Med surg
Renal System
● Diet for dialysis pts - high in protein, low in Phosphorus (milk, dairy, yogurt), low in Na+,
restrict fluids (d/t existing fluid retention)
● Functions of the kidney include
1. Filters blood
2. Maintains electrolyte imbalances
3. Maintains acid-base balances
4. Synthesizes Vitamin D
5. Stimulates RBC production
6. Regulates BP
7. Excretes waste products
Parts of the kidneys
● Nephron - the functional unit of the kidneys
● Glomerulus - responsible for filtering the blood
● Tubules - absorb and secrete electrolytes, water, amino acids, and urea
● Antidiuretic hormone (ADH) - helps retain fluids in the body to maintain normal blood
volume
● Aldosterone - also helps retain sodium and water for normal blood volume
Diagnostics for renal disease
● Obtain a 24 hour urinalysis
● Renal biopsy - definitive diagnosis; evaluates a piece of the kidney to determine type of
disease and severity
● CBC & BMP labs
● Check GFR (glomerular filtration rate)
● May have a renal US - to evaluate kidney function
● Renal CT
Acute Kidney injury
● Pre- renal disease: Hypovolemia/Hypotension and decreased CO
● Renal disease: acute tubular necrosis, acute interstitial nephritis, acute
glomerulonephritis
● Post renal disease: uterine, bladder neck, and urethral obstruction
●
Glomerulonephritis - group of diseases that affects both kidneys; causes inflammation of
the glomerulus and small blood vessels
○ 3rd leading cause of renal failure
○ Causes of glomerular disease (glomerulonephritis):
- Infection ; strep throat and UTI
- Autoimmune disease ; Lupus, sickle cell, Hodgkin’s, diabetes
- Obstruction; nephrolithiasis (aka renal calculi or kidney stones)
- Malformations ; vesicoureteral reflux - the abnormal flow of urine from the
bladder back to the tubules
- Drug toxicity; NSAIDs, ASA, ibuprofen
○ S/S of glomerulonephritis:
- Can be asymptomatic! (obtain 24 hr urinalysis)
- Check for proteinuria & hematuria
- Azotemia; high levels of nitrogen and urea in the blood
- Assess for oliguria (insufficient UO) and anuria (inability to urinate)
- HTN and edema (d/t fluid retention)
Acute Poststreptococcal Nephritis (APSGN)
● The most common cause of glomerulonephritis - strep throat (infection of tonsils,
pharynx, or skin)
● Strep can lead to glomerular disease 5 to 21 days post-infection - group A betahemolytic streptococci
○ The body’s immune response to fight off this bacteria can cause it to settle in the
glomeruli
● S/S of acute postreptococcal nephritis:
○ Dark reddish brown urine ; edema/ swelling in eyes, hands and feet ; oliguria ;
fatigue d/t mid anemia (low levels of iron in the blood will be seen)
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●
Diagnostics - obtain a throat culture*, skin culture, kidney biopsy
Interventions - manage the symptoms (edema and HTN)
○ Self limiting after 4 wks; treat any active strep infection identified w antibiotics
○ Diuretics for edema
○ Teach low Na+ diet for HTN
○ Good personal hygiene to prevent spread of infection
● The long term goal for glomerulonephritis is to maintain normal renal function before it
progresses to end stage renal failure. Intervene fast!
