RENAL SYSTEM MAJOR SIDE EFFECTS

Functions of the Kidney  N/V, decreased absorption of folacin (irritation

1. Controls fluid and electrolyte balance. of gastric mucosa)
2. Controls of acid-base balance  hypersensitivity
3. Excrete end products of body metabolism  Malaise (decreased RBCs)
4. Secrete renin & eryhtropoietin  Blood dyscrasias (decreased RBCs, WBCs,
5. Manufacture & activation of vitamin D platelet synthesis)
Laboratory and Diagnostic Test  Crystalluria (drug precipitation in acidic urine)
A. Urine Sudies  Stomatitis (GI irritation)
1. URINALYSIS  Headache (CNS effect)
2. URINE CULTURE and SENSITIVITY
3. RESIDUAL URINE NURSING CARE
4. CREATININE CLEARANCE • Assess client for hx of drug allergy.
5. VANILYLMANDELIC ACID (VMA) TEST • Promote increased fluid intake.
6. URINE ACID TEST • Caution the client to avoid direct exposure to
B. IVP sunlight.
C. Renal Angiography • Assess vital signs during course of therapy.
D. Ct scan and MRI • Maintain alkaline urine.
E. Cystometrogram • Administer at routine intervals RTC.
F. Bladder ultrasonography • Monitor blood work during therapy.
• - Potential for megaloblastic anemia (Folacin
Kidney Specific Anti-Infectives deficiency) Assess for potentiation of oral
DESCRIPTION anticoagulant and oral hypoglycemic effects.
• Exert an antibacterial effect on the renal • Evaluate client’s response to medication.
tissue including ureters and bladder •
• Used to treat local urinary tract infections. URINARY SPASMOLYTIC
EXAMPLES DESCRIPTION
• Nalidixic acid (NegGram), • Directly affects the smooth muscle of the
• Nitrofurantoin (Furadantin, Macrodantin) urinary tract.
MAJOR SIDE EFFECTS • Used for symptomatic relief of incontinence
• N/V EXAMPLES
• Skin rash Flavoxate HCl (Urispas)
Oxybutynin Cl (Ditropan)
• CNS disturbances (Neurotoxicity)
Probantheline chloride (Pro-Banthine)
• Blood dyscrasias
NURSING CARE MAJOR SIDE EFFECTS
1. Administer with meals to reduce - anticholinergic effect
GI irritation. • Tachycardia
2. Monitor blood work, cultures, and
• Palpitations
urinary output.
3. EOf TO promote drug excretion • Dry mouth
and prevent toxicity. • Constipation
4. Nalidixic acid: assess for • Drowsiness
potentiation of anticoagulant effect. • Blurred vision
5. Nitrofurantoins
• Urinary retention
6. Dilute oral suspensions in milk or
juice to prevent staining of teeth. – NURSING CARE
7. Instruct the client that the urine  Do not administer if GI obstruction is
will appear brown in color. present.
SULFONAMIDES  Administer cautiously to clients with
DESCRIPTION - ANTIBIOTIC/ ANTIINFECTIVE glaucoma.
EXAMPLES  Advise clients to avoid driving and
other hazardous
• Succinylsulfathiazole
 activities.
(Sulfasuxidine),Sulfisoxazole (Gantrisin)  Monitor urinary output.
• (Bactrim, Septra)
DISORDER OF THE GENITO-URINARY a teaching program.
SYSTEM 3. Discuss social aspects of living with a
stoma
CYSTITIS (sexuality, changes in body image).
CLINICAL FINDINGS 4. Assess understanding and emotional
• Abdominal or flank pain/tenderness response of client/significant others.
• Frequency and urgency of urination 5. Bowel prep for procedures involving
• Pain on voiding the ileum
or colon.
• Nocturia
6. Inform client of post-op procedures.
• Fever NURSING CARE: POST-OP
DIAGNOSTIC TESTS • Provide routine post-op care.
• Urine culture and sensitivity • Maintain integrity of the stoma.
- presence of E. coli (80%) a. Monitor for and report signs of impaired stomal
NURSING CARE healing.
