Nur 216 Renal

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URINARY TRACT INFECTION
° Classification
° Etiology and pathophysiology
° Clinical manifestations
° Diagnostic studies
° Collaborative care and drug therapy
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URINARY TRACT INFECTION (UTI)
° Second most common bacterial disease
° Most common bacterial infection in women due to
shortened urethra
° Can occur in upper or lower Urinary area.

° Flank (costo vertebral angle) pain
° Both are of concern
^
URINARY TRACT INFECTION (UTI)
(CONT·D)
° Accounts for more than 8 million office visits per
year
° >100,000 people hospitalized annually due to UTI
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URINARY TRACT INFECTION (CONT·D)
° >15% patients who develop
gram-negative bacteria infection die
% of these caused by infections originating in
urinary tract

° Bladder and its contents are free of bacteria in
majority of healthy patients
° Minority of healthy individuals have colonizing
bacteria in bladder
Called Ú Ú Ú
Ú and does not justify
treatment

°

Úmost common pathogen
° Counts of 105 CFU/ml or more indicate
significant UTI
° Counts as low as 102 CFU/ml in a person with
signs/symptoms are indicative of UTI
° If recurrent, pt. should urinate after intercourse
to flush out bacteria

° Fungal and parasitic infections can cause UTIs
° Patients at risk
Immunosuppressed
Have diabetes
Undergone multiple antibiotic courses
Traveled to certain underdeveloped countries

CLASSIFICATION
° Upper versus lower
Upper tract
° Renal parenchyma, pelvis, and ureters
° Typically causes fever, chills, flank pain
° Example
° Pyelonephritis: Inflammation of renal parenchyma and
collecting system
° Assess Costovertebral angle for upper UTI
° RISK FOR SEPTIC SHOCK!!
° Pt Fluctuates temp, cool due to lack of blood flow and hot
due to fever
'
CLASSIFICATION
° Upper versus lower (cont·d)
Lower tract
° Lower urinary tract
° Usually no systemic manifestations
° Example
° Cystitis (inflammation of bladder wall)
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SITES OF INFECTIOUS PROCESSES
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CLASSIFICATION (CONT·D)
° Complicated versus uncomplicated
Uncomplicated
° Occurs in otherwise normal urinary tract
° Usually only involves the bladder

CLASSIFICATION
° Complicated versus uncomplicated (cont·d)
Complicated
° Those with coexisting presence of
° Obstruction
° Stones
° Catheters
° Existing diabetes/neurologic disease
° Pregnancy-induced changes
° Recurrent infection
^
° According to natural history
Initial infection
° First or isolated
° Uncomplicated UTI in person who never had one or
experiences one remote from a previous UTI (separated by

period of years)
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CLASSIFICATION
° Natural history (cont·d)
Recurrent
° Caused by second pathogen in a person who experienced a
previous infection that was eradicated
° If it occurs because original infection was not eradicated, it
is classified as unresolved bacteriuria or bacterial
persistence

° Unresolved bacteriuria
Occurs when
° Bacteria resistant to antibiotic
° Drug discontinued before bacteriuria is completely
eradicated
° Antibiotic agent fails to achieve adequate concentrations in
bloodstream or urine to kill bacteria

° Bacterial persistence
Occurs when
° Bacteria develop resistance to antibiotic agent
° Foreign body in urinary system allows bacteria to survive

ETIOLOGY AND PATHOPHYSIOLOGY
° Urinary tract above urethra normally sterile
° Defense mechanisms exist to maintain
sterility/prevent UTIs
Complete emptying of bladder
Ureterovesical junction competence
URETHRITIS: Infection of Urethra
Sx in men: Purulent discharge

