Objectives
At the end of this session students will be able
to:
Describe the nursing management of
patients with acute and chronic renal failure.
Describe the nursing management of the
renal transplant.
Develop a postoperative plan of nursing care
and teaching plan for the patient undergoing
kidney surgery and transplantation
Kidney
Glomerulus
This is the only
place in the system
where the blood is
actually filtered.
Blood pressure is
used to push
plasma through
capillary walls and
into the Bowmans
capsule.
Proximal tubule
Nutrients (salts, vitamins, etc.) are
moved out of the tubule through active
transport.
Water follows the nutrients by osmosis.
Functions of kidney
Excretion
~ remove nitrogenous
waste i.e. urea, salts, water,
heat, toxic substance
Osmoregulation
~ controlling amount of
water in body
~ maintain osmotic
potential
Question
Is the following statement True or
False?
The most accurate indicator of fluid
loss or gain in an acutely ill patient is
weight.
Answer
True
The most accurate indicator of fluid
loss or gain in an acutely ill patient is
weight. An accurate daily weight
must be obtained and recorded. A 1
kg weight gain is equal to 1000 mL of
retained fluid.
Definition
Acute Renal Failure is defined as
sudden, rapid, potentially reversible
deterioration of renal function.
Chronic Renal Failure is the end
result of progressive, irreversible loss
of functioning renal tissue.
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
Causes of Chronic Renal Failure
Diabetes mellitus
Hypertension
Chronic glomerulonephritis,
Pyelonephritis or other infections
Obstruction of urinary tract
Hereditary lesions
Causes of Chronic Renal Failure
Vascular disorders
Medications or toxic agents
Collaborative Problems/Potential
Complications
Hyperkalemia
Pericarditis
Pericardial effusion
Pericardial tamponade
Hypertension
Anemia
Bone disease and metastatic
calcifications
The Care of the Patient with Renal Failure
Assessment
Fluid status
Nutritional status
Patient knowledge
Activity tolerance
Self-esteem
Potential complications
Nursing Management
Inspect neck veins for engorgement,
and extremites abdomen,
sacrum,and eyelids for oedema.
Administer prescribed medication
which may include antibiotics,
calcium supplements
Assess for infection, especially of the
respiratory and urinary tracts
Nursing Management
Monitor vital signs
Weigh patient daily
Assess for signs and symptoms of
fluid volume excess, and keep
accurate I&O
Nursing Management
Explain to patient and family the
rationale for the fluid restriction
Assist patient to cope with the fluid
restriction
Provide or encourage frequent oral
hygiene
Nursing Management
Assess nutritional status; weight
changes and lab data
Assess patient nutritional patterns and
history; note food preferences
Encourage high-quality nutritional
foods while maintaining nutritional
restrictions
Nursing Management
Assess and modify intake related to
factors that contribute to altered
nutritional intake, eg, stomatitis or
anorexia
Adjust medication times related to meals
Encourage high calorie, low-protein,
low-sodium and low potassium snacks
between meals
Nursing Management
Assess for evidence of inadequate
protein intake: edema, delayed wound
healing and decreased serum albumin
levels
Provide patient with food preferences
within dietary restrictions
Assist patient to cope with the
discomforts resulting from fluid
restrictions
Nursing Management
Monitor urinary output and urine
specific gravity.
Monitor for signs of hypervolemia and
hypovolemia because the regulating
capacity of the kidneys are inadequate.
Instruct patient about the importance
of following prescribed diet and
avoiding foods high in potassium.
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
Risk for Situational Low Self Esteem
Explore alternate ways of sexual
expression
Discuss role of giving and receiving
love, warmth, and affection
Acute Glomerulonephritis
Refers to a group of kidney diseases
in which there is an inflammatory
reaction in the glomeruli
tea coloured urine
Oliguria
Fatigue and anorexia
Hypertension
Clinical
Manifestations
Anemia
Possible headache
Puffiness of face
Edema of extremities
Nursing Management
Monitor vital signs, intake and output
and maintain dietary restrictions
Encourage rest
Administer medications as ordered
and evaluate patients response to
antihypertensives, diuretics and
antibiotics.
Nursing Management
Monitor for signs of heart failure,
distended neck veins, tachycardia,
enlarged and tender liver
Observe for hypertensive
encephalopathy and any evidence of
seizure activity.
