– Overflow – spinal cord injury, bladder wont empty and it starts to
leak
– Functional (cognitive impairment) Don’t know when to recognize
when its time (Dementia, unresponsive individual)
The brain sends nerve signals telling muscles to hold urine or let it out.
Nerves send signals to the brain. Signals tell when the bladder is full or
empty.
Collaborative Management
▪ • Assessment: thorough client history (make sure not
constipated)
▪ • Clinical exam to R/O cystocele (herniation of bladder into
vagina), rectocele, prolapsed uterus & assess perineal
sensation; medication history
▪ • Urinalysis: R/O infection
▪ • Radiographic assessment & other diagnostic assessments
to determine urinary system health
(Lightly touch anus, contract when it touch, if it doesn’t contract then they
may have nerve root problem to bladder)
▪ • Interventions include:
– Keeping a diary
– Behavioral interventions
– Diet modification: weight loss, no caffeine, alcohol
– Pelvic floor exercises (Kegels)
– Drug therapy: Estrogen, Pro-Banthine, Ditropan, Detrol (increase
intraocular Pressure) see eye dr. can cause glaucoma; Trofranil-
Antianxiety and has anticolingeric; all these meds cause DRY
MOUTH, URINARY RETENTION
– Vaginal cone weights
– Urinary habit training (freq basis)
– Intermittent self-catheterization (clean technique)
– Containment of urine and protection of the client’s skin
– Applied devices: penile clamp, pessaries (object place inside
vagina that cystisilfallen bladder, take out clean etc), condom
Last resort: Urinary catheterization
Surgical Management
▪ • Preoperative care (Abdominal surgical procedure)
▪ • Operative procedure: see list pg 1692 (1. Inject collagen
which works 50% of the time. 2. Surgery to pull bladder back
to be surgically correct (bladder tack-up) 3. Suprapublic cath)
▪ • Postoperative care (Airway #1, at risk for pneumonia b/c
they won’t want to deep breath due to pain; Circulation: DVT
(calf pain edema & pulmonary embolism is main concern which
pt has chest pain SOB and alter gas exchange)
– Assess for and intervene to prevent or detect complications.
– Secure urethral or suprapubic catheter.
– No sex until post-op check (~6 wk) to allow good healing
– No heavy lifting for 3 months (5lbs)
– No exercise such as running, aerobics, stair-climbers until
completely healed
Any pelvic surgery puts them at higher risk for DVT (ambulation,
antiembolism stockins, etc.)
Urolithiasis
▪ • Presence of calculi (stones) in the urinary tract
▪ • History of urologic stones
▪ • Clinical manifestations ---- EXTREME pain when stone
moves
NCLEX says pain is a psychological diagnosis so if this appears, it’s most
likely not the number 1 choice.
▪ • Laboratory assessment: -- UA, ↑WBC if infection
▪ • Radiographic assessment: CT of abdomen, (IVP)
Pain when stone actually moving; (pain location depends, if stone in pelvis is
in back, upper ureter in upper side and when it starts moving down it starts
moving toward the bladder) 25 yr old female pain in right lower abdomen
(ectopic preg, appendicitis, ovaries problems) Have pt go for cat scan b/c the
IVP (needs bowel prep) will not be bowel prep;
Stones make WBC go up just like infection does;
Question: A pt with urolithiasis has not voided in 7 hr. What is primary
concern for this pt?
1. Hematuria
2. Hydronephrosis (water on nephron);
3. Infection
4. Pain
Risk for blockage; risk for infection (physiology) Pain;
Answer: B - A primary concern is prolonged obstruction. As the blockage
persists, hydronephrosis and permanent kidney damage may develop. Other
concerns with urolithiasis include infection, hematuria, and effective tx of pt
pain
Interventions
▪ • Drug therapy often with Opioid analgesics (morphine) IV;
Watch for resp distress; constipation
▪ • Nonsteroidal anti-inflammatory drugs
▪ • Pain medications at regular intervals
▪ • Constant delivery system
▪ • Spasmolytic drugs (Ditropan & Pro-Banthine)—important
for relief of pain
▪ • Complementary and alternative therapy
Anticipate pt to be on increase Fluids (rates greater than typical amt) Watch
for fluid vol overload; get a filter or strainer; Pt probably nausea and
probably on an antibiotic to prevent infection;
Lithotripsy
▪ • Extracorporeal shock wave lithotripsy uses sound, laser, or
dry shock wave energy to break the stone into small
fragments. (Sound waves used outside of body to crush stones
so that they can move) sore abdomen with bruising,
hematuria; tell pt to ice the abdomen etc
▪ • Client undergoes conscious sedation
▪ • Topical anesthetic cream is applied to skin site of stone.
▪ • Continuous monitoring is by electrocardiography
Surgical Management (Cysto – scope thru bladder up ureters and
using implement with a loop try to get above stone and scoop it
down) expect pain, hematuria, inflammation;
▪ • Minimally invasive surgical procedures
▪ • Stenting; after scraping there will be a stent (small tube)
to keep ureter open until inflammatory response stops; there
may be string out peepee hole :] make sure pt don’t put out
string b/c that will remove stent; (week to ten days
inflammation)
▪ • Retrograde ureteroscopy
▪ • Percutaneous ureterolithotomy and nephrolithotomy
▪ • Open surgical procedures
– Preoperative care
– Operative procedure
Postoperative Care
▪ • Routine postoperative care procedures for assessment of
bleeding, urine, and adequate fluid intake
▪ • Strained urine
▪ • Infection prevention
▪ • Drug therapy
▪ • Diet therapy
▪ • Prevention of obstruction
Drug Therapy
▪ • Drug selection to prevent obstruction depends on what is
forming the stone:
– Calcium; Low Ca diet, hydrodiurl promotes resorption of Ca into
blood
– Oxalate; Low oxalate diet; zyloprim, vit B6
– Uric acid; metabolic disease GOUT makes kidney stones, low
purine diet (low in proteins and greens) Med allopurinol often given,
also probencid
– Cystine – hydration, alkalinazation, captopril
Urothelial Cancer – abnormal growth of abnormal cells

▪ • Collaborative management
▪ • Assessment
▪ • Diagnostic assessment
▪ • Nonsurgical management
– Prophylactic immunotherapy
– Chemotherapy
– Radiation therapy
Prevention of Bladder Cancer- Protect self against inhaled chemicals; drink
lots of fluids & void freq; extra Vit A (protectant); NO MARIJUANA or
cigarettes (its an irritant to bladder)
Tx of bladder cancer: Intravesical Chemotherapy (medication instilled into
the bladder – intravesical – through a foley medicine get up there and the
foley will be clamped so medicine will get contact with bladder lining and
cancer (NPO, so it wont dilute the medicine) SAVE bladder, drug is not
absorbed and will not have side effects to rest of body;
Surgical Management – if cancer is stage 4 and taking bladder out is
a must;
▪ • Preoperative care
▪ • Operative procedures – preserve bladder if possible; if not
-> cystectomy & ileal conduit; ileal conduit, urostomy – take
out bladder and resect 6in of bowel and create tube (one end
is closed the other end is brought to skin –stoma – ureters are
implanted into the tube and urine will flow to the stoma
constanly) this pt will be incontinent – flowing of urine
constantly (POUCH)
▪ • Postoperative care includes:
– Collaboration with enterostomal (WOCN) therapist
– Kock’s pouch or Indiana pouch – took segment of bowel and made
pouch and the connected tube and got a stoma – this pt is continent
– Advantage is that its continent; pt will cath pouch every 4 hrs, no
external pouch needed and learn sense of fullness (in right quad)
Disdvantage – special surgeon, longer surgery time,
– Neobladder – make new bladder if ureters weren’t affected with
cancer, less common;
Nursing – assess skin around stoma, not red or inflamed; stoma pink, moist
(look like lining of mouth) Constant flow of urine;
Urostomy Stoma & Pouches
Nephrostomy- tube placed into pelvis of kidney, pouch system with stent
draining urine in pouch; high risk for infection;
Question: Pt with hydronephrosis she had nephrostomy tube placed. Which
assessment data requires immediate intervention and notification of Dr?
1. Hematuria
2. Cloudy Urine
3. Pt complaint of back pain
4. Pot 4.9
Answer: C if the amt of drainage decreases and the pt has back pain, the
nephrostomy tube may be clogged or dislodged.
Ureterostomy – bring ureters out to skin
Crystals: Occur when urine is too alkaline. Can cause stomal irritation and or
bleeding. Urinary crystals can be prevented by keeping it clean;
Bladder Trauma
▪ • Causes may be due to injury to the lower abdomen or
stabbing or gunshot wounds.
▪ • Surgical intervention is required.
▪ • Fractures should be stabilized before bladder repair.
Frank – very red!!! NOT GOOD;;
Interventions for Clients with Renal Disorders Chapter 74
Polycystic Kidney Disease
▪ • Inherited (autosomal dominant) disorder in which fluid-
filled cysts develop in the nephrons – 50% chance of getting it;
▪ • Key features include: Causes cysts to form in the kidney
– Abdominal or flank pain (swelling of kidney) – diminished blood
flow releasing renin
– Hypertension from release of renin
– Nocturia can’t concentrate urine
– Increased abdominal girth from swelling of kidney
NO CURE!!
Prevent complication
Genetic Testing
KIDNEY TRANSPLANT!!!!

