Renal Nursing
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KOMUNITAS BLOGGER UNIVERSITAS SRIWIJAYA
THE GENITOURINARY SYSTEM Urological Assessment Key Signs and Symptoms of
Urological Problems EDEMA - associated with fluid retention - renal dysfunctions usually
produce ANASARCA PAIN Suprapubic pain= bladder Colicky pain on the flank= kidney
HEMATURIA Painless hematuria may indicate URINARY CANCER! Early-stream hematuria
- urethral lesion Late-stream hematuria - bladder lesion DYSURIA - Pain with urination lower UTI POLYURIA - More than 2 Liters urine per day OLIGURIA - Less than 400 mL per
day ANURIA - Less than 50 mL per day Urinary Urgency Urinary retention Laboratory
examination 1. Urinalysis 2. BUN and Creatinine levels of the serum 3. Serum electrolytes
Diagnostic examination 1. Radiographic 2. IVP 3. KUB x-ray 4. KUB ultrasound 5. CT and
MRI 6. Cystography Implementation Steps for selected problems Provide PAIN relief ?
Assess the level of pain ? Administer medications usually narcotic ANALGESICS Maintain
Fluid and Electrolyte Balance ? Encourage to consume at least 2 liters of fluid per day ? In
cases of ARF, limit fluid as directed ? Weigh client daily to detect fluid retention Ensure
Adequate urinary elimination ? Encourage to void at least every 2-3 hours ? Promote
measures to relieve urinary retention: 1. Alternating warm and cold compress 2. Bedpan 3.
Open faucet 4. Provide privacy 5. Catheterization if indicated Urinary Tract Infection (UTI)
Bacterial invasion of the kidneys or bladder (CYSTITIS) usually caused by Escherichia coli
Predisposing factors include Poor hygiene Irritation from bubble baths Urinary reflux
Instrumentation Residual urine, urinary stasis Urinary Tract Infection (UTI)
PATHOPHYSIOLOGY The invading organism ascends the urinary tract, irritating the mucosa
and causing characteristic symptoms Ureter - ureteritis Bladder - cystitis Urethra - urethritis
Pelvis - pyelonephritis Assessment findings Low-grade fever Abdominal pain Enuresis
Pain/burning on urination Urinary frequency Hematuria Assessment findings: Upper UTI
Fever and CHIILS Flank pain Costovertebral angle tenderness Laboratory Examination
Urinalysis Urine Culture Nursing interventions Administer antibiotics as ordered. Provide
warm baths and allow client to void in water to alleviate painful voiding. Force fluids. Nurses
may give 3 liters of fluid per day. Encourage measures to acidify urine (cranberry juice, acidash diet). n Provide client teaching and discharge planning concerning 1. Avoidance of tub
baths 2. Avoidance of bubble baths that might irritate urethra 3. Importance for girls to wipe
perineum from front to back 4. Increase in foods/fluids that acidify urine. Pharmacology 1.
Sulfa drugs Highly concentrated in the urine Effective against E. coli! 2. Quinolones
Nephrolithiasis/Urolithiasis Presence of stones anywhere in the urinary tract calcium oxalate
uric acid Nephrolithiasis/Urolithiasis Predisposing factors Diet: large amounts of calcium and
oxalate Increased uric acid levels Sedentary life-style, immobility Family history of gout or
calculi Hyperparathyroidism Pathophysiology Supersaturation of crystals due to stasis Stone
formation May pass through the urinary tract OBSTRUCTION, INFECTION and
HYDRONEPHROSIS Assessment findings 1. Abdominal or flank pain 2. Renal colic radiating
to the groin 3. Hematuria 4. Cool, moist skin 5. Nausea and vomiting Diagnostic tests 1. KUB
Ultrasound and X-ray: pinpoints location, number, and size of stones 2. IVP: identifies site of
obstruction and presence of non-radiopaque stones 3. Urinalysis: indicates presence of
bacteria, increased protein, increased WBC and RBC (hematuria) Medical management 1.