Kidney Surgery
Preoperative considerations
Perioperative concerns
Postoperative management
Potential hemorrhage and shock
Potential abdominal distention and
paralytic ileus
Kidney Surgery
Potential infection
Potential thromboembolism
Patient Positioning and Incisional
Approaches
Renal Transplantation
Postoperative Nursing Management
Assessment: include all body systems,
pain, fluid and electrolyte status, and
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
Postoperative Nursing Management
Complications: bleeding ,
pneumonia, infection, and DVT
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
Nursing Management
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
Nursing Management
Monitor for signs and symptoms of
bleeding
Encourage leg exercises, early
ambulation, and monitor for signs of
DVT
Use strict asepsis with catheter and
appropriate technique in providing all
care
Patient Teaching
Instruct both patient and family
Drainage system care
Strategies to prevent complications
Signs and symptoms
Follow-up care
Fluid intake
Health promotion and health screening
Renal Transplant
Kidney transplantation is performed on
patients with chronic kidney failure, or
end-stage renal disease (ESRD).
ESRD occurs when:
a disease, disorder, or congenital
condition damages the kidneys so that
they are no longer capable of
adequately removing fluids and wastes
from the body
Renal Transplant
or of maintaining the proper level of
certain kidney-regulated chemicals in
the bloodstream. Without long-term
dialysis or a kidney transplant, ESRD
is fatal.
Open nephrectomy
The surgical procedure to remove a kidney
from a living donor is called a nephrectomy.
In a traditional, open nephrectomy, the
kidney donor is administered general
anesthesia and a 610-in (15.225.4-cm)
incision through several layers of muscle is
made on the side or front of the abdomen.
Open nephrectomy
The kidney and an attached section of
ureter are removed from the donor. A
similar procedure is used to harvest
cadaver kidneys, although both
kidneys are typically removed at once,
and blood and cell samples for tissue
typing are also taken.
Kidney transplant
During the transplant operation, the
kidney recipient is typically under
general anesthesia and administered
antibiotics to prevent possible
infection. A catheter is placed in the
bladder before surgery begins.
Kidney transplant
An incision is made in the flank of
the patient, and the surgeon implants
the kidney above the pelvic bone and
below the existing, non-functioning
kidney by suturing the kidney artery
and vein to the patient's iliac artery
and vein.
Kidney transplant
The ureter of the new kidney is attached
directly to the kidney recipient's bladder.
Once the new kidney is attached, the
patient's existing, diseased kidneys may or
may not be removed, depending on the
circumstances surrounding the kidney failure.
Barring any complications, the transplant
operation takes about three to four hours.
Complications
Infection
Acute rejection appears within the first 6
months after transplantation and affects
approximately 15% of transplanted kidneys
Chronic rejection occurs more than 1 year
after transplantation
Complications
Hypertension
Renal vein thrombosis is typically an early
complication presenting as graft tenderness and
edema
Class Activity
Formulate nursing interventions for
the following diagnoses:
Risk for anxiety related to transplant
experience, potential for rejection,
and side effects of medications.
Class Activity
Risk for ineffective management of
therapeutic regimen related to
insufficient knowledge of prevention
of infection, and dietary
management.
Risk for Fear related to diagnosis and
anticipated surgical experience.
Patient Teaching
Explain and reinforce symptoms of
rejection- fever, chills, sweating,
hypertension, lassitude, weight gain,
decrease in urine output, peripheral
oedema.
Stress that follow up care after
transplantation is a life long process.
Patient Teaching
Advise avoidance of contact sports
for life to prevent trauma to the
transplanted kidney.
Patient Teaching
Instruct patient and family about
prescribed immuno-suppressants and
complication of therapy.
Observe for symptoms of urine leak,
such as sudden loss of kidney
function, pain over transplant site
and copious drainage of yellow fluid
from the wound
Bladder Cancer
Bladder cancer involves any one of
the following cell carcinomas in the
lining of the bladder: transitional,
squamous, or adenocarcinoma. This is
most common form of cancer
associated with the urinary track.
Bladder cancer is rare before the age
of 50 and occurs more frequently in
men than in women.
Risk Factors
Carcinogens in the workplace, such
as dyes, rubber, leather, paint
Recurrent bacterial infection of
urinary tract
Smoking
Bladder stones
Risk Factors
High urinary Ph
High cholesterol intake
Cancers arising from prostate, colon
and rectum in males
Clinical Manifestations
Hematuria
Pain and a mass in the flank
Dull pain in the back from pressure
produced by compression of the
ureter
Extension of the tumour into the
perirenal area
Clinical Manifestations
Haemorrhage into the kidney tissues
Colicky pains occur if mass or clot of
tumour cells passes down from the
ureter
Unexplained weight loss
Clinical Manifestations
Gross, painless hematuria
Urinary frequency
Urgency
Dysuria
Pelvic or back pain with metastasis
Treatment
Chemotherapy
There are three main ways that
chemotherapy can be used to treat
muscle-invasive bladder cancer. It
can be used:
before radiotherapy and surgery to
shrink the size of any tumours
Treatment
in combination with radiotherapy
before surgery (chemoradiation)
to slow the spread of incurable,
advanced bladder cancer .