PKD DIAGNOSIS
Ultrasound
CT
MRI
Genetic history
Urinalysis (protein & blood)
Decreased kidney function
Interventions
▪ • Pain management- caution NSAIDs
▪ • Bowel management- constipation from enlarged kidneys
▪ • Medication management - ACE inhibitors & other HBP
meds
▪ • Energy management
▪ • Fluid monitoring – low Na+ diet
▪ • Urinary retention care – Credé –emptying bladder by
manually pushing or pulling butt hairs (may have incontinence)
▪ • Infection protection
Question: A possible outcome for the pt being treated with spironolactone for
nephritic syndrome is the development of
A) Hyponatremia
B) Hyperkalemia
C) Hypercalcemia
D) Hypophosphatemia
Answer B
Pyelonephritis (chapter 74)
▪ • Bacterial infection in the kidney (upper urinary tract)
▪ • Key features include:
– Fever, chills, tachycardia, and tachypnea
– Flank, back, or loin pain
– Abdominal discomfort
– Turning, nausea and vomiting, urgency, frequency, nocturia
– General malaise or fatigue
▪ • Hypertension
▪ • Inability to conserve sodium
▪ • Decreased concentrating ability
▪ • Tendency to develop hyperkalemia and acidosis
More likely in females!!

Acute Pain Interventions

▪ • Pain management interventions
▪ • Drug therapy
– Antibiotics
– Urinary antiseptics (macrodantin)
▪ • Diet therapy
– Force fluids
Surgical Management – for structural problems
▪ • Preoperative care
– Antibiotics
– Client education
▪ • Operative procedure: pyelolithotomy, nephrectomy,
ureteral diversion, ureter reimplantaton
▪ • Postoperative care for urologic surgery

Glomerulonephritis= Nephritic Syndrome

▪ • Assessment ~ 10 days after infection usually
Streptococcus (resulting in antibody/antigen reactions within
glomerulus); edema (if protein not in vessel water leaks into
interstial), proteinuria, hematuria HBP, fatigue,
 ↓GFR,↑BUN/Cr, + Strep titers
▪ • Management of infection
▪ • Prevention of complications
– Diuretics
– Sodium, water, potassium, and protein restrictions
– Dialysis, plasmapheresis
– Client education
Chronic Glomerulonephritis -- Results in loss of nephrons leading to
↓GFR → renal failure

Question: Male pt complains of progressive fatigue, anorexia, wt gain and

dysuria with dark colored urine what is the priority nursing care?
1. Do you have family hx of renal disease
2. Have you had recent infection
3. Do you experience freq UTI
4. When did you first notice symptoms
Answers: B : The onset of symptoms is 10 days from time of infection.
Systemic strept infection is more common in men as precursor infection of
acute glomerulonephritis
Nephrotic Syndrome
▪ • Condition of increased glomerular permeability that
allows larger protein molecules to pass through the membrane
into the urine and be removed from the blood
▪ • Severe loss of protein into the urine; larger molecules
Proteinuria; lots of bubbles in toilet; plum (periorbital edema) sclera edema;
chest for pulmonary edema; (AIR IS BLACK ON CHEST X-RAY); STREP
▪ • Treatment involves:
– Immunosuppressive agents (Reverse/Protective Isolation –
neutropenic) Wear mask, gloves, gown AT RISK FOR INFECTION
– Angiotensin-converting enzyme inhibitors
– Heparin
– Diet changes
Rest!
- Mild diuretics
Question: The older adult pt with acute glomerulonephritis is often
misdiagnosed with
1. CVA
2. Transient ischemic attack
3. Aortic aneyrysm
4. CHF
Answers: D
Renal Trauma
▪ • Minor injuries such as contusions, small lacerations
▪ • Major injuries such as lacerations to the cortex, medulla,
or branches of the renal artery
▪ • Collaborative management
▪ • Nonsurgical management: drug therapy and fluid therapy
▪ • Surgical management: nephrectomy or partial
nephrectomy
BLEEDING major problem if there is trauma; prep for blood transfusion,
surgery, etc. Don’t want to overstress kidneys after this kind of accident!
Renal Cancer
Stage 1 7cm; Stage II 7Cm; Stage III Gerota’s fascia; Stage IV other organs
and lympg nodes
Cancer is abnormal growth of abnormal cells; SPREAD to other body organs
(the spread to the lung, etc. is usually when manifestation starts; Cure rate
for renal cancer is not really high; difficult to treat b/c we don’t find the
disease early;
Tx: Remove diseased kidney f (long incision from diaphragm to center of
abdomen and all around sides; Have to spread all those kidneys; PT coming
straight from surgery #1 priority is AIRWAY, BREATHING, CIRCULATION
(watch for hemorrhage, vitals, pulse quality, skin color, output from drain,
the hr after pt comes back should be sangious, 48hr after it should be sero-
sang, BUN and creatinine should stay normal; Pain should be the next
concern;
Nephrectomy: Traditional vs Laproscopic
Lapro: less heal time, not as painful, smaller scars; (CO2) - absorbed by
body, shoulder pain; RISK for bleeding b/c they can’t see.