Surgery a. Percutaneous nephrostomy: tube is inserted through skin and underlying tissues
into renal pelvis to remove calculi. b. Percutaneous nephrostolithotomy: delivers ultrasound
waves through a probe placed on the calculus. 2. Extracorporeal shock-wave lithotripsy:
delivers shock waves from outside the body to the stone, causing pulverization a. Pain
management : Morphine or Meperidine b. Diet modification Nursing interventions 1. Strain all
urine through gauze to detect stones and crush all clots. 2. Force fluids (3000—4000
cc/day). 3. Encourage ambulation to prevent stasis. 4. Relieve pain by administration of
analgesics as ordered and application of moist heat to flank area. 5. Monitor intake and
output 6. Provide modified diet, depending upon stone consistency: Calcium, Oxalate and
Uric acid stones Calcium stones - limit milk/dairy products; provide acid-ash diet to acidify
urine (cranberry or prune juice, meat, eggs, poultry, fish, grapes, and whole grains) Oxalate
stones - avoid excess intake of foods/ fluids high in oxalate (tea, chocolate, rhubarb,
spinach); maintain alkaline-ash diet to alkalinize urine (milk; vegetables; fruits except prunes,
cranberries, and plums) Uric acid stones - educe foods high in purine (liver, beans, kidneys,
venison, shellfish, meat soups, gravies, legumes); maintain alkaline urine 7. Administer
allopurinol (Zyloprim) as ordered, to decrease uric acid production. 8. Provide client teaching
and discharge planning concerning: ? Prevention of Urinary stasis by maintaining increased
fluid intake especially in hot weather and during illness; mobility; voiding whenever the urge
is felt and at least twice during the night ? Adherence to prescribed diet ? Need for routine
urinalysis (at least every 3—4 months) ? Need to recognize and report signs/
symptoms of recurrence (hematuria, flank pain). Acute Renal Failure Sudden interruption of
kidney function to regulate fluid and electrolyte balance and remove toxic products from the
body PATHOPHYSIOLOGY ? Pre-renal failure ? Intra-renal failure ? Post-renal failure
Prerenal CAUSE: Factors interfering with perfusion and resulting in diminished blood flow
and glomerular filtrate, ischemia, and oliguria; include CHF, cardiogenic shock, acute
vasoconstriction, hemorrhage, burns, septicemia, hypotension, anaphylaxis Intrarenal
CAUSE: Conditions that cause damage to the nephrons; include acute tubular necrosis
(ATN), endocarditis, diabetes mellitus, malignant hypertension, acute glomerulonephritis,
tumors, blood transfusion reactions, hypercalcemia, nephrotoxins (certain antibiotics, x-ray
dyes, pesticides, anesthetics) Postrenal CAUSE: Mechanical obstruction anywhere from the
tubules to the urethra; includes calculi, BPH, tumors, strictures, blood clots, trauma, and
anatomic malformation Three phases of acute renal failure Oliguric phase Diuretic phase
Convalescence or recovery phase Four phases of acute renal failure (Brunner and Suddarth)
Initiation phase Oliguric phase Diuretic phase Convalescence or recovery phase Assessment
findings: The Three Phases of Acute Renal Failure 1. Oliguric phase Urine output less than
400 cc/24 hours duration 1—2 weeks Manifested by dilutional hyponatremia,
hyperkalemia, hyperphosphatemia, hypocalcemia, hypermagnesemia, and metabolic
acidosis Diagnostic tests: BUN and creatinine elevated 2. Diuretic phase Diuresis may occur
(output 3—5 liters/day) due to partially regenerated tubule’s inability to
concentrate urine Duration: 2—3 weeks; manifested by hyponatremia, hypokalemia,
and hypovolemia Diagnostic tests: BUN and creatinine slightly elevated 3. Recovery or
convalescent phase Renal function stabilizes with gradual improvement over next
3—12 months Laboratory findings: ? Urinalysis: Urine osmo and sodium ? BUN and
creatinine levels increased ? Hyperkalemia ? Anemia ? ABG: metabolic acidosis Nursing
interventions ? Monitor fluid and Electrolyte Balance ? Reduce metabolic rate ? Promote
pulmonary function ? Prevent infection ? Provide skin care ? Provide emotional support
Nursing interventions Monitor and maintain fluid and electrolyte balance. a. Measure l &
O every hour. note excessive losses in diuretic phase b. Administer IV fluids and electrolyte
supplements as ordered. c. Weigh daily and report gains. d. Monitor lab values; assess/treat
fluid and electrolyte and acid-base imbalances as needed Monitor alteration in fluid volume.