° Defense mechanisms (cont·d)
Peristaltic activity
Acidic pH
High urea concentration
Abundant glycoproteins
'
(CONT·D)
° Alteration of defense mechanisms increases risk
of contracting UTI
° Predisposing factors
Factors increasing urinary stasis
° Examples: BPH, tumor, neurogenic bladder
Foreign bodies
° Examples: Catheters, calculi, instrumentation
"
° Predisposing factors (cont·d)
Anatomic factors
° Examples: Obesity, congenital defects, fistula
Compromising immune response factors
° Examples: Age, HIV, diabetes
)
° Predisposing factors (cont·d)
Functional disorders
° Example: Constipation
Other factors
° Examples: Pregnancy, multiple sex partners (women)

(CONT·D)
° Menopause factor in incidence
of UTI
Postmenopausal women have lower estrogen levels, Ņ
in vaginal lactobacilli, Ń in vaginal pH
° Overgrowth of other organisms results
Low-dose intravaginal estrogen replacement may be
effective in treating recurrent UTIs
^
(CONT·D)
° Organisms introduced via the ascending route
from the urethra and originate in the perineum
° Less common routes
Bloodstream
Lymphatic system
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(CONT·D)
° Gram-negative bacilli normally found in GI tract
common cause
° Urologic instrumentation allows bacteria to enter
urethra and bladder

(CONT·D)
° Contributing factor: Urologic instrumentation
Allows bacteria present in opening of urethra to enter
urethra or bladder
° Sexual intercourse promotes ´milkingµ of bacteria
from perineum and vagina
May cause minor urethral trauma
'
(CONT·D)
° Rarely result from hematogenous route
° For kidney infection to occur from hematogenous
transmission, must have prior injury to urinary
tract
Obstruction of ureter
Damage from stones
Renal scars
'
(CONT·D)
° Hospital-acquired UTI accounts for 1% of all
nosocomial infections
Causes
° Often:

° Seldom:
Ú
Catheter-acquired UTIs
° Bacteria biofilms develop on inner surface of catheter
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CLINICAL MANIFESTATIONS
° Symptoms related to either bladder storage or
bladder emptying
Bladder storage
° Urinary frequency
° Abnormally frequent (> every 2 hours)
° Urgency
° Sudden strong desire to void immediately
° Incontinence
° Loss or leakage or urine
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Bladder storage (cont·d)
° Nocturia
° Waking up 2 times at night to void
° Nocturnal enuresis
° Complaint of loss of urine during sleep
Bladder emptying
° Weak stream
° Hesitancy
° Difficulty starting the urine stream
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Bladder emptying (cont·d)
° Intermittency
° Interruption of urinary stream while voiding
° Postvoid dribbling
° Urine loss after completion of voiding
° Urinary retention
° Inability to empty urine from bladder
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Bladder emptying (cont·d)
° Dysuria
° Difficulty voiding
° Pain on urination
'
CLINICAL MANIFESTATIONS (CONT·D)
° Urine may contain visible blood or sediment,
giving cloudy appearance
° Flank pain, chills, and fever indicate infection of
upper tract
Pyelonephritis
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° In older adults
Symptoms often absent
Experience nonlocalized abdominal discomfort rather
than dysuria
May have cognitive impairment
Less likely to have a fever
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° Patients with significant bacteriuria
May have no symptoms
Nonspecific symptoms such as fatigue or anorexia
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DIAGNOSTIC STUDIES
° History and physical examination
° Dipstick urinalysis
Identify presence of nitrates, WBCs,
and leukocyte esterase
Culture and sensitivity
"
"
DIAGNOSTIC STUDIES (CONT·D)
° Urine for culture and sensitivity
(if indicated)
Clean-catch sample preferred
Specimen by catheterization or suprapubic needle
aspiration more accurate
Determine bacteria susceptibility to antibiotics
"
° Imaging studies
IVP or abdominal CT when obstruction suspected
"'
COLLABORATIVE CARE
DRUG THERAPY
° Antibiotics
Selected on empiric therapy or results of sensitivity
testing
Uncomplicated cystitis
° Short-term course (1 to days)
Complicated UTIs
° Requires long-term treatment (7 to 14 days)
° Bactrim is Antibiotic of choice, if allergic, use Cipro
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COLLABORATIVE CARE
DRUG THERAPY
° Antibiotics (cont·d)
Trimethoprim/sulfamethoxazole (TMP/SMX)
° Used to treat uncomplicated or initial
° Inexpensive
° Taken BID
°
resistance to TMP-SMX Ń
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COLLABORATIVE CARE
DRUG THERAPY
° Antibiotics (cont·d)
Nitrofurantoin (Macrodantin)
° Given three or four times a day
° Long-term use
° Pulmonary fibrosis
° Neuropathies
Fluoroquinolones
° Treat complicated UTIs
° Example: Ciprofloxacin (Cipro)
"
COLLABORATIVE CARE
DRUG THERAPY (CONT·D)
° Urinary analgesic
Pyridium
° Used in combination with antibiotics
° Provides soothing effect on urinary tract mucosa
° Stains urine reddish orange
° Can be mistaken for blood and may stain underclothing
° OTC AZO can be used
° Drink Cranberry juice
° Avoid spicy foods, acidic juices etc.
"^
COLLABORATIVE CARE
DRUG THERAPY
° Urinary analgesic (cont·d)
Urised
° Used in combination with antibiotics
° Used to relieve UTI symptoms
° Preparations with methylene blue tint urine blue or green
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COLLABORATIVE CARE
° Prophylactic or suppressive antibiotics
sometimes administered to patients with
repeated UTIs
"
COLLABORATIVE CARE
° Suppressive therapy often effective on short-term
basis
Limited because of antibiotic resistance ultimately
leading to breakthrough infections
)
NURSING MANAGEMENT
NURSING ASSESSMENT
° Health history
Previous UTIs, calculi, stasis, retention, pregnancy,
STDs, bladder cancer
Antibiotics, anticholinergics, antispasmodics
Urologic instrumentation
Urinary hygiene
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NURSING MANAGEMENT
NURSING ASSESSMENT
° Health history (cont·d)
N/V, anorexia, chills, nocturia, frequency, urgency
Suprapubic/lower back pain, bladder spasms,
dysuria, burning on urination
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NURSING MANAGEMENT
NURSING ASSESSMENT (CONT·D)
° Objective Data
Fever
Hematuria, foul-smelling urine, tender, enlarged
kidney
Leukocytosis, positive findings for bacteria, WBCs,
RBCs, pyuria, ultrasound, CT scan, IVP
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NURSING MANAGEMENT
NURSING DIAGNOSES
° Impaired urinary elimination
° Ineffective therapeutic regimen management
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NURSING MANAGEMENT
PLANNING
° Patient will have
Relief from lower urinary tract symptoms
Prevention of upper urinary tract involvement
Prevention of recurrence
))
NURSING MANAGEMENT
NURSING IMPLEMENTATION
° Health Promotion
Recognize individuals at risk
° Debilitated persons
° Older adults
° Underlying diseases (HIV, diabetes)
° Taking immunosuppressive drug or corticosteroids
° Wear cotton crotched underwear
° Wipe the right way, DUH !
)
NURSING MANAGEMENT
° Health Promotion (cont·d)
Emptying bladder regularly and completely
Evacuating bowel regularly
Wiping perineal area front to back
Drinking adequate fluids (15 ml/lb)
° 20% fluid comes from food
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NURSING MANAGEMENT
Cranberry juice or cranberry essence may help
decrease risk
Avoid unnecessary catheterization and early removal
of indwelling catheters
Aseptic technique must be followed during
instrumentation procedures
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NURSING MANAGEMENT
Wash hands before and after contact
Wear gloves for care of urinary system
Routine and thorough perineal care for all
hospitalized patients
Avoid incontinent episodes by answering call light
and offering bedpan at frequent intervals
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NURSING MANAGEMENT
NURSING IMPLEMENTATION (CONT·D)
° Acute Intervention
Adequate fluid intake
° Patient may think will worsen condition due to discomfort
° Dilutes urine, making bladder less irritable
° Flushes out bacteria before they can colonize