Lupus Nephritis - secondary cause of glomerulonephritis
● Causes inflammation and scarring of small blood vessels in the kidneys
● May manifest as nephrotic syndrome (seen w proteinuria)
● S/S of lupus nephritis:
○ Edema, HTN, proteinuria, hematuria
○ Could lead to complete renal failure
○ Kidney transplant possible after 3 mnths dialysis
● Treatment - steroids
Hydronephrosis
● Kidneys become swelled and ureters are blocked d/t buildup of urine
● Could be d/t renal calculi, tumor, enlarged prostate, blood clot or infection
● S/S - difficulty w/ urination and abd. pain
Benign Prostate Hypertrophy (BPH)
● An obstructional cause of glomerulonephritis - enlarged prostate that causes obstructed
urine flow
● Treatment
○ Transurethral resection of the prostate (TURP) - surgical procedure to remove
apart of the prostate that is impeding w urine flow
○ Catheter placement
Nephrolithiasis - aka renal calculi
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●
Another obstructional cause to glomerulonephritis
Risk factors - male gender, age 20 to 55, fam hx, summer season
○ More than 50% of cases will have recurrence
● S/S of nephrolithiasis
○ Back, flank, or abd. Pain w Guarding
○ Fever
○ Dehydration and N/V
● Complications of renal calculi
○ Obstruction (leads to hydronephrosis)
○ Sepsis
○ Abscess formation
○ Ureteral scarring and stenosis
○ Ureteral perforation
○ Chronic kidney disease
● Diagnostics of nephrolithiasis
○ Obtain a CT of the abdomen WITHOUT contrast
○ Labs: BUN and Cr will be elevated
○ Urinalysis (UA) - detects RBCs, WBCs (pyuria), crystals, casts, minerals,
bacteria
○ 24 hour UA - detects inc. uric acid, Ca+, and phosphorus levels
● Interventions - Urine strainer
○ Confirm size of the stone w imaging greater than 5 mm
○ Analgesics for pain; antibiotics for infection
○ Assess kidney function w UO
○ Administer Tamsulosin (Flomax) - helps w urinary retention
○ Lithotripsy - uses shock waves to break up calculi; teach that hematuria and
ureteral stent placement will remain post-op for 2 wks
○ Nephrostomy tube
○ Cystoscopy w stent placement
● Teachings and other nursing interventions
○ Urine strainer
○ Diet - low purine (meats and fish), low oxalate (dark greens, tomatoes, beets),
low Ca+ (milk and dairy), low Vitamin D (inc. absorption of Ca+)
○ Inc fluids and ambulation
Malformations that cause glomerulonephritis
● Vesicoureteral reflux - defect in the ureters that causes urine flow to move upward
● Renal fusion - horseshoe kidney; has two excretory systems and two ureters
Pyelonephritis
● Originates from infection in the lower urinary tract
● Bacteria causes - E.coli ; Proteus; Klebsiella ; Enterobacter
● Also caused by pre-existing problems - BPH, vesicoureteral reflux, renal calculi
● Can lead to chronic kidney disease
● S/S of pyelonephritis
○ Chills, fever, vomit, malaise, flank pain
○ Lower urinary tract symptoms - dysuria, frequency, urgency
○ Costovertebral angle tenderness (“I buy low pies at costco”)
● S/S of chronic Pyelonephritis
○ Inc. urination (polyuria), weight loss, anorexia, fatigue, and headache
● Diagnostics
○ Obtain a urine and blood culture before antibiotic admin
○ UA - detects pyuria, bacteriuria, hematuria, and WBC casts
○ CBC labs - detects leukocytosis (high WBC)
○ Obtain kidney US (not a CT) - to detect for abnormalities, hydronephrosis,
abscess or stones
● Interventions
○ Admin broad spectrum antibiotics (get a urine and blood culture first)
■ Cipro and Levaquin (fluroquinolones class)
■ Teach to finish all prescribed antibiotics. Do not double doses
■ Follow up w urine culture results
○ Inc. fluids, admin antipyretics, and obtain cultures and imaging
■ Teach 8 glasses of water intake/day
○ Provide rest
Tubulointerstitial injury
● The causes
○ Acute tubular necrosis - caused by drug abuse, sepsis, and hypotension
○ Acute tubular nephritis - caused by drug abuse and infection
○ Heavy metal nephropathies - contain lead, copper, gold, iron, mercury, arsenic
○ Reflux nephropathies - vesicoureteral reflux
○ Multiple myeloma - cx of plasma cells
● S/S of tubulointerstitial diseases
○ Can be asymptomatic
○ Obtain a UA for - proteinuria
○ Electrolyte imbalances - hyperkalemia, hyperchloremia, metabolic acidosis
○ Increased urination - polyuria
Acute tubular necrosis
● Assessment
○ Pt will have decreased LOC; coma; delusion; lethargy; drowsiness or confusion
○ Decreased UO (oliguria) or anuria
○ Generalized edema and swelling - fluid retention
○ N/V
● Causes of acute tubular necrosis
○ Hypotension, prolonged pre renal state, or sepsis
● diagnosis/ treatment
○ Treat the symtpoms (diuretics for edema and HTN)
○ Avoid NSAIDs and ACE inhibitors (nephrotoxic)
○ Dialysis if needed - 80% will recover if intervened early
Acute tubular nephritis
●