[KE1]MAP = (2 X DP) + SP/ 3

410 Lectures
- Over 2 millions nephrons; As we age the cortical nephrons are
nonfunctionals and so we lose nephrons.
- ***KNOW THE PARTS OF A NEPHRON; The start is Bowman’s capsule
and that makes up the glomerulus (beginning stages of urine formed there-
filtration) this network of capillaries have a semipermeable membrane (in a
normal environment the membrane don’t allow protein), filtrate results from
filtration; filtrate is like serum w/ the exception of protein (watery clear part
of blood without RBC);
- Strept throat (the bacteria can cause a antibody response in the
glomerulus), Hypertension, UTI & Diabetes(damage membrane) sometimes
causes protein to get into the filtrate, once its in the filtrate it is lost in urine
and no longer in the body; (Pregnant women with proteinurea will have a
decrease amt of serum protein) All these things can damage the glomerulus
and Bowman’s capsule;
- What is the consequence of having low serum protein? Delivery of
medication, muscle and cell problems, slow healing, **Risk for delayed
healing rt to low serum protein from proteinurea;
Now Check for edema esp. in face w/ these patients (water was leaving the
cells, protein holds water in the intravascular compartment) Also, skin
integrity rt fluid in interstitial space; capillary refill will be sluggish, skin color
pale b/c less blood supply, mental status altered; Water is all in the intestinal
space, intravascular vol deficit w/ interstitial volume excess- fluid is in wrong
space all b/c protein is gone;
▪ Give this pt a hypertonic soln or give pt shot of protein (albumin); If it
works pt will have stronger pulse and bp and urine will increase, less
edema, better capillary refill
- Second part of nephron is PCT – proximal convulted tubule, (120 mL
per min forming filtrate) 90% of what is filtered is reabsorbed, surrounding
the PCT is an arteriole and the products move back into the blood; 90% of
whats filtered is reabsorbed;
▪ If the PCT is broken the urine volume will INCREASE! The volume in
our body will be low… decrease pulse, bp, cold clammy skin, etc. If
potassium cant be reabsorbed it will be low in the serum along with
other electrolytes
- The third is the Loop of Henle it concentrates urine (Loop Diuretics
work here and block the reabsorption of sodium, which water follows);
- The DCT is next, Distal convulated tubule, the primary role is
secretion; vesicles around DCT pick up any extra concentrated electrolytes
back into the nephron after they were reabsorbed;
▪ ADH has its effect on the DCT, water is reabsorbed and not secreted
into the urine;
- The fifth part is the collecting duct, it transfers the filtrate to the
renal pelvis. FINAL part of the tube and now the filtrate is called URINE;
- Urine then flows down the ureters to the bladder into the uretha to
EXCRET so the collecting ducts are for excretion;
- Question: Which pt is more likely to experience renal compromise
(decreased urine production)?
▪ A pt w/ blood pressure of 92/45 for 12 hr
▪ A pt w/ white blood cell count of 12,000 (5-10,000 – normal)
▪ A pt w/ 5 yr hx of DM
▪ A pt w/ hx of myocardial infection
- The ANSWER is A b/c this blood pressure has a mean arterial pressure
(MAP[KE1] ) of 62 mm hg. The kidney has a difficult time regulating GFR w/ a
MAP less then 65 mm Hg; If this was my pt from ER what would we see if
fluid vol overload, increased resp rate, nasal flaring, HOB elevated, pulse
oximeter, crackles in lung sound or rales, so primary for this pt would be
pulmonary; Next Cardiac mayb distended neck veins, puffy & edema, could
have pounding pulse w/ increased rate, will hear S3 (APEX is where this will
be heard)
- Filtration must have adequate blood flow and pressure, when pressure
falls vol of filtrate decreases and vol of urine decreases which can cause fluid
overload b/c all of it is retained. Prolonged hypotension can cause fluid
overload. Failure to filter is retention in the body, so electrolytes will go up,
like Potassium (meaning Cardiac should be evaluated when something is
wrong with filtration)
Bicarbonate Reabsorption
▪ • Secretion of hydrogen ions
▪ • Secretion of nonvolatile [acids that do not form a gas]
acids (phosphate, ammonia, urea, etc)
STORY - COPD pt have CO2 trapped and our levels increased which leads to
elevated carbonic acid; If this pt had healthy kidney it would recompensate
for it by holding onto bicarbonate and secrete other acids like ammonia but
when we have renal problems the kidney can’t do this and if it cant do that
the bicarb goes in the urine and the body has a low bicarb level This pt will
get bicarb tablets w/ pt having high resp rate b/c lungs tries to get rid of it;
** IF this was Pt is in fluid vol excess & have fluid in alveoli (resp rate goes
up); This pt will be sicker b/c they cant blow off the CO2; ( This pt would be
at risk for pneumonia, if a pt came in with or at risk for other respiratory
problems on top of renal problems & COPD they would be closer to nurse
station bc they are so prone to getting acidosis)
Make and reabsorb bicarb and secrete others like ammonia.
Renal Failure → Metabolic Acidosis
Regulation of Blood Pressure