1. Force fluids (3L/day) - pale, dark red, or blue-black color
2. Warm sitz bath for comfort. - increased stomal height
3. Assess urine for odor, hematuria, - edema, bleeding
& sediment. b. Maintain stomal circulation by using properly fitted
4. Use strict aseptic technique in FBC faceplate.
5. Administer medications as c. Monitor for S/Sx of stomal obstruction
ordered. - sudden decrease in urine output
6. Client teaching - increased abdominal tenderness and distention.
NURSING CARE: POST-OP
BLADDER CANCER  Prevent skin irritation and breakdown.
ASSESSMENT FINDINGS - Inspect skin areas for signs of breakdown daily.
• Intermittent, painless hematuria Change appliance only when necessary and when
• Dysuria production of urine is slowest. (early morning) Place
• Frequent urination wick (rolled gauze pad) on stomal opening when
DIAGNOSTIC TESTS appliance is off.
1. Cystoscopy with biopsy reveals malignancy - Cleanse peristomal skin with mild soap and water.
2. Cytologic exam of the urine reveals - Remove alkaline encrustations by applying vinegar
malignant cells and water solution to periostomal area.
- Implement measures to maintain urine acidity.
BLADDER SURGERY - acid-ash foods
CYSTECTOMY - vitamin C
- Removal of the urinary bladder - Omission of milk/dairy products

NURSING CARE: POST-OP

URINARY DIVERSIONS • Provide client teaching and discharge planning
1. URETEROSIGMOIDOSTOMY concerning :
2. ILEAL CONDUIT 1. Maintenance of stomal/periostomal
3. CUTANEOUS URETEROSTOMY skin integrity
4. NEPHROSTOMY 2. Proper application of appliance
3. Recommended method of cleaning
CONTINENT URINARY DIVERSION reusable ostomy equipment
1. CONTINENT ILEAL URINARY (manufacturer’s
RESERVOIR (KOCK POUCH) recommendations)
1. FUNCTIONAL RESERVOIR 4. Information regarding prevention of
ANASTOMOSED TO URETHRA UTIs
(ILEOCYSTOPLASTY)  Adequate fluids
 Empty pouch when half full
NURSING CARE: PRE-OP  Change to bedside bag at night
1. Provide routine pre-op care.  Control of odor.
2. Assess client’s ability to learn prior  Adequate fluids
to starting  Avoid foods with strong odor
  Place small amount of vinegar or b. Force fluids (3000 – 4000 ml/day).
deodorizer in pouch c. Encourage ambulation to prevent stasis.
d. Relieve pain by administration of analgesics as
NEPRHOLITHIASIS/UROLITHIASIS ordered and application of moist heat to flank
GENERAL INFORMATION area.
• Presence of stones anywhere in the urinary e. Monitor I & O.
tract. f. Provide modified diet, depending upon stone
• Frequent compositions of stones: consistency.
- calcium (phosphate), uric acid and cystine
(rare) stones DIET MODIFIED/STONE
CALCIUM STONES
• Most often occurs in men age 20-55 years;
• Low calcium diet ( 400 mg daily)
more common in the summer
PREDISPOSING FACTORS • Achieved by eliminating milk/dairy products
• Diet: large amount of calcium, oxalate • Provide acid-ash diet to acidify urine
• Increased uric acid levels - Cranberry or prune juice
- Meat
• Sedentary lifestyles, immobility
- Eggs
• Family history of gout or calculi - Poultry
• Hyperparathyroidism Fish
CLINICAL FINDINGS Grapes
 Abdominal pain or flank pain Whole grains
 Renal colic Take vitamin A & C, Folic acid supplements and
 severe pain in the kidney area radiating Riboflavin
down the flank to the pubic area
 Hematuria, frequency, urgency, nausea DIET MODIFIED/STONE
 History of prior associated health problems OXALATE STONES
 gout, parathyroidism, immobility, Avoid excess intake of foods/fluids high in
dehydration, UTI oxalate
 Diaphoresis - Tea
 Pallor - Chocolate
 Grimacing - Rhubarb
 Vomiting - Spinach
 Pyuria if infection is present • Maintain alkaline-ash diet to alkalinize urine
- Milk
MEDICAL MANAGEMENT - Vegetables
1. SURGERY - Fruits except prunes, cranberries and plums
A. PERCUTANEOUS NEPHROSTOMY
Tube is inserted through skin and underlying tissues URIC ACID STONES
into renal pelvis to remove calculi.  Uric acid is a metabolic product of purines
B. PERCUTANEOUS NEPHROLITHOTOMY  Reduce foods high in purine
Delivers U/S waves thorough a probe placed on the - Liver, brains, kidneys, venison, shellfish, meat
calculus soups, gravies,legumes and whole grains
C. PERCUTANEOUS ULTRASONIC  Maintain alkaline urine
LITHOTRIPSY (PUL) -  Alkaline-ash diet
Nephroscope is inserted through skin into NURSING CARE
kidney.Ultrasonic waves disintegrate stones that are Administer Allopurinol (Zyloprim) as ordered.