Causes renal tubular dysfunction that will lead to renal dysfunction - renal function can
be reversed, but the tubulars will remain damaged
● 95% cases are d/t infection or allergic drug reaction
● S/S of acute tubular nephritis
○ Polyuria and nocturia
● Interventions
○ Give antibiotics if the cause was infection
○ Steroid admin for allergic drug reaction
Chronic Kidney disease
● Diagnosed w a GFR > 60 for at least 3 months; permanent kidney damage
● Risk factors
○ Prolonged medication use
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Fam hx→ if a pt has fam hx and renal disease, it is already considered chronic
○ Diabetes
○ HTN
○ Autoimmune disease (sickle cell, lupus, rheumatoid arthritis)
○ Recurrent UTIs
○ Malformations
Stages of Chronic renal disease
1. Kidney damage w normal GFR over 90
2. Mild → GFR is 60-89
3. Moderate → GFR is 30-59
4. Severe → GFR is 15 to 29
5. End stage renal disease → GFR is less than 15; requires dialysis
● Any acute kidney disease can progress to chronic
● Demerol (pain med) cannot be excreted by the kidneys
● Depression is frequent in chronic kidney disease
Hereditary chronic kidney diseases
● Polycystic kidney disease - an autosomal dominant disorder
○ Can damage the liver heart or intestines
○ End stage renal disease will onset at age 60 in both men and women
○ S/S of PKD - feeling of heaviness in back side or abd; HTN; hematuria; UTI or
urinary calculi; chronic pain; palpable enlarged kidneys on assessment
○ Diagnostics - obtain a renal US (best measure); identify s/s and fam hx; CT scan
○ Interventions ■ prevent UTIs (good peri care)
■ Nephrectomy: may be needed for pain, bleeding, or infection
■ Kidney transplant - the only cure for PKD
■ Restrict fluids (pt cannot excrete fluids)
■ Admin hypertensives
■ Bedrest w/ restricted activity (can cause more damage to kidneys)
●
Sickle cell nephropathy - caused by glomerular hypertrophy, ingestion of analgesics,
and glomerulosclerosis
○ Can lead to nephrotic syndrome
○ S/S of sickle cell nephropathy - renal tubular acidosis; proteinuria and hematuria;
HTN; renal failure; hyperkalemia
○ Interventions - monitor BUN and Cr levels w GFR (kidney function); pain
management w analgesics; adequate hydration status - teach to drink 8
glasses/day; avoid foods high in K+
○ Complications of sickle cell nephropathy may lead to- secondary
hyperparathyroidism; anemia (low iron levels in the blood); uricemia (high uric
acid levels); metabolic acidosis
○ Admin Kayexalate - to deplete excess K+ in the body; teach to expect diarrhea
as a normal SE
○ Phosphorus levels should be kept under 4.5; teach to limit phosphorus foods
(meats and organs)
■
Phosphate binder drugs include - Renvela, Renagela, PhosLo → teach to
take w meals to limit calcium absorption
■
Hyperphosphatemia - high phosphorus in the blood; causes muscle
weakness or calculi in dialysis pts
○ Albumin - keep levels above 4.0.; found in milk, fish, eggs, yogurt
○ Teach to limit protein intake in end stage renal disease or CKD - diet should be
low in Na+, phosphorus, and protein (avoid meats)
● Nursing interventions for CKD
○ Keep BP under 130/80. Monitor BS levels
○ Prevent progression to CKD
Complications of kidney disease
● Nephrotic syndrome - complication
○ S/S: massive proteinuria (greater than 3 g PCR or greater than 300 mg MCR);
edema; serum hypoalbuminemia; hypercoagulability (blood clot formation in renal
vein)
○ Primary causes- glomerular disease and multiple myeloma (paraproteinemia)
○ Secondary causes- DM, lupus, viral infections (Hep B, hep C, HIV), amyloidosis,
preeclampsia (pregnancy induced HTN)
○ Nursing interventions for nephrotic syndrome
■ Control the primary disease
■ Diuretics for edema
■ Diet intake- low fat, low Na+, low cholesterol w high fruits and veggies
■ Hyperlipidemia management - lipitor/statins
■ Blood thinners/anticoagulants - warfarin (coumadin)
■ Support for altered body image
Kidney cancer
● Usually asymptomatic - can later be seen w hematuria, flank pain, palpable mass in
flank area, weight loss, fever, HTN, and anemia
● Diagnosis - MRI, CT scan, biopsy, renal US, blood tests to meas GFR
● Intervention - may need nephrectomy
End stage renal disease
● CKD: stage 5 is end stage; GFR less than 15
● S/S of end stage renal disease - tremors; anorexia; N/V; severe body aches
● Treatment - peritoneal dialysis; may need hemodialysis or kidney transplant
Renal replacement therapies
● Hemodialysis access
○ Arteriovenous fistula - a permanent access that connects an artery to a vein
(surgical procedure); the forearm is the preferred site
○ Arteriovenous graft - uses a synthetic tunnel under the skin; can be used early
than an arteriovenous fistula; used in 3 to 6 weeks
○ Dialysis access- never do a BP, stick a needle, or place a tourniquet on the
affected arm w the access!