▪ • Production of Renin – regulates blood pressure

▪ Renin is produced when there is a decrease in blood pressure into the
kidney;
▪ • Structures within the DCT (macula densa cells – lie beside
renin producing cells) sense decrease perfusion/pressure --
release renin -- renin converts angiotensinogen (from liver)
into Angiotensin I which converts (in lung) into Angiotensin II
(increases afterload & stimulates release of Aldosterone (from
adrenal) to enhance sodium reabsorption (pg 202)
▪ • Renal Failure -> often hypertension
▪ CHF has less CO and less blood flow to kidney, with Renin in these
people the vessel are constricted which causes it to have even more
decrease in the CO, this is when we start meds like lisinopril (ACE
INHIBITOR) they block angiotension I to angiotension II which
ultimately causes less constriction. People who come in after
accidents taking this med is the most important.
▪ Aldactone – Potassium sparing diuretic; if you give this you are
blocking Aldosterone which is blocking sodium reabsorption meaning
Sodium is going to be urinated out & Potassium is reabsorbed; what
should they drink with aldactone? Water, OJ, apple, pineapple? Apple
juice, cranberry juice, water (NO TROPICAL JUICES b/c they are high in
potassium)
Red Blood Cell Synthesis
▪ Produces erythropoietin: when oxygen delivery to kidney
decreased, erythropoietin is released which stimulates the
bone marrow to release RBCs into the circulation
▪ Renal failure → chronic anemia
The renal failure pt will have problem making this and will exhibit anemia
hemoglobin less than 12; these pt have low oxygen; How would you
evaluate a Hemoglobin of 8 (perform ADL w/out shortness of breath, absence
of heart pain & arrhythmias, Confusion due to not enough blood to brain,
seizure)
Epogen, Procrit – if these are effective hemoglobin level goes up, no
confusion, etc.
Place these pt close to nursing station bc of low oxygen delivery to body due
to anemia!! Angina or arrhythmias from low o2 to heart; rest b/t activities;
diminished oxygen to body results in fatigue, SOB when carrying activities;
QUESTION: A pt with renal failure is complaining of dyspnea. The pt pulse
ox reading is 96% on room air. However, the pt is visibly distressed with a
respiratory rate of 32 breaths/min. A priority intervention would be:
A) Elevate HOB 90 degrees
B) Notify the respiratory therapist
C) Administer a resp nebulizing treatment
D) Administer Oxygen by NC
Answer: D high oxygen sat is an anemic pt that is showing signs of resp
distress may still be hypoxemic. Thus administering oxygen is necessary.
Conversion of Vitamin D (necessary for Ca++ absorption)
Ultraviolet light converts 7-dehydrocholesterol in skin to
cholecalciferol Kidney (& liver) hydroxylates this vitamin D into an
activated form
- Active Vit D is necessary for Ca absorption in the small intestine
- Renal Failure -> Low serum Calcium; Decrease in bone mass
(osteoporosis) due to PTH acting on bones to extract calcium out of bones.
These pt will take Vit D and calcium tablets; Calcium is best absorbed w/
food;
- Teach pt about bone breakage, fall precautions; (take away rugs,
extension cords, get safety in bathroom, lighting, etc) FALL RISK PT; use pull
sheet vs. pulling on arms; heart muscle may have problems if low serum
calcium; weak again risk for falls, peristalsis activity down and may get
constipation ALL B/C VIT D!!! Coagulation, delayed so they bleed easy; TUMS
is the cheapest source of Ca but must give with food, also antacid for acid
reflux drugs so take this on an empty stomach; Ca and P oppositely related,
Administer drug called PHOS-LOW when the Ca is low so this inhibits
Phosphorus absorption, Corn & Milk is high in Phosphorus, they can take the
phos-low so the phosphorus is inhibited so now they will just reabsorb Ca;
Basal-gal another phosphorus binding agent, block it from absorbing;
Tubules: Filtration, Reabsorption, Secretion, Excretion &
Regulation of Electrolytes
Glomerulus – Filtration
Proximal Tutble- reabsorption
Loop of Henele – concentration of urine
Distal tubule- secrete
Collecting Duct – excrete
▪ Calcium 9.0-10.5 mg/dl
▪ • Decrease in serum calcium stimulates secretion of PTH to
increase reabsorption of calcium & excretion of phosphate;
mobilization of calcium from bone
▪ • ¯ Ca+ level from Vitamin D in Renal Fail.
▪ • A ¯ Ca+ level can also occur from: 1) Corticosteroids (¯
Ca+ absorption), 2) Diuretics Ca+ excretion, 3) diet
Signs and Symptoms of altered calcium levels
Consequences of altered calcium levels
Regulation of Electrolytes
▪ • Sodium – the major extracellular cation (norm =135-145
mEq/l)
▪ • Sodium reabsorption increases
l Decreased GFR, Aldosterone secretion, action of Atrial natriuretic
peptide
▪ • Sodium reabsorption decreases
l Increased GFR & excess ECF volume
l Secretion of ADH
l Loop-affecting diuretics
▪ • Potassium (norm = 3.5 - 5.5 mEq/L)
▪ • Major intracellular cation
▪ • Factors enhancing potassium excretion
l Increase in cellular potassium
l Metabolic/respiratory alkalosis
l High urine flow rates
l Aldosterone
l Loop Diuretics
Other Electrolytes of Concern
▪ • Phosphate
▪ • Magnesium
▪ • Need to know Signs and symptoms of electrolyte
alterations, consequences of electrolyte alterations, foods
high/low in these electrolytes; nursing implications
Changes in Kidneys Associated with Aging
▪ • Reduced renal blood flow causing kidney loss of cortical
tissue by 80 years of age
▪ • Thickened glomerular and tubular basement membranes,
reducing filtrating ability
▪ • Decreased tubule length with decreased glomerular
filtration rate
▪ • Nocturnal polyuria and risk for dehydration (volume
deficit)
Collecting duct is first to go and there is an inability to concentrate urine,
NOCTURIA, polyuria, sleep deprivation, slower thinking, emotional instability,
memory is altered;
- Consequences of changes:
Reduced ability to filter
Reduced ability to excrete waste products
Nephrons more vulnerable to damage from low or high BP/& or DM
Assessment Techniques
▪ • Family history and genetic risk assessment – DM, HTN,
Polycystic kidney disease
▪ • Demographic data and personal history- where you work,
chemicals that’s nephrotoxic, Fast food,
▪ • Diet history- High sodium intake from so much fast food;
diets high in protein trying to lose wt,
▪ • Socioeconomic status
▪ • Current health problems: DM HTN, etc. Meds toxic to
kidneys nonsteriodal anti-inflammatory (ibuprofen, Advil,
Motrin, Aspirin, all the general aches and pain w/ exception of
Tylenol) most arthritis drugs, ace inhibitors, loop diuretics,
antibiotics (REALLY NEPHROTOXIC),
Question: A pt with hx of renal disease is admitted with acute shoulder
pain. Which order should the nurse question?
1. Pan cultures for temp >38.5 c
2. Metoprolol (beta blocker) 50mg by mouth BID
3. Ibuprofen 600mg by mouth every 8 hr as needed for pain: nurse could
suggest Tylenol
4. Digoxin 0.125 mg daily
Answer C: these are nephrotoxic and should not be given to a renal patient
Physical Assessment
▪ • Inspection- discoloration (greater risk for bruising),
edema, color (pallor- look at mucous membranes), uremia
(yellow skin color)
▪ • Auscultation – lungs crackles, S3 in heart, listen for renal
bruit abnormal blood flow b/c renal artery stenosis esp. HTN pt
(high sound so listen with diaphragm on midclavicular line
around belly button);
▪ • Palpation- kidneys can be palpable but its advanced
practice;
▪ • Percussion- check for inflammation of kidney, rule out
CVA tenderness;
▪ • Assessment of the urethra – visual, look for blood, mucus
or pus
- BODY WT for fluid balance!!!!!
Urinalysis
▪ • Color, odor, and turbidity – can be very dilute or
concentrated
▪ • Specific gravity varies w/ hydration
▪ • pH
▪ • Glucose **
▪ • Ketone bodies **
▪ • Protein ** (look at glomerulus)
▪ • Leukoesterase ** (UTI)
Nitrates** UTI
▪ • Cells, casts, crystals, and bacteria ** (don’t worry about
these as much)
Normal urine shouldn’t have the ***
- WBC 18,000 orders urine for Culture: Clean Catch urine sample: clean
front to back, void, catch; from Foley, clamp for while to build up urine,
cleanse port, attach syringe to aspirate urine.
- 24 Hour urine is a direct reflection of glomeruler filtration;
Blood Tests
▪ • Serum creatinine – Renal is only thing that would make
this high;
▪ o Normal value is 0.8-1.5;
▪ § # is as important as trend, normal it should stay same, if it
alters then something is wrong in kidneys
▪ • Blood urea nitrogen- Tells about protein metabolism:
Renal, hydration, GI, dietary protein intake
▪ o State of hydration affects BUN; (Dehydration can elevate
BUN)
▪ o May indicate GI bleeding (Elevate BUN)
▪ • Ratio of blood urea nitrogen to serum creatinine ~ 10:1
-GFR Rate: Greater than 65 normal. Should be around 120;
- 24 hours for creatinine clearance: How many mL of blood should have
creatinine filtered off; it should be 120 mL; get big 3L jug with preservative so
the metabolic activity stops when you put uine in there so put it on ice; tell pt
to empty bladder (if they cant go make sure they tell you next time) If she
empties at 10 don’t collect that first sample but start then and collect all
urine after emptying collected; You must start over if for some reason you
miss one void, or if there is contamination of sample (poop); If not in hospital
keep ice in cooler, use Foleys only if absolutely necessary;
- 24 hr direct reflection of GFR: if normal is 120 but report is 40, GF is
impaired. This tells you they have 30% fx left, if they cant filter serum levels
of electrolytes and things go up & Substances stay in blood (K+ cardiac
problems)
- If filtration is significantly impaired, meds will stay in body; STORY: dr.
orders digoxin (increase contractility ad CO, before hand ou must check HR
b/c this slows HR… used for tachycardia and atrial arrhythmia… visal defects
(halos) indicate dig tox, seeing yellow lights, N/V) If creatinine clearance is
30mL/min tell dr he may want to decrease dose bc this is high value (not
filtering well)
Other Urine Tests
▪ • Creatinine clearance—best indication of overall kidney
function norm ~ 120 ml/min
l Nursing Implications 24 hr urine (described above), bucket and ice
▪ • Urine electrolytes – Usually nephrologist consulted bc
they aren’t making enough urine
▪ • Urine drug screens – observe pt void then you directly
take to lab (chain of command)
▪ • Serum Osmolarity - Urine and plasma ( plasma norm
~290) & urine osmolarity
Have pt empty bladder, start at that time and go to the other 24hr container;

If filtration is reduced to 30% of normal; Substances are staying in the blood..

medications will stay in body, etc. Digoxin – check hr, it increases
contractiility and output; Give digoxin to control a irregular rhythm; (Digoxin
toxic – see visual halos, n/v, yellow lights);
Question: What to do first, Laxic or collect sample of urine? Sample of urine
b/c a lasix increases urine output by blocking reabsorption of sodium;
Urine Culture
Front back cleaning, etc. look over clean catch; remember to stop the
drainage (DON’T GET SAMPLE FROM BAG) clamp Foley to build it up then take
it from the port after CLEANSING;
Other Diagnostic Tests
▪ • Bedside sonography/bladder scanners – want to know how
much urine is in bladder; looking for post void residual usually;
not invasive or painful;
▪ • Computed tomography (CT scan) – doesn’t matter if fecal
is there b/c it slices and can get the picture. VERY SHORT, 5-
10 min. Looks like a doughnut table that goes through the
hole, (hold your breath now breathe) usually they need to
inject contrast dye (dye is nephrotoxic- ask if they are allergic
to iodine or shellfish (shrimp lobsters, etc), if the pt was
 allergic then the Dr. would order a antihistamine and a steroid
and epinephrine should be on hand just in case things got out
of hand. Metformin + contrast dye = renal failure, so STOP the
metformin 48hr before and after the test, make sure you get
some other diabetic med like insulin; Muco-Mist given orally
48hr before and after contrast medium may protect kidneys,
this med is also a mucolytic which loosens pulmonary
secretions and is the antidote for acetaminophen;
▪ • Kidney, ureter, and bladder x-rays (KUB) (come in to ER
abdominal x-ray must have bowel preparation to be helpful)
▪ • Renal Ultrasound – noninvasive, quick, painless, need
fluids so NPO isn’t necessary, looks at the structures, NO DYE!
▪ • Intravenous pyelography (IVP) iv injection of contrast
medium but with x-ray no CT; If bowel is full same as KUB must
do NPO, bowel prep, allergy, nephrotoxicity;
l Bowel preparation
l Allergy information
l Fluids

