Unit 8
Renal Conditions
Part 1
Gordons Functional Health Pattern
Elimination Pattern
Do Case Studies from Critical Thinking Book Before Class!
1st CS on pg:327 Acute Renal Failure
2nd CS on pg:307 ESRD
3rd CS on pg:331 UTI
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Common Fluid and Electrolyte
Disturbances in Renal Disorders
• Fluid volume loss or excess
• Protein deficit
• Electrolyte abnormalities including Na+, K+, Ca++,
Mg++, bicarbonate, and phosphorus
• See Table 44-1
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Question
The most accurate indicator of fluid loss or gain in an
acutely ill patient is which of the following?
a. Abdominal girth
b. Weight
c. Skin turgor
d. Level of consciousness
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Glomerular Diseases
• An inflammation of the glomerular capillaries
• Acute glomerulonephritis
• Chronic glomerulonephritis
• Nephrotic syndrome
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Acute Glomerulonephritis
• Postinfectious glomerulonephritis, rapidly
progressive glomerulonephritis, and membranous
glomerulonephritis
• Manifestations include hematuria, edema,
azotemia, proteinuria, and hypertension
• May be mild or may progress to acute renal
failure
• Medical management includes supportive care
and dietary modifications; treat cause, if
appropriate, using antibiotics, corticosteroids,
and immunosuppressants
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Sequence of Events in
Acute Glomerulonephritis
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Nursing Management—Acute
Glomerulonephritis
• Patient assessment
• Maintain fluid balance
• Fluid and dietary restrictions
• Patient education
• Follow-up care
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Chronic Glomerulonephritis
• Causes include repeated episodes of acute glomerular
nephritis, hypertensive nephrosclerosis, hyperlipidemia,
and other causes of glomerular damage
• Some patients are asymptomatic for years; as
glomerular damage increases, signs and symptoms of
renal insufficiency and renal failure develop
• Abnormal laboratory test results include urine with
fixed specific gravity, casts, and proteinuria; electrolyte
imbalances; and hypoalbuminemia
• Medical management is determined by symptoms
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Nursing Management of
Chronic Glomerulonephritis
• Assessment
• Potential fluid and electrolyte imbalances
• Cardiac status
• Neurologic status
• Emotional support
• Teaching self-care
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Nephrotic Syndrome
• Any condition that seriously damages the
glomerular membrane and results in increased
permeability to plasma proteins
• Results in hypoalbuminemia and edema
• Causes include chronic glomerulonephritis, diabetes
mellitus with intercapillary glomerulosclerosis,
amyloidosis, lupus erythematosus, multiple
myeloma, and renal vein thrombosis
• Medical management includes drug and dietary
therapy
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Sequence of Events in
Nephrotic Syndrome
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Renal Failure
• Results when the kidneys cannot remove wastes
or perform regulatory functions
• A systemic disorder that results from many
different causes
• Acute renal failure is a reversible syndrome that
results in decreased glomerular filtration rate (GFR)
and oliguria
• Chronic renal failure (ESRD) is progressive;
irreversible deterioration of renal function results
in azotemia
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Causes of Acute Renal Failure
• Hypovolemia
• Hypotension
• Reduced cardiac output and heart failure
• Obstruction of the kidney or lower urinary tract
• Obstruction of renal arteries or veins
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Causes of Chronic Renal Failure
• Diabetes mellitus
• Hypertension
• Chronic glomerulonephritis
• Pyelonephritis or other infections
• Obstruction of urinary tract
• Hereditary lesions
• Vascular disorders
• Medications or toxic agents
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Question
Tell whether the following statement is true or false.
Hypercalcemia is the most life-threatening of the fluid and
electrolyte changes that occur in patients with renal
disturbances.
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Treatment Options for Renal Failure
• Hemodialysis
• Peritoneal dialysis
• Continuous renal replacement therapies (CCRT)
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Hemodialysis System
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Hemodialysis Catheter
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Internal Arteriovenous Fistula and Graft
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Continuous Venovenous Hemofiltration
With Dialysis
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Peritoneal Dialysis
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Peritoneal Dialysis (cont.)
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Question
The movement of solute (waste products) from an area of
higher concentration to an area of lower concentration is
which of the following?
a. Anuria
b. Diffusion
c. Osmosis
d. Ultrafiltration
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Nursing Management of the Hospitalized
Patient on Dialysis
• Protect vascular access; assess site for patency and
signs of potential infection, and do not use it for blood
pressure or blood draws
• Monitor fluid balance indicators and monitor IV therapy
carefully; keep accurate I&O and IV administration
pump records
• Assess for signs and symptoms of uremia and
electrolyte imbalance; regularly check lab data
• Monitor cardiac and respiratory status carefully
• Monitor blood pressure; antihypertensive agents must
be held on dialysis days to avoid hypotension
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Nursing Management of the Hospitalized
Patient on Dialysis (cont.)