Treatment
Radiotherapy that is used to shrink
tumours and achieve a cure is given
by a machine that beams the
radiation at the bladder (external
radiotherapy).
Class activity
Formulate nursing interventions for
the following nursing diagnoses:
Risk for infection related to invasive
procedures.
Nursing Management
Risk for Impaired Skin Integrity related to
the effects of radiation and chemotherapy,
immunologic deficits, decreased nutrient
intake and anemia.
Risk for Sexual Dysfunction related to deficit
of knowledge / skills about alternative
responses to health transition, decreased
function / structure, the effects of treatment.
Urinary Calculi
Kidney stones (renal lithiasis) are small,
hard deposits that form inside your
kidneys. The stones are made of mineral
and acid salts. Kidney stones have many
causes and can affect any part of your
urinary tract from your kidneys to your
bladder. Often, stones form when the
urine becomes concentrated, allowing
minerals to crystallize and stick together.
Risk Factors
Family or personal history.
Dehydration.
Certain diets. Too much sodium in your
diet increases the amount of calcium
your kidneys must filter and significantly
increases your risk of kidney stones.
Being obese. High body mass index
(BMI)
Risk Factors
Digestive diseases and surgery.
Gastric bypass surgery, inflammatory
bowel disease or chronic diarrhea can
cause changes in the digestive
process that affect your absorption of
calcium and water, increasing the
levels of stone-forming substances in
your urine.
Clinical Manifestations
A kidney stone may not cause
symptoms until it moves around
within your kidney or passes into
your ureter the tube connecting
the kidney and bladder. At that point,
these signs and symptoms may
occur:
Clinical Manifestations
Severe pain in the side and back,
below the ribs
Pain that spreads to the lower
abdomen and groin
Pain that comes in waves and
fluctuates in intensity
Pain on urination
Pink, red or brown urine
Clinical Manifestations
Cloudy or foul-smelling urine
Nausea and vomiting
Persistent urge to urinate
Urinating more often than usual
Fever and chills if an infection is
present
Diagnostic Tests
Blood tests. Blood tests may reveal
too much calcium or uric acid in your
blood.
Urine tests. Tests of your urine,
such as the 24-hour urine collection,
may show that you're excreting too
many stone-forming minerals or too
few stone-preventing substances.
Diagnostic Tests
Imaging tests. Imaging tests may
show kidney stones in your urinary
tract.
Analysis of passed stones. You
may be asked to urinate through a
strainer to catch stones that you
pass. Lab analysis will reveal the
makeup of your kidney stones.
Health Education/Promotion
Lifestyle changes
You may reduce your risk of kidney
stones if you:
Drink water throughout the day.
For people with a history of kidney
stones, doctors usually recommend
passing about 2.6 quarts (2.5 liters)
of urine a day.
Health Education/Promotion
Eat fewer oxalate-rich foods. If
you tend to form calcium oxalate
stones, your doctor may recommend
restricting foods rich in oxalates.
These include rhubarb, beets, okra,
spinach, sweet potatoes, nuts, tea,
chocolate and soy products.
Health Education/Promotion
Continue eating calcium-rich
foods, but use caution with
calcium supplements. Calcium in
food doesn't have an effect on your
risk of kidney stones. Continue eating
calcium-rich foods unless your doctor
advises otherwise.
Health Education/Promotion
Ask your doctor before taking
calcium supplements, as these have
been linked to increased risk of
kidney stones. You may reduce the
risk by taking supplements with
meals.
Health Education/Promotion
Choose a diet low in salt and
animal protein. Reduce the amount
of salt you eat and choose non
animal protein sources, such as
legumes.
References
Nachman, P.H, et al. (2008).Primary
glomerular disease. In: Brenner BM.
Brenner & Rector's The Kidney. 8th
ed. Philadelphia, Pa.: Saunders
Elsevier.
Nettina. S (2010). Lippincott Manual
of Nursing Practice. 9th ed. Lippincott
Williams & Wilkins.
References
Stoller, M.L. (2008)Urinary stone
disease. In: Tanagho EA, et al. Smith's
General Urology. 17th ed. New York,
N.Y.: McGraw-Hill Medical.
References
Watkins, R,W. (2007)Urolithiasis
(kidney and bladder stones). In: Rakel
D. Integrative Medicine. 2nd ed.
Philadelphia, Pa.: Saunders Elsevier.
Worcester EM, et al.(2008).
Nephrolithiasis. Primary Care: Clinics
in Office Practice. 35, 369