Urodynamic Studies
▪ • Studies that examine the process of voiding include:
l Cystometrography – how strong is urinary stream
l Urethral pressure profile
l Electromyography
l Urine stream test

Cystography and Cystourethrography-

Instilling dye into bladder via urethral catheter
▪ • Monitoring for infection
▪ • Encouraging fluid intake
▪ • Monitoring for changes in urine output and for
development of infection from catheter placement
Retrograde Procedures
▪ • Retrograde procedures go against the normal flow of
urine.
▪ • Procedure identifies obstruction or structural
abnormalities with the instillation of dye into lower urinary
tract.
▪ • Monitor for infection. High risk than normal;
▪ • Follow-up care is the same as for a cystoscopic
 examination.
Dye not absorbed it’s a topical, not nephrotoxic;
Cystoscopy/Cystourethroscopy=“Cysto” see all way up ureters
l Procedure is invasive.
l Consent is required.
l Postprocedure care includes monitoring for airway patency, vital
signs, and urine output.
l Monitor for bleeding and infection.
l Encourage client to take oral fluids.
▪ • Conscious sedations – morphine, fintanyl, versaid – quick
onset, short acting! Need a driver they can’t drive themselves
home; Invasive and inserting larger than typical cath, size 26
usually) – quick onset, short acting but leave loopy- risk for
FALLS;
Renal Arteriography (Angiography)-injection of dye in renal artery to show
blood flow into kidney
▪ • Possible bowel preparation;
▪ • Light meal evening before, then NPO
▪ • Injection of radiopaque dye into renal arteries, √ allergies
▪ • Assessment for bleeding
▪ • Monitoring of vital signs
▪ • FLUIDS
▪ • Absolute bedrest for 4 to 6 hours
▪ • Serum creatinine may be measured for several days to
assess effects of test/dye
▪ Remember all the allergies, etc.
▪ Large cath inserted in femoral artery and gone up the renal artery
inject dye, check for hemmorage (big cath in big artery) First when pt
back do vital signs and check insertion site and palpate site blood will
go back; Hr will increase and bp decrease with pallor, weak pulse –
HEMMORAHGE; if pt is bleed & surrounding tissue is hard –
indurations; Interventions to prevent bleeding pt must remain at bed
rest supine with leg straight hob elevated not more than 30degrees;
force fluids, etc.;

▪ Question: An expected outcome for the pt who has undergone a renal

arteriogram is
A) maintaining bedrest for 12 hr
B) Maintaining the leg in a straight position for 12 hours
C) Discouraging ankle flexing and wt shifting
D) measuring serum creatinine for several days
Answer: D
When creatinine gets around a 7 creatinine they are exhibiting uremia
symptoms; Diaylsis is usually instituted around this time (Pt could have a 3
creatinine but could still need dialysis due to other factors like electrolytes)
- *** (STORYTIME) Compartmental syndrome – (upper arms in football
players) swelling in tissue (impairs arterial circulation, below arm impaired,
death of muscle protein finally, dead muscle releases rhabdomyolysis, this
rhabdo causes renal failure, so those football players were at risk for ARF; ;;;
89 yr old brother caregiver for 91 yr old sister, 89yr old put sis to bed buddle
up and put her to bed but he feel and remained in floor overnight eventually
found but since it was winter with no heat he laid in a cold environment for a
long amount of time and he became hypothermic severe rhadomyolsis,
etc.;;;;
Renography
▪ • Small amount of radioactive material, a radionuclide,
used; not radioactive, no safe precautions needed;
▪ • Procedure via intravenous infection
▪ • Follow-up care:
l Small amount of radioactive material may be excreted = force
fluids
l Maintain standard precautions.
l Client should avoid changing posture rapidly and avoid falling.
5 P’s Pain, Pulse Pallor, Paresthesia, Paralysis (Look at pictures on
Blackboard)
Percutaneous Renal Biopsy
• Clotting studies
• Preprocedure care
• Follow-up care
l Assessment for bleeding for 24 hours
l Strict bedrest
l Monitoring for hematuria
Increase Comfort measures after procedure
Insertion of long needle thru skin (back) and poke and pull out a piece of
tissue (bleeding is a complication) place pt on back or sandback to put
pressure on kidney biopsy; vitals to assess for hemorrhaging; strict bedrest,
watch urine for blood b/c if so the kidney is bleeding;
Question: A priority assessment of a pt who had kidney biopsy include:
A) assess for compliance w/ strict bedrest
B) assess for signs of hypovolemia
C) Monitor for hematuria
D) assess for pain;
Answer: B; at risk for bleeding ad hemorrhage

E. coli: medicine for that is gentamycin but this is nephrotoxic and ototoxic;
ARF- SUDDEN ONSET, reversible, ESRD/HD end stage renal disease;
Question: A pt w/ ESKD has serum lab analysis: K+ 5.9 mEq/L, Na+ 152
mEq/L, creatinine 6.2mg/dL, BUN 60 mg/dL. A priority intervention would be:
A) Assess heart rate and rhythm.
B) Contact the Dr
C) Prepare the pt for dialysis therapy
D) Evaluate pt resp stat E) Weigh Pt
Answer: A: Potassium is very high!!
K+ is the most lethal problem with the labs so check cardiac.
Interventions for Clients with Acute & Chronic Renal Failure Chapter
71
Acute Renal Failure= ARF SUDDEN ONSET!!!
• Pathophysiology- rapid decline in function
• Types of acute renal failure include:
– Prerenal (cause = decreased perfusion)
– Intrarenal =Intrinsic = ATN (cause = meds, bacteria, NSAIDs, &
pre/post renal)
– Postrenal (cause = obstruction to urine flow)
30 urine per hr if not red flags should be up that something is wrong with
renal
Intervention: bolus with fluids; diuretic; dopamine to improve blood flow;
acute tubular necrosis –
Phases of ARF
• Phases include:
– Onset – precipitating event (First thing lost by kidney is lost to
concentrate urine);
– Diuretic (non-oliguirc) non-oliguirc is that they are excreting water
just not the metabolic wastes
– Oliguric /anuria Less than 30ml hour/no urine; RISK FOR FLUID
OVERLOAD, hyperkalemia (no more OJ); Kayexlate orally or rectally –
it’s a Na, high sodium on one side and Potassium goes into Gut
which is good but we don’t want that much Sodium in body so we
mix it with a hypoosmolar that’s a sugar to even it out because
water will be pulled in and sodium will follow, pt K+ will go down
and the pt will poop a lot; Insulin pushes sugar in the cell and K
goes with the sugar so by giving insulin potassium will follow, give
reg insulin IV if you do this an the pt does not need insulin with their
sugar level you can give 50% dextrose with it;
– Recovery
• Acute syndrome may be reversible with prompt intervention.
Assessment
• History – precipitating event
• Clinical manifestations- depends on phase/type (could be
hypo/hypervolemia); Increasing K, P, Mg and decreasing Ca & GFR
• Laboratory assessment ↑Creatinine, BUN, K+, Phos, Mg++; ↓Cr
Clearance, Ca++
• Radiographic assessment
• Other diagnostic assessments such as renal biopsy
Interventions:
• Prerenal
– Fluid bolus
– Diuretics
• Intrinsic=Intrarenal
– Low dose Dopamine (~3 mcg/kg/min)
– Monitor fluid volume status
– Calcium Channel Blockers (improve renal blood flow)
– Monitor for medication toxicities; dose adjustments
• Postrenal
– Remove/bypass obstruction to urine flow
Medication Considerations
• Cardioglycides = digoxin toxicity = ↓ dose
• Vitamins and minerals-may need B9 & iron – boost all the blood
• Biologic response modifiers= Epogen (Erythropoietin)
• Phosphate binders= Amphojel to ↓ phos absorption, TUMS to
↑Ca++
• Stool softeners and laxatives
• Diuretics
• Calcium channel blockers & HBP control; dilate renal artery;
DON’T TAKE ANYTHING WITH OTHER STUFF IN IT!! Fleets phosphate
or milk mag, etc, they cant excrete these;
K+ management
Treatment
• Diet therapy
– Protein intake – according to client needs
– Watch foods high/low in electrolytes of concern
– Watch fluid intake
– If elemental or TPN needed – special Renal Formula