then remove by suction and irrigation. - to decrease uric acid production
4. EXTRACORPOREAL SHOCK-WAVE - force fluids when giving Allopurinol
LITHOTRIPSY (ESWL) Encourage daily weight-bearing exercise
- Client is placed in water and exposed to shock Provide client teaching and discharge planning
waves that disintegrate stones so that they can be concerning:
passed with urine.This procedure is non-invasive. - Prevention of urinary stasis by EOF esp. in hot
weather and during illness, mobility,
NURSING CARE voiding whenever the urge is felt and at least twice
a. Strain all urine through gauze to detect during the night.
stones and crush all clots. - Adherence to prescribed diet.
 - Need for routine U/A (at least every 3-4 months) - Diet: high calorie, low protein
- Need to recognize and report S/Sx of recurrence
- hematuria, flank pain RENAL FAILURE
NURSING CARE A. Pre-Renal
Provide care ff a nephrolithotomy or PUL  Hypotention
- Change dressings frequently during the first  Cardiogenic shock
24 hours after a nephrolithotomy.  Acute vasoconstriction
- Maintain patency of ureteral catheter as well as  Hemorrhage
urethral catheter to prevent hydronephrosis.  Burn
- Encourage use of incentive spirometry and  Septicemia
coughing and deep breathing to prevent atelectasis.  CHF
B. Renal
PYELONPHRITIS  Acute tubular necrosis
Inflammation of the renal pelvis & parenchyma,  DM
commonly caused by bacterial invasion  Malignant hypertension
 Acute glumerular nephritis
Acute Infection  Tumor
- usually ascends from the lower urinary tract or  Blood transfusion reaction
following an invasive procedure of the urinary tract  Hypercalcemia
- can progress to bacteremia or chronic  Nephrotoxins
pyelonephritis C. Post-Renal
ASSESSMENT  Calculi
 Fever & Chills  Tumor
 N/V  Blood clots
 CVA tenderness, flank pain on the affected  BPH
side  Strictures
 Headache, muscular pain, dysuria  Trauma
 Frequency & urgency  Anatomic malfornation

Chronic Infection ACUTE RENAL FAILURE

- Major cause is ureterovesical reflux CLINICAL FINDINGS
- Result of recurrent infections is eventual A. Oliguric phase
parenchymal  Hypernatremea
deterioration and possible renal failure  Hypocalcemia
 Hyperkalemia
ASSESSMENT  Hyperphosphatemia
1. Client usually unaware of the disease  Hypermanesemia
2. May have bladder irritability  Metabolic acidosis
3. Chronic fatigue B. Diuretic phase
4. Slight dull ache over the kidneys  Hyponatremia
5. Eventually develops hypertension, atrophy  Hypokalemia
of the kidneys  Hypercalcemia
6. Azotemia C. Convalescence phase
 normal urine volume
NURSING CARE  increase LOC
1. Monitor I & O  BUN stable and normal
2. EOF  May develop CHF
3. Encourage adequate rest NURSING CARE
4. Administer antibiotics, analgesics as • Monitor fluid and electrolyte balance.
ordered. • Monitor alteration in fluid volume.