NURSING MANAGEMENT
° Acute Intervention (cont·d)
Avoid caffeine, alcohol, citrus juices, chocolate, and
highly spiced foods
° Potential bladder irritants

NURSING MANAGEMENT
Application of local heat to suprapubic or lower back
may relieve discomfort
Instruct patient about drug therapy and side effects

NURSING MANAGEMENT
Emphasize taking full course despite disappearance
of symptoms
Second or reduced drug may be ordered after initial
course in susceptible patients
'
NURSING MANAGEMENT
Instruct patient to watch urine for changes in color
and consistency and decrease in cessation of
symptoms
Counsel that persistence of lower tract symptoms
beyond treatment, onset of flank pain, or fever should
be reported immediately
"
NURSING MANAGEMENT
° Ambulatory and Home Care
Emphasize compliance with drug regimen
° Take as ordered
Maintain adequate fluids
Regular voiding (every to 4 hours)
Void after intercourse
)
NURSING MANAGEMENT
° Ambulatory and Home Care (cont·d)
Temporarily discontinue use of diaphragm
Instruct on follow-up care
Recurrent symptoms typically occur
1 to 2 weeks after therapy

NURSING MANAGEMENT
EVALUATION
° Use of nonanalgesic relief measures
° Appropriate use of analgesics
° Pass urine without urgency
° Urine free of blood
° Adequate intake of fluids
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° Inflammation of renal parenchyma and collecting
system
° Caused most commonly by bacteria
° Fungi, protozoa, or viruses infecting kidneys can

also cause
^
(CONT·D)
° Urosepsis
Systemic infection from urologic source
Prompt diagnosis/treatment critical
° Can lead to septic shock and death
° Septic shock: Outcome of unresolved
bacteremia involving gram-negative

organism
^
(CONT·D)
° Usually begins with colonization and infection of
lower tract via ascending urethral route
° Frequent causes

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Enterobacter
^
(CONT·D)
° Preexisting factor usually present
Vesicoureteral reflux
° Backward movement of urine from lower to upper urinary
tract
Dysfunction of lower urinary tract
° Obstruction from BPH
° Stricture
° Urinary stone
^'
(CONT·D)
° Commonly starts in renal medulla and spreads to
adjacent cortex
° Recurring episodes lead to scarred, poorly
functioning kidney and chronic pyelonephritis
^"
(CONT·D)
° One of most important risk factors
Pregnancy-induced physiologic changes in urinary
system
^)
° Mild fatigue
° Chills
° Fever
° Vomiting
° Malaise
^
° Flank pain
° Lower urinary tract symptoms characteristic of
cystitis
° Costovertebral tenderness usually present on
affected side
° Manifestations usually subside in a few days,
even without therapy
Bacteriuria and pyuria still persist
^^
DIAGNOSTIC STUDIES
° History
° Physical examination
Palpation for CVA pain
° Laboratory tests
Urinalysis
Urine for culture and sensitivity
CBC with differential
Blood culture (if bacteremia is suspected)
û
° Ultrasound
° CT scan
^
° Urinalysis shows pyuria, bacteriuria, and varying
degrees of hematuria
° WBC casts indicate involvement of renal
parenchyma
° CBC will show leukocytosis with increase in
immature bands
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° Imaging studies (IVP or CT) requiring
intravenous injection of contrast metals
Usually not obtained in early stages to prevent
possible spread of infection
° Ultrasonography of urinary system to identify
anatomic abnormalities or presence of
obstructing stone
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° Imaging studies also used to assess complications
of pyelonephritis
Impaired renal function
Scarring
Chronic pyelonephritis
Abscesses
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° If bacteremia is a possibility, close observation
and vitals monitoring are essential
° Prompt recognition and treatment of septic shock
may prevent irreversible damage or death
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COLLABORATIVE CARE
° Hospitalization for patients with
severe infections and complications
Such as nausea and vomiting with dehydration
° Signs/symptoms typically improve within 48 to
72 hours after starting therapy
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COLLABORATIVE CARE (CONT·D)
° Drug therapy
Antibiotics
° Parenteral in hospital to rapidly establish high drug levels
NSAIDs or antipyretic drugs
° Fever
° Discomfort
Urinary analgesics
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° Relapses may be treated with 6-week course of
antibiotics
° Follow-up urine culture and imaging studies
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° Reinfections treated as individual episodes or
managed with long-term therapy
Prophylaxis may be used for recurrent infection
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NURSING MANAGEMENT
NURSING ASSESSMENT
° Health history
Previous UTIs, calculi, stasis, retention, pregnancy,
STDs, bladder cancer
Antibiotics, anticholinergics, antispasmodics
Urologic instrumentation
Urinary hygiene
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NURSING MANAGEMENT
NURSING ASSESSMENT
° Health history (cont·d)
Nausea, vomiting, anorexia, chills, nocturia,
frequency, urgency
Suprapubic or lower back pain, bladder spasms,
dysuria, burning on urination
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NURSING MANAGEMENT
NURSING ASSESSMENT (CONT·D)
° Objective Data
Fever
Hematuria, foul-smelling urine, tender, enlarged
kidney
Leukocytosis, positive findings for bacteria, WBCs,
RBCs, pyuria, ultrasound, CT scan, IVP