• Monitor all medications and medication dosages
carefully; avoid medications containing potassium and
magnesium
• Address pain and discomfort
• Implement stringent infection control measures
• Monitor dietary sodium, potassium, protein, and fluid;
address individual nutritional needs
• Provide skin care: prevent pruritus; keep skin clean and
well moisturized; trim nails and avoid scratching
• Provide CAPD catheter care
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Nursing Process—Assessment of the
Patient With Renal Failure
• Fluid status
• Nutritional status
• Patient knowledge
• Activity tolerance
• Self-esteem
• Potential complications
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Nursing Process—Diagnosis of the
Patient With Renal Failure
• Excess fluid volume
• Imbalanced nutrition
• Deficient knowledge
• Risk for situational low self-esteem
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Collaborative Problems/Potential
Complications
• Hyperkalemia
• Pericarditis
• Pericardial effusion
• Pericardial tamponade
• Hypertension
• Anemia
• Bone disease and metastatic calcifications
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Nursing Process—Planning the Care of the
Patient With Renal Failure
• Goals include maintaining IBW without excess
fluid, maintenance of adequate nutritional intake,
increased knowledge, participation in activities
within tolerance, improved self-esteem, and
absence of complications
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Question
As renal failure progresses and the GFR falls below 50
mL/min, which change occurs?
a. Metabolic acidosis
b. Hypokalemia
c. Hypercalcemia
d. Hypophosphatemia
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Excess Fluid Volume
• Assess for signs and symptoms of fluid volume
excess; keep accurate I&O and daily weight
records
• Limit fluid to prescribed amounts
• Identify sources of fluid
• Explain to patient and family the rationale for the
restriction
• Assist patient in coping with the fluid restriction
• Provide or encourage frequent oral hygiene
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Imbalanced Nutrition
• Assess nutritional status, weight changes, and lab data
• Assess patient nutritional patterns and history; note
food preferences
• Provide food preferences within restrictions
• Encourage high-quality nutritional foods while
maintaining nutritional restrictions
• Assess and modify intake related to factors that
contribute to altered nutritional intake, ie, stomatitis or
anorexia
• Adjust medication times related to meals
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Risk for Situational Low Self-Esteem
• Assess patient and family responses to illness and
treatment
• Assess relationships and coping patterns
• Encourage open discussion about changes and
concerns
• Explore alternate ways of sexual expression
• Discuss role of giving and receiving love, warmth,
and affection
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Question
A patient receiving peritoneal dialysis is complaining of pain
with rebound tenderness. The dialysate drainage is
cloudy. This symptom is indicative of which acute
complication?
a. Hernia
b. Bleeding
c. Leakage
d. Peritonitis
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Kidney Surgery
• Preoperative considerations
• Perioperative concerns
• Postoperative management
– Potential hemorrhage and shock
– Potential abdominal distention and paralytic ileus
– Potential infection
– Potential thromboembolism
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Patient Positioning and Incisional
Approaches
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Renal Transplantation
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Postoperative Nursing Management
• Assessment: include all body systems, pain, fluid, and
electrolyte status; patency and adequacy of urinary
drainage system
• Diagnoses: ineffective airway clearance, ineffective
breathing pattern, acute pain, fear and anxiety,
impaired urinary elimination, and risk for fluid
imbalance
• Complications: bleeding, pneumonia, infection, and
DVT
• See Chart 44-9
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Interventions
• Pain relief measures and analgesic medications
• Promote airway clearance and effective breathing pattern
by appropriate pain relief, deep-breathing coughing
exercises, and incentive spirometry and positioning
• Monitor UO and maintain potency of urinary drainage
systems
• Use strict asepsis with catheter and appropriate
techniques in providing all care
• Monitor for signs and symptoms of bleeding
• Encourage leg exercises, early ambulation, and monitor
for signs of DVT
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Patient Teaching
• Instruct both patient and family
• Care of drainage system
• Strategies to prevent complications
• Signs and symptoms
• Follow-up care
• Fluid intake
• Health promotion and health screening
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Renal Cancer
• Accounts for 3% of U.S. cancer deaths
• Risk factors include male sex, increased BMI, tobacco use
• Manifestations include hematuria, pain, and mass in flank
• Treatments
– Surgery: radical nephrectomy, laparoscopic
nephrectomy, and partial nephrectomy
– Renal artery embolization
– Palliative radiation therapy
– Use of chemotherapy is limited
– Developing therapies
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