■ Limit needle sticks in upper extremities of CKD pts
○ Catheters - a temporary access where a cath is placed in a large central vein;
subclavian or internal jugular vein preferred
○ Peritoneal dialysis - dialysis fluid (dialysate) is infused into the abdomen via the
peritoneal cavity thru a catheter
■ Follow standard precautions - dec. risk for infection
■ Wash hands often
■ Good personal hygiene
■ Check cath for kinks or loops if drainage is not flowing properly; never
palpate the adomen
● Nursing interventions and teachings:
○ Restrict fluid intake - teach to chew gum to dec thirst
○ Keep BS levels low
○ Decrease Na+ intake
Urinary System
Infections
● Urethritis - difficult to diagnose in females
○ Risk factors- infection; Trichomonas (STI); Monilial infection (yeast infection);
Chlamydia and gonorrhea
○ S/S of urethritis - dysuria (pain w urination); urinary retention; irritation and
erythema of the vulva; perineal pain; or may be ASYMPTOMATIC
○ Interventions - medical management
■ If cause was bacterial - Sulfamexathoxazole or nitrofurantoin
■ If cause was trichomonoas- give metronidazole (Flagyl) or clotrimazole
■ If cause was monillial - give Nystatin (mycostatin) or Fluconazole
■ If cause was chlamydia - give Azithromycin or Doxycycline
● Cystitis - aka UTI; caused by E.coli in most cases or staph (rare cause)
○ S/S of cystitis (aka UTI) - dysuria, urinary frequency, hematuria (blood clots in
urine), urinary urgency, suprapubic pain
●
Cystitis complicated UTI - caused by pregnancy, pyelonephritis, nephrolithiasis (renal
calculi) and STIs (chlamydia, gonorrhea, herpes); more aggressive and recurrent
○ Interventions- treat based on bacteria
■ Sulfamexathoxazole for bacterial
■ Give Nitrofurantoin for E.coli, Klebsiella, staph aureus
Urinary Incontinence
● Risk higher in women over age 50 - not a normal sign of aging!
● Complications - confusion/depression; infection; urinary retention; fecal impaction;
restricted mobility; atrophic vaginitis
● Interventions - lifestyle mods
○ Weight loss; smoking cessation; avoid caffeine; bowel schedule regimen;
schedule bowel and urine training program
○ Pelvic floor/ Kegal exercises (for urinary incontinence)
○ Biofeedback therapy
○ Use of pessary device to dec. incontinence in females; penile compression
devices in males
○ High fiber diet (prevent constipation)
Bladder Cancer
● Risk factors - male gender, caucasian, smoking, exposures to dyes and rubbers, long
term indwelling catheter use, females who have had radiation for cervical cx, or recurrent
UTIs or renal calculi episodes
● Assessment - palpable tumors in the bladder; microscopic or painless hematuria (if
chronic); dysuria frequency and urgency
● Diagnostics of bladder cx
○ Cystoscopy and biopsy - definitive diagnosis
○ UA, US, MRI, CT to rule out any other diseases
● Interventions
○ Radiation, chemo, or immunotherapy
○ Transurethral resection of the bladder tumor (TURBT)
○ Cystectomy w urinary revision