5. Support client and significant others and
• Promote optimal nutritional status
explain the possibility of dialysis, transplant
options if significant renal deterioration. • Prevent complications from impaired mobility
6. Provide client teaching and discharge • Prevent fever and infection
planning: • Support client/S.O. & reduce/relieve anxiety
- Medication regimen
  Seizures
CHRONIC RENAL FAILURE  Abnormal reflexes
GENERAL INFORMATION  Administer Aluminum hydroxide gels as
• Progressive, irreversible destruction of the ordered.
kidneys that continues until nephrons  Amphogel, AlternaGEL
are replaced by scar tissue.  Promote/maintain maximal cardiovascular
• Loss of renal function is gradual. function.
PREDISPOSING FACTORS  Provide care for client receiving dialysis.
• Recurrent infections
DIALYSIS
• Exacerbations of nephritis GENERAL INFORMATIO
• Urinary tract obstructions • Removal by artificial means of metabolic
• Diabetes mellitus wastes, excess electrolytes and excess fluid
• Hypertension from clients with renal failure.
PRINCIPLES
CLINICAL FINDINGS o DIFFUSION
Nausea and vomiting Diarrhea or constipation o OSMOSIS
Decreased urinary output Dyspnea o ULTRAFILTRATION
Stomatitis Hypotension (early)
Hypertension (later) Lethargy
Convulsions Memory impairment PURPOSES
Pericardial friction rub CHF • Remove the end products of protein
metabolism from blood.
CLINICAL FINDINGS • Maintain safe levels of electrolytes.
STAGE 1
• Correct acidosis and replenish the blood
 Diminished renal reserve
STAGE 2 bicarbonate system.
 Renal insufficiency • Remove excess fluid from the blood.
 Hypokalemia TYPES
 Hypovolemia o Hemodialysis
STAGE 3 o Peritoneal dialysis
 End stage
 Increase LOC HEMODIALYSIS
 BUN stable and normal GENERAL INFORMATION
 May develop CRF o Shunting of blood from the client’s vascular
system through an artificial dialyzing system
DIAGNOSTIC TESTS and return of dialyzed blood to the client’s
Urinalysis circulation.
- CHON, Na and WBC elevated o Dialysis coil acts as the semi-permeable
- Specific gravity, platelets and Ca decreased membrane.
MEDICAL MANAGEMENT o Dialysate is a specially prepared solution.
a. Diet restrictions
b. Multivitamins NURSING CARE:
c. Hematinics (BEFORE and DURING HEMODIALYSIS)
d. Aluminum hydroxide gels 1. Have client void.
e. Antihypertensives 2. Chart client’s weight.
NURSING CARE 3. Assess vital signs before and every 30 mins.
 Prevent neurologic complications. during procedure.
 Promote optimal GI function. 4. Withhold antihypertensives, sedatives, and
 Monitor/prevent alteration in F/E. vasodilators.to prevent hypotensive episode
 Promote maintenance of skin integrity. (unless ordered otherwise).
 Monitor for bleeding complications, and 5. Ensure bed rest with frequent position changes
prevent injury. for comfort.
 Assess for hyperphosphatemia. 6. Inform client that headache and nausea may
 Paresthesias occur.
 Muscle cramps
 7. Monitor closely for signs of bleeding since
blood has been heparinized for procedure.
NURSING CARE:(POST- DIALYSIS)
• Chart client’s weight.
• Assess for complications.
A. HYPOVOLEMIC SHOCK
- may occur as a result of rapid removal or
ultrafiltration of fluid from the intravascular
compartment.
B. DIALYSIS DISEQUILIBRIUM SYNDROME
- Urea is removed more rapidly from the blood
than from the brain.
Assess for nausea, vomiting, elevated BP,
disorientation, leg cramps, and peripheral
paresthesias.
PERITONEAL DIALYSIS
GENERAL INFORMATION
Introduction of a specially prepared dialysate
solution into the abdominal cavity, where the
peritoneum acts as a semi-permeable membrane
between the dialysate and blood into the abdominal
vessels.
NURSING CARE
1. Chart client’s weight.
2. Assess V/S before, q15 min during first
exchange, &qH thereafter.
3. Assemble specially prepared dialysate
solution with added medications.