• Dialysis therapies
– If needed for fluid, electrolyte, azotemia control
– Hemodialysis
– Peritoneal dialysis
– ‘Continuous Renal Replacement Therapy’ (for fluid overload)
Posthospital Care
• If renal failure is resolving, follow-up care may be required.
• There may be permanent renal damage and the need for chronic
dialysis or even transplantation.
• Temporary dialysis is appropriate for some clients.
• May take ~ 1 year to resolve

Chronic Renal Insufficiency Failure ESRD

• Progressive, irreversible kidney injury; kidney function does not
recover
Changes in Chronic Renal Failure → ESRD
• Metabolic – azotemia -> uremia – causes HTN, creatinine is a
irritant (infects mucous membranes and linings of all organs) the <3
has the worst effect;
– Urea and creatinine (around 7)
• Electrolytes
– Sodium (hyponatremia/hypernatremia)
– Potassium (hyperkalemia)
• Acid-base balance
• Metabolic acidosis
• Calcium and phosphorus
• Hyperphosphatemia/hypocalcemia

Clinical Manifestations
• Neurologic: lethargy - coma
• Cardiovascular: HBP, CHF, P E, dysrhythmias; “rub”; high
hyperlipidemia; uremic pericarditis
• Respiratory: tachypnea, pleurisy
• Hematologic: anemia, bruising; Low WBC & Platelets;
• Gastrointestinal: bleeding, ulceration, hiccups,
• Urinary: decreased output
• Skin: yellow/gray discoloration, pruritus, frost, ecchymoses
• Sexuality: infertility, dryness, impotence
Proton pump inhibiter (protonix); lining should be resonance but if there is
fluid it will be dull;
Hemodialysis – there is a blood that flows to dialyzer, and the hemodialyzer
(where the filtering takes place); Blood flows back to body;
Give heparin and get PTT’s done;
▪ If a heparin pt has dialysis and needs a thorascentis do the thora first
before the heparin; so give protamin sulfate to reverse the heparin;
heparin stays active 6hr; if air or dialysate got in the airway it would
shut down;
Vascular Access
• Arteriovenous fistula, or arteriovenous graft for long-term
permanent access
• Hemodialysis catheter, dual or triple lumen, or arteriovenous
shunt for temporary access
• Precautions: no restrictive clothing, tourniquets, NO BP, IV, or
blood draw
• Complications: clotting (= loss of access= no HD), infection
• Listen for bruit, palpate for thrill; Assess any vascular assess
devices- listen for bruit, (sounds like a little air gun)
Hemodialysis Nursing Care
• Postdialysis care:
– Monitor for complications such as hypotension, headache, nausea,
malaise, vomiting, dizziness, and muscle cramps (disequilibrium
syndrome).
– Monitor vital signs and weight.
– Avoid invasive procedures 4 to 6 hours after dialysis.
– Continually monitor for hemorrhage.
– Administer meds that were held prior to dialysis: HBP, dialyzable
antibiotics, digoxin, etc
There is an unequal another of creatinine in the CSF and serum (eventually
they will diffuse and be equal) BAD CSF problems. SS above.
HOLD MEDS PRIOR TO DIALYSIS OTHERWISE THEY WILL GO OUT!!
Peritoneal Dialysis
• Procedure involves special catheter placed into the abdominal
cavity for infusion of dialysate.
• Types of peritoneal dialysis:
– Continuous ambulatory peritoneal
– Automated peritoneal
– Intermittent peritoneal
– Continuous-cycle peritoneal
PD more closely mimics the kidney it just doesn’t make Vit D and
erythropoietin;
Complications
• Peritonitis
• Pain
• Exit site and tunnel infections
• Poor dialysate flow
• Dialysate leakage
• Other complications
Nursing Care During Peritoneal Dialysis
• Before treating: evaluate baseline vital signs, weight, and
laboratory tests.
• Continually monitor the client for respiratory distress, pain, and
discomfort.
• Monitor prescribed dwell time and initiate outflow.
• Observe the outflow amount and pattern of fluid.
Complications of Hemodialysis

• Dialysis disequilibrium syndrome

• Infectious disease
• Hepatitis B and C infections & HIV exposure—poses some risk for
clients undergoing dialysis & staff
Cost, time
Renal Transplantation
• Candidate selection criteria
• Donors
• Preoperative care
• Immunologic studies
• Surgical team
• Operative procedure
Postoperative Care
• Urologic management
• Assessment of urine output hourly for 48 hours.
• Complications include:
– Rejection
• S/S: increased Temp, BP, pain, UO, Cr/BUN, weight
– Acute tubular necrosis
– Thrombosis
– Renal artery stenosis
– Other complications
– Immunosuppressive drug therapy
–Psychosocial preparation
Cystitis & Infections of Lower Urinary Tract (Chapter 69)
• Inflammation of the bladder
Most commonly caused by bacteria (or viruses, fungi, or parasites ) from the
rectum/vagina moving into the external urethra to the bladder, ureter, &
even to the kidney (pyelonephritis)
E. Coli is the most common bacteria
Catheter related infections common during hospital stay
• HIGH RISK: UROSEPSIS with high mortality
UTI – Urinary tract infection – inflammation of lower urinary system (FOLEY
CATH is highest in hospital) Women are more likely to get it because urethra
is shorter & Perneal area so close; Men get it due to enlarged prostate b/c it
obstructs urine; (Empty bladder q 3 hr)
Cystitis – visible vessels, lots of tiny red dots, hemorrhagic area from
infection;
Most common sign is: FREQUENCY: PAIN (burning);
Incidence and Prevalence of Cystitis
• 2nd most common reason to visit to HCP
• ASSESSMENT
– Frequent urge to urinate
– Dysuria
– Urgency
• UA needed to test for leukocyte esterase (+ in UTI), also WBCs,
RBCs (WBC URINE CLOUDLY) (SMOKY or pink/red if RBC in urine)
For older adults in the hospital, the 1st sign is altered mental status.
Type of organism confirmed by urine culture
↑serum WBCs with ↑ in ‘bands’ (adolescent WBC)
When we are faced with an infection bone marrow will release adolescent
aged WBC to help the “tired already in circulation” WBC; should not have
these “bands” unless we are sick; LOOK AT TYPE OF WBC (are they in
the correct proportion) Bandemia
E. coli is the most common type of bacteria found as a cause of
UTI;
CYSTO to R/O abnormalities
Pharmacological Therapy
•Urinary antiseptics: Macrobid, Macrodantin (nitrofurodantin); Pt will frequent
recurring UTI may have a low dose daily; this decreases bacteria growth
•Antibiotics: Septra, Cipro, Levaquin, Amoxil, Duricef
•Analgesics: Pyridium (overcounter med) Orange color urine; will diminish
burning but doesn’t address cause; drink LOTS of liquids;
•Antispasmodics: Anaspaz (b/c the bladder is irritated so it needs something
to diminish the spasm)
•Antimicrobials: Bactrim/Septra, Cipro/Levaquin, Amoxil, Duricef
•Antifungal agents: Nizoral
Long-term antibiotic therapy for chronic, recurring infections
•Intravaginal Estrogen for postmenopausal women (general dryness as
women age) cream or tablets
QUESTION: What is an expected outcome for the older adult male pt
with a history of asthma who is being treated w/ nitrofurntin
(Macrobid)?
A. Orange-colored urine
B. Constipation
C. Blurred vision
D. Flu-like symptoms;
Answer: D - monitor these symptoms in older pt taking
nitrofurantoin and those with pulmonary disease;
Nonpharmacological Management
• Urinary elimination after sex & before bedtime
Urinate q 3-4hr
• Diet therapy: all food groups, ↑ calorie RT ↑ increase in
metabolism caused by the infection; ↑ intake 2-3 L/day of fluids,
possible intake of cranberry juice; d/c caffeine; Vit C foods/fluids
•Other pain relief measures, such as warm sitz baths but not
vigorous cleaning of perineum or douching
• Cotton undies/no tight jeans
•Daily perineal cleansing (but not vigorous cleaning, douching or bubble
baths)
Question: 21 yr old male complaining of burning and difficulty with
urination. Priority question in obtaining info about pt chief complaint would
be:
1. How long have you had these symptoms?
2. Do you have low back pain?
3. Are you sexually active?
4. Have you had fever in past 24 hr
Answer: C Most common cause of urethritis in men is STD: Ureaplasma,
Chlamydia or Trichomonas vaginalis!!
Can lead to pylenephritis & Urosepsis ; Altered mental status
(decreased blood flow to brain)