a. Monitor vital signs, PAP, PCWP, CVP as needed. b. Weigh client daily. c. Maintain strict I
& O records. Assess every hour for hypervolemia a. Maintain adequate ventilation. b.
Restrict FLUID intake c. Administer diuretics and antihypertensives Promote optimal
nutritional status. a. Weigh daily. b. Administer TPN as ordered. c. With enteral feedings,
check for residual and notify physician if residual volume increases. d. Restrict protein intake
to 1 g/kg/day e. Restrict POTASSIUM intake d. HIGH CARBOHYDRATE DIET, calcium
supplements Prevent complications from impaired mobility (pulmonary embolism, skin
breakdown, and atelectasis) Prevent fever/infection. a. Assess for signs of infection. b. Use
strict aseptic technique for wound and catheter care. Support client/significant others and
reduce/ relieve anxiety. a. Explain pathophysiology and relationship to symptoms. b. Explain
all procedures and answer all questions in easy-to-understand terms c. Refer to counseling
services as needed Provide care for the client receiving dialysis. Provide client teaching and
discharge planning concerning a. Adherence to prescribed dietary regimen b. Signs and
symptoms of recurrent renal disease c. Importance of planned rest periods d. Use of
prescribed drugs only e. Signs and symptoms of UTI or respiratory infection need to report to
physician immediately Chronic Renal Failure Gradual, Progressive irreversible destruction of
the kidneys causing severe renal dysfunction. The result is azotemia to UREMIA
Predisposing factors: a. DM= worldwide leading cause b. Recurrent infections c
Exacerbations of nephritis d. urinary tract obstruction e. hypertension Pathophysiology
STAGE 1= reduced renal reserve, 40-75% loss of nephron function STAGE 2= renal
insufficiency, 75-90% loss of nephron function STAGE 3= end-stage renal disease, more
than 90% loss. DIALYSIS IS THE TREATMENT! Assessment findings 1. Nausea, vomiting;
diarrhea or constipation; decreased urinary output 2. Dyspnea 3. Stomatitis 4. Hypertension
(later), lethargy, convulsions, memory impairment, pericardial friction rub Diagnostic tests: a.
24 hour creatinine clearance urinalysis b. Protein, sodium, BUN, Crea and WBC elevated c.
Specific gravity, platelets, and calcium decreased D. CBC= anemia Medical management 1.
Diet restrictions 2. Multivitamins 3. Hematinics and erythropoietin 4. Aluminum hydroxide
gels 5. Anti-hypertensive 6. Anti-seizures 7. DIALYSIS Nursing interventions Prevent
neurological complications. a. Assess every hour for signs of uremia (fatigue, loss of
appetite, decreased urine output, apathy, confusion, elevated blood pressure, edema of face
and feet, itchy skin, restlessness, seizures). b. Assess for changes in mental functioning. c.
Orient confused client to time, place, date, and persons; institute safety measures to protect
client from falling out of bed. d. Monitor serum electrolytes, BUN, and creatinine as ordered
Promote optimal GI function. a. Assess/provide care for stomatitis b. Monitor nausea,
vomiting, anorexia c. Administer antiemetics as ordered. Monitor/prevent alteration in fluid
and electrolyte balance Assess for hyperphosphatemia (paresthesias, muscle cramps,
seizures, abnormal reflexes), and administer aluminum hydroxide gels (Amphojel) as ordered
Promote maintenance of skin integrity. a. Assess/provide care for pruritus. b. Assess for
uremic frost (urea crystallization on the skin) and bathe in plain water Monitor for bleeding
complications, prevent injury to client. a. Monitor Hgb, hct, platelets, RBC. b. Hematest all
secretions. c. Administer hematinics as ordered. d. Avoid lM injections Promote/maintain
maximal cardiovascular function. a. Monitor blood pressure and report significant changes. b.