4. Have client void.
5. Warm dialysate solution to body
temperature.
6. Assist physician with trocar insertion.
• Inflow: Allow dialysate to flow unrestricted
into peritoneal cavity.
- 10-20 minutes
• Dwell: Allow fluid to remain in peritoneal
cavity for prescribed period
- 30-45 minutes
• Drain: Unclamp outflow tube and allow to
flow by gravity.
NURSING CARE
• Observe characteristics of dialysate
outflow.
a. CLEAR PALE YELLOW
- normal
b. CLOUDY
- infection, peritonitis
c. BROWNISH
- bowel perforation
d. BLOODY
- common during first few exchanges
- ABNORMAL: if continuous
• MIO and maintain records.
• Assess for complications
NURSING CARE
A. PERITONITIS
B. RESPIRATORY DIFFICULTY
C. PROTEIN LOSS
- Most serum proteins pass through the peritoneal
membrane and are lost in the dialysate fluid.
- Monitor serum protein levels closely.
CONTINIUOUS AMBULATORY PERITONEAL
DIALYSIS
GENERAL INFORMATION
1. A continuous type of peritoneal dialysis at home
by the client or significant others.
2. Dialysate is delivered from flexible plastic
containers through a permanent peritoneal
catheter.
3. Following infusion of the dialysate into the
peritoneal cavity, the bag is folded and tucked
away during the dwell period.
NURSING CARE
• Provide client teaching and discharge planning
concerning:
- Need to assess the permanent peritoneal catheter for
complications:
a. Dialysate leak
b. Exit site infection
c. Bacterial/Fungal contamination
d. Obstruction
• Adherence to high-protein (if indicated), well-
balanced diet.
• Importance of periodic blood chemistries.
• Daily weights.
KIDNEY TRANSPLANTATION
GENERAL INFORMATION
• Transplantation of a kidney from a donor to
recipient to prolong the life of person with
renal failure.
SOURCES OF DONOR SELECTION
• Living relative with compatible serum and
tissue studies, free from systemic infection
and emotionally stable.
• Cadavers with good serum and tissue
crossmatching, free from renal disease,
neoplasms and sepsis, absence of
ischemia/trauma.
NURSING CARE: PRE-OP
• Provide routine pre-op care.
• Discuss the possibility of post-op
dialysis/immunosuppressive drug therapy with
client and significant others.
NRSG CARE: POST-OP
• Provide routine post-op care.
 • Monitor fluid and electrolyte balance - Acne
carefully. NURSING CARE: POST-OP
- Monitor I & O hourly and adjust IV fluid • Assess for signs of rejection.
administration Note for:
accordingly. - Decreased urine output
- Anticipate possible massive diuresis. - Fever/pain over transplant site
• Encourage frequent and early ambulation. - Edema
• Monitor V/S esp. temperature and report - Sudden weight gain
significant changes. - Increasing BP
- Generalized malaise
• Provide mouth care and Nystatin
- Rise in serum creatinine
(Myostatin) mouthwashes for - Decrease in creatinine clearance
Candidiasis.
• Provide client teaching and discharge planning
• Administer immunosuppressive agents as
concerning:
ordered. - Medication regimen
A. CYCLOSPORINE (SANDIMMUNE) - S/Sx of tissue rejection and the need to
- does not cause significant bone marrow report it immediately to the physician
depression. - Dietary restrictions
Assess for: - Restricted Na and calories
- Hypertension - Increased CHON
- Hypermagnesemia - Daily weights
- Hyperkalemia - Daily measurements of I & O
- Decreased bicarbonate - Resumption of activity and avoidance of contact
- Neurologic functioning sports in which the transplanted kidney may be injured
B. AZATHIOPRINE (IMURAN)
Assess for: NEPHRECTOMY
- Anemia GENERAL INFORMATION
- Leukopenia
• Surgical removal of an entire kidney.
- Thrombocytopenia
- Oral lesions INDICATIONS
C. CYCLOPHOSPHAMIDE (CYTOXAN) • Renal tumor
Assess for: • Massive trauma
- Alopecia • Removal for a donor
- Hypertension • Polycystic kidneys
- Kidney/Liver toxicity NURSING CARE: PRE-OP
- Leukopenia
• Provide routine pre-op care.