Urinary Incontinence
• Impacts > 13 million in USA. Mostly ♀
• Not a normal result of aging, but does ↑ with age
• Five types of incontinence include:
– Stress – little when coughing, sneezing, vomiting;
– Urge – Cant make it to the bathroom
– Mixed
– Overflow – spinal cord injury, bladder wont empty and it starts to
leak
– Functional (cognitive impairment) Don’t know when to recognize
when its time (Dementia, unresponsive individual)
The brain sends nerve signals telling muscles to hold urine or let it out.
Nerves send signals to the brain. Signals tell when the bladder is full or
empty.
Collaborative Management
• Assessment: thorough client history (make sure not constipated)
• Clinical exam to R/O cystocele (herniation of bladder into
vagina), rectocele, prolapsed uterus & assess perineal sensation;
medication history
• Urinalysis: R/O infection
• Radiographic assessment & other diagnostic assessments to
determine urinary system health
(Lightly touch anus, contract when it touch, if it doesn’t contract then they
may have nerve root problem to bladder)
• Interventions include:
– Keeping a diary
– Behavioral interventions
– Diet modification: weight loss, no caffeine, alcohol
– Pelvic floor exercises (Kegels)
– Drug therapy: Estrogen, Pro-Banthine, Ditropan, Detrol (increase
intraocular Pressure) see eye dr. can cause glaucoma; Trofranil-
Antianxiety and has anticolingeric; all these meds cause DRY
MOUTH,

URINARY RETENTION
– Vaginal cone weights
– Urinary habit training (freq basis)
– Intermittent self-catheterization (clean technique)
– Containment of urine and protection of the client’s skin
– Applied devices: penile clamp, pessaries (object place inside
vagina that cystisilfallen bladder, take out clean etc), condom
Last resort: Urinary catheterization
Surgical Management
• Preoperative care (Abdominal surgical procedure)
• Operative procedure: see list pg 1692 (1. Inject collagen which
works 50% of the time. 2. Surgery to pull bladder back to be
surgically correct (bladder tack-up) 3. Suprapublic cath)
• Postoperative care (Airway #1, at risk for pneumonia b/c they
won’t want to deep breath due to pain; Circulation: DVT (calf pain
edema & pulmonary embolism is main concern which pt has chest
pain SOB and alter gas exchange)
– Assess for and intervene to prevent or detect complications.
– Secure urethral or suprapubic catheter.
– No sex until post-op check (~6 wk) to allow good healing
– No heavy lifting for 3 months (5lbs)
– No exercise such as running, aerobics, stair-climbers until
completely healed
Any pelvic surgery puts them at higher risk for DVT (ambulation,
antiembolism stockins, etc.)
Urolithiasis
• Presence of calculi (stones) in the urinary tract
• History of urologic stones
• Clinical manifestations ---- EXTREME pain when stone moves
NCLEX says pain is a psychological diagnosis so if this appears, it’s most
likely not the number 1 choice.
• Laboratory assessment: -- UA, ↑WBC if infection
• Radiographic assessment: CT of abdomen, (IVP)
Pain when stone actually moving; (pain location depends, if stone in pelvis is
in back, upper ureter in upper side and when it starts moving down it starts
moving toward the bladder) 25 yr old female pain in right lower abdomen
(ectopic preg, appendicitis, ovaries problems) Have pt go for cat scan b/c the
IVP (needs bowel prep) will not be bowel prep;
Stones make WBC go up just like infection does;

Question: A pt with urolithiasis has not voided in 7 hr. What is primary

concern for this pt?
1. Hematuria
2. Hydronephrosis (water on nephron);
3. Infection
4. Pain
Risk for blockage; risk for infection (physiology) Pain;
Answer: B - A primary concern is prolonged obstruction. As the blockage
persists, hydronephrosis and permanent kidney damage may develop. Other
concerns with urolithiasis include infection, hematuria, and effective tx of pt
pain
Interventions
• Drug therapy often with Opioid analgesics (morphine) IV; Watch
for resp distress; constipation
• Nonsteroidal anti-inflammatory drugs
• Pain medications at regular intervals
• Constant delivery system
• Spasmolytic drugs (Ditropan & Pro-Banthine)—important for
relief of pain
• Complementary and alternative therapy
Anticipate pt to be on increase Fluids (rates greater than typical amt) Watch
for fluid vol overload; get a filter or strainer; Pt probably nausea and
probably on an antibiotic to prevent infection;
Lithotripsy
• Extracorporeal shock wave lithotripsy uses sound, laser, or dry
shock wave energy to break the stone into small fragments. (Sound
waves used outside of body to crush stones so that they can move)
sore abdomen with bruising, hematuria; tell pt to ice the abdomen
etc
• Client undergoes conscious sedation
• Topical anesthetic cream is applied to skin site of stone.
• Continuous monitoring is by electrocardiography
Surgical Management (Cysto – scope thru bladder up ureters and
using implement with a loop try to get above stone and scoop it
down) expect pain, hematuria, inflammation;
• Minimally invasive surgical procedures
• Stenting; after scraping there will be a stent (small tube) to keep
ureter open until inflammatory response stops; there may be string
out peepee hole :] make sure pt don’t put out string b/c that will
remove stent; (week to ten days inflammation)
• Retrograde ureteroscopy
• Percutaneous ureterolithotomy and nephrolithotomy
• Open surgical procedures
– Preoperative care
– Operative procedure
Postoperative Care
• Routine postoperative care procedures for assessment of
bleeding, urine, and adequate fluid intake
• Strained urine
• Infection prevention
• Drug therapy
• Diet therapy
• Prevention of obstruction
Drug Therapy
• Drug selection to prevent obstruction depends on what is
forming the stone:
– Calcium; Low Ca diet, hydrodiurl promotes resorption of Ca into
blood
– Oxalate; Low oxalate diet; zyloprim, vit B6
– Uric acid; metabolic disease GOUT makes kidney stones, low
purine diet (low in proteins and greens) Med allopurinol often given,
also probencid
– Cystine – hydration, alkalinazation, captopril
Urothelial Cancer – abnormal growth of abnormal cells