Auscultate for pericardial friction rub. c. Perform circulation checks routinely.
Promote/maintain maximal cardiovascular function. a. Administer diuretics as ordered and
monitor output. b. Modify drug doses Provide care for client receiving dialysis. DIALYSIS a
procedure that is used to remove fluid and uremic wastes from the body when the kidneys
cannot function Two methods Hemodialysis Peritoneal dialysis Nursing management 1. Meet
the patient\'s psychosocial needs 2. Remember to avoid any procedure on the arm with the
fistula (HEMO) 3. Monitor WEIGHT, blood pressure and fistula site for bleeding 4. Monitor
symptoms of uremia 5. Detect complications like infection, bleeding (Hepatitis B/C and HIV
infection in Hemodialysis) 6. Warm the solution to increase diffusion of waste products
(PERITONEAL) 7. Manage discomfort and pain 8. To determine effectiveness, check serum
creatinine, BUN and electrolytes Male reproductive disorders DIGITAL RECTAL
EXAMINATION- DRE Recommended for men annually with age over 40 years Screening
test for cancer Ask patient to BEAR DOWN TESTICULAR EXAMINATION Palpation of
scrotum for nodules and masses or inflammation BEGINS DURING ADOLESCENCE
Prostate specific antigen (PSA) Elevated in prostate cancer Normal is 0.2 to 4
nanograms/mL Cancer - over 4 BENIGN PROSTATIC HYPERPLASIA - Enlargement of the
prostate that causes outflow obstruction - Common in men older than 50 years old
Assessment findings 1. DRE: enlarged prostate gland that is rubbery, large and NON-tender
2. Increased frequency, urgency and hesitancy 3. Nocturia, DECREASE IN THE VOLUME
AND FORCE OF URINE STREAM Medical management 1. Immediate catheterization 2.
Prostatectomy 3. TRANSURETHRAL RESECTION of the PROSTATE (TURP) 4.
Pharmacology: alpha-blockers, alpha-reductase inhibitors. SAW palmetto Nursing
Intervention 1. Encourage fluids up to 2 liters per day 2. Insert catheter for urinary drainage
3. Administer medications – alpha adrenergic blockers and finasteride 4. Avoid
anticholinergics 5. Prepare for surgery or TURP 6. Teach the patient perineal muscle
exercises. Avoid valsalva until healing Nursing Intervention: TURP 1. Maintain the three way
bladder irrigation to prevent hemorrhage 2. Only initially the drainage is pink-tinged and
never reddish 3. Administer anti-spasmodic to prevent bladder spasms PROSTATE
CANCER - a slow growing malignancy of the prostate gland - Usually an adenocarcinoma This usualy spread via blood stream to the vertebrae Predisposing factor ? Age Assessment
Findings 1. DRE: hard, pea-sized nodules on the anterior rectum 2. Hematuria 3. Urinary
obstruction 4. Pain on the perineum radiating to the leg Diagnostic tests 1. Prostatic specific
antigen (PSA) 2. Elevated SERUM ACID PHOSPHATASE indicates SPREAD or Metastasis
Medical and surgical management 1. Prostatectomy 2. TURP 3. Chemotherapy: hormonal
therapy to slow the rate of tumor growth 4. Radiation therapy Nursing Interventions 1.
Prepare patient for chemotherapy 2. Prepare for surgery Nursing Interventions: Postprostatectomy 1. Maintain continuous bladder irrigation. Note that drainage is pink tinged
w/in 24 hours 2. Monitor urine for the presence of blood clots and hemorrhage 3. Ambulate
the patient as soon as urine begins to clear in color DOWNLOAD