D. ANTILYMPHOCYTIC GLOBULIN (ALG) • Ensure adequate fluid intake.
ANTITHYMOCYTIC GLOBULIN (ATG) • Assess electrolyte values and correct any
Assess for: imbalances
- Fever before surgery.
- Chills • Avoid nephrotoxic agents in any diagnostic
- Anaphylactic shock tests.
- Hypertension • Advise client to expect flank pain after surgery
- Rash
if
- Headache
retroperitoneal approach (flank incision) is used.
E. CORTICOSTEROIDS (PREDNISONE,
 Explain that the client will have chest
METHYLPREDNISOLONE Na SUCCINNATE
tube if thoracic approach is used.
[SOLU-MEDROL])
 Provide routine post-op care.
Assess for:
 Assess urine output every hour.
- PUD and GI bleeding
 Observe urinary drainage on dressing
- Na/water retention
and estimate amount.
- Muscle weakness
 Weigh daily.
- Delayed wound healing
 Maintain adequate functioning of chest
- Mood alterations
drainage, ensure adequate
- Hyperglycemia
 oxygenation and prevent - Normal: <4 ng/ml
pulmonary complications. • Cystoscopy
 Administer analgesics as ordered. - reveals enlargement of gland and obstruction of
 Encourage early ambulation. urine flow
 Teach client to splint incision while NURSING CARE
turning, coughing, and deep • Administer antibiotics as ordered.
breathing.
• Provide client teaching concerning medications
 Teach client teaching and
discharge planning concerning: - Terazocin (Hytrin)
- Prevention of urinary stasis - relaxes bladder spincter and makes it easier to
- Maintenance of acidic urine urinate
- Avoidance of activities that might cause trauma - may cause hypotension and dizziness
to remaining kidney - Finasteride (Proscar)
- contact sports, horse back riding - shrinks enlarged prostate
- No lifting of heavy objects for at least 6 months • Force fluids.
- Need to urine output, flank pain on unoperative • Provide care for the catheterized client.
side, hematuria • Provide care for the client with prostatic
• Teach client teaching and discharge surgery.
planning
concerning: PROSTATIC SURGERU
- Need to notify physician if cold or other GENERAL INFORMATION
infection present for more than 3 days • Indicated for benign prostatic hypertrophy and
- Medication regimen and avoidance of OTC prostatic cancer
drugs that may be nephrotoxic (except with TYPES
physician approval) 1. TRANSURETHRAL RESECTION
2. SUPRAPUBIC PROSTATECTOMY
DISORDER OF MALE REPRODUCTIVE ORGAN 3. RETROPUBIC PROSTATECTOMY
4. RADICAL PERINEAL PROSTATECTOMY
BENIGN PROSTATIC HYPERTROPHY NURSING CARE: PRE-OP
GENERAL INFORMATION 1. Provide routine pre-op care.
• Most common problem of the male 2. Information about the procedure & the
reproductive system expected post-op care, including catheter
- occurs in 50% of men over age 50 drainage, irrigation, and monitoring of
- 75% of men over age 75 hematuria is discussed.
ETIOLOGY 3. Reinforce what surgeon has told
• Unknown client/significant others regarding effects of
- may be related to hormonal mechanism surgery on sexual function.
CLINICAL FINDINGS 4. Bowel prep
• Nocturia 5. Force fluids, administer antibiotics, acid-ash
diet to eradicate UTI.
• Frequency
• Decreased force and amount of urinary NURSING CARE: POST-OP
stream 1. Provide routine post-op care.
• Hesitancy 2. Maintain patency of urethral catheter placed
- difficulty in starting voiding after surgery
• Hematuria 3. Prevent Infection
• Enlargement of prostate gland upon 4. Relieve pain
palpation by digital rectal exam 5. Reduce anxiety
DIAGNOSTIC TESTS 6. Health education and health maintenance
• Urinalysis
- alkalinity increased
- specific gravity normal or increased
• BUN and creatinine elevated
- if long standing BPH
• Prostate-specific antigen (PSA) elevated