• Collaborative management
• Assessment
• Diagnostic assessment
• Nonsurgical management
– Prophylactic immunotherapy
– Chemotherapy
– Radiation therapy
Prevention of Bladder Cancer- Protect self against inhaled chemicals; drink
lots of fluids & void freq; extra Vit A (protectant); NO MARIJUANA or
cigarettes (its an irritant to bladder)
Tx of bladder cancer: Intravesical Chemotherapy (medication instilled into
the bladder – intravesical – through a foley medicine get up there and the
foley will be clamped so medicine will get contact with bladder lining and
cancer (NPO, so it wont dilute the medicine) SAVE bladder, drug is not
absorbed and will not have side effects to rest of body;
Surgical Management – if cancer is stage 4 and taking bladder out is
a must;
• Preoperative care
• Operative procedures – preserve bladder if possible; if not ->
cystectomy & ileal conduit; ileal conduit, urostomy – take out
bladder and resect 6in of bowel and create tube (one end is closed
the other end is brought to skin –stoma – ureters are implanted into
the tube and urine will flow to the stoma constanly) this pt will be
incontinent – flowing of urine constantly (POUCH)
• Postoperative care includes:
– Collaboration with enterostomal (WOCN) therapist
– Kock’s pouch or Indiana pouch – took segment of bowel and made
pouch and the connected tube and got a stoma – this pt is continent
– Advantage is that its continent; pt will cath pouch every 4 hrs, no
external pouch needed and learn sense of fullness (in right quad)
Disdvantage – special surgeon, longer surgery time,
– Neobladder – make new bladder if ureters weren’t affected with
cancer, less common;
Nursing – assess skin around stoma, not red or inflamed; stoma pink, moist
(look like lining of mouth) Constant flow of urine;

Urostomy Stoma & Pouches

Nephrostomy- tube placed into pelvis of kidney, pouch system with stent
draining urine in pouch; high risk for infection;
Question: Pt with hydronephrosis she had nephrostomy tube placed. Which
assessment data requires immediate intervention and notification of Dr?
1. Hematuria
2. Cloudy Urine
3. Pt complaint of back pain
4. Pot 4.9
Answer: C if the amt of drainage decreases and the pt has back pain, the
nephrostomy tube may be clogged or dislodged.
Ureterostomy – bring ureters out to skin
Crystals: Occur when urine is too alkaline. Can cause stomal irritation and or
bleeding. Urinary crystals can be prevented by keeping it clean;
Bladder Trauma
• Causes may be due to injury to the lower abdomen or stabbing or
gunshot wounds.
• Surgical intervention is required.
• Fractures should be stabilized before bladder repair.
Frank blood – very red!!! NOT GOOD;;

Interventions for Clients with Renal Disorders Chapter 74

Polycystic Kidney Disease
• Inherited (autosomal dominant) disorder in which fluid-filled
cysts develop in the nephrons – 50% chance of getting it;
• Key features include: Causes cysts to form in the kidney
– Abdominal or flank pain (swelling of kidney) – diminished blood
flow releasing renin
– Hypertension from release of renin
– Nocturia can’t concentrate urine
– Increased abdominal girth from swelling of kidney
NO CURE!!
Prevent complication
Genetic Testing
KIDNEY TRANSPLANT!!!!

PKD DIAGNOSIS
Ultrasound
CT
MRI
Genetic history
Urinalysis (protein & blood)
Decreased kidney function
Interventions
• Pain management- caution NSAIDs
• Bowel management- constipation from enlarged kidneys
• Medication management - ACE inhibitors & other HBP meds
• Energy management
• Fluid monitoring – low Na+ diet
• Urinary retention care – Credé –emptying bladder by manually
pushing or pulling butt hairs (may have incontinence)
• Infection protection
Question: A possible outcome for the pt being treated with spironolactone for
nephritic syndrome is the development of
A) Hyponatremia
B) Hyperkalemia
C) Hypercalcemia
D) Hypophosphatemia
Answer B

Pyelonephritis (chapter 74)

• Bacterial infection in the kidney (upper urinary tract)
• Key features include:
– Fever, chills, tachycardia, and tachypnea
– Flank, back, or loin pain
– Abdominal discomfort
– Turning, nausea and vomiting, urgency, frequency, nocturia
– General malaise or fatigue
• Hypertension
• Inability to conserve sodium
• Decreased concentrating ability
• Tendency to develop hyperkalemia and acidosis
More likely in females!!

Acute Pain Interventions

• Pain management interventions
• Drug therapy
– Antibiotics
– Urinary antiseptics (macrodantin)
• Diet therapy
– Force fluids
Surgical Management – for structural problems
• Preoperative care
– Antibiotics
– Client education
• Operative procedure: pyelolithotomy, nephrectomy, ureteral
diversion, ureter reimplantaton
• Postoperative care for urologic surgery

Glomerulonephritis= Nephritic Syndrome

• Assessment ~ 10 days after infection usually Streptococcus
(resulting in antibody/antigen reactions within glomerulus); edema
(if protein not in vessel water leaks into interstial), proteinuria,
hematuria HBP, fatigue, ↓GFR,↑BUN/Cr, + Strep titers
• Management of infection
• Prevention of complications
– Diuretics
– Sodium, water, potassium, and protein restrictions
– Dialysis, plasmapheresis
– Client education
Chronic Glomerulonephritis -- Results in loss of nephrons leading to
↓GFR → renal failure
Question: Male pt complains of progressive fatigue, anorexia, wt gain and
dysuria with dark colored urine what is the priority nursing care?
1. Do you have family hx of renal disease
2. Have you had recent infection
3. Do you experience freq UTI
4. When did you first notice symptoms
Answers: B : The onset of symptoms is 10 days from time of infection.
Systemic strept infection is more common in men as precursor infection of
acute glomerulonephritis
Nephrotic Syndrome
• Condition of increased glomerular permeability that allows
larger protein molecules to pass through the membrane into the
urine and be removed from the blood
• Severe loss of protein into the urine; larger molecules
Proteinuria; lots of bubbles in toilet; plum (periorbital edema) sclera edema;
chest for pulmonary edema; (AIR IS BLACK ON CHEST X-RAY); STREP
• Treatment involves:
– Immunosuppressive agents (Reverse/Protective Isolation –
neutropenic) Wear mask, gloves, gown AT RISK FOR INFECTION
– Angiotensin-converting enzyme inhibitors
– Heparin
– Diet changes
Rest!
- Mild diuretics
Question: The older adult pt with acute glomerulonephritis is often
misdiagnosed with
1. CVA
2. Transient ischemic attack
3. Aortic aneyrysm
4. CHF
Answers: D
Renal Trauma
• Minor injuries such as contusions, small lacerations
• Major injuries such as lacerations to the cortex, medulla, or
branches of the renal artery
• Collaborative management
• Nonsurgical management: drug therapy and fluid therapy
• Surgical management: nephrectomy or partial nephrectomy
BLEEDING major problem if there is trauma; prep for blood transfusion,
surgery, etc. Don’t want to overstress kidneys after this kind of accident!
Renal Cancer
Stage 1 7cm; Stage II 7Cm; Stage III Gerota’s fascia; Stage IV other organs
and lympg nodes
Cancer is abnormal growth of abnormal cells; SPREAD to other body organs
(the spread to the lung, etc. is usually when manifestation starts; Cure rate
for renal cancer is not really high; difficult to treat b/c we don’t find the
disease early;
Tx: Remove diseased kidney f (long incision from diaphragm to center of
abdomen and all around sides; Have to spread all those kidneys; PT coming
straight from surgery #1 priority is AIRWAY, BREATHING, CIRCULATION
(watch for hemorrhage, vitals, pulse quality, skin color, output from drain,
the hr after pt comes back should be sangious, 48hr after it should be sero-
sang, BUN and creatinine should stay normal; Pain should be the next
concern;
Nephrectomy: Traditional vs Laproscopic
Lapro: less heal time, not as painful, smaller scars; (CO2) - absorbed by
body, shoulder pain; RISK for bleeding b/c they can’t see.