NURSING MANAGEMENT
NURSING DIAGNOSES
° Acute pain
° Impaired urinary elimination

NURSING MANAGEMENT
PLANNING
° Patient will have
Relief of pain
Normal body temperature
No complications
Normal renal function
No recurrence of symptoms

NURSING MANAGEMENT
° Health Promotion
Early treatment for cystitis to prevent ascending
infections
° Patient with structural abnormalities is at high risk
° Stress for regular medical care
'
NURSING MANAGEMENT
° Ambulatory and Home Care
Need to continue drugs as prescribed
Need for follow-up urine culture
Identification of risk for recurrence or relapse
Encourage adequate fluids
"
NURSING MANAGEMENT
° Ambulatory and Home Care (cont·d)
Rest to increase comfort
Low-dose, long-term antibiotics to prevent relapses or
reinfections
Explain rationale to enhance compliance
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NURSING MANAGEMENT
EVALUATION
° Use of nonanalgesic relief measures
° Appropriate use of analgesics
° Pass urine without urgency
° Urine free of blood
° Adequate intake of fluids

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CASE STUDY
° 27-year-old female with urgency to urinate,
frequent urination, and urethral burning during
urination
° Symptoms began 48 hours ago
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CASE STUDY (CONT·D)
° Urine has strong odor and cloudy appearance
° History of recurring urinary tract infections since

22 years of age when she got married

° Allergic to penicillin
° Temperature 98.6° F orally
° Blood pressure 114/64 mm Hg

° Urinalysis results
Color: dark yellow
pH: 6.5
Nitrates: positive
Leukocytes: large amount
Trace occult blood
Urine culture:
>106 CFU/ml
° Sensitivity to ampicillin, nitrofurantoin, ciprofloxacin,
cephalexin, TMP-SMX

DISCUSSION QUESTIONS
1. What type of urinary tract infection does she

probably have?
2. Why might she be having recurring infections?

DISCUSSION QUESTIONS (CONT·D)
. What is the priority of care for her?
4. What teaching should be done

with her?
'
INTERSTITIAL CYSTITIS/PAINFUL
BLADDER SYNDROME
° Collaborative care and drug therapy
° Nursing management: Interstitial cystitis/painful
bladder syndrome
° For Tx: avoid acidic foods and caffeinated beverages.
° DMSO drug used to desensitize bladder therefore

reducing pain
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GLOMERULONEPHRITIS
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ACUTE POSTSTREPTOCOCCAL
GLOMERULONEPHRITIS
° Clinical manifestations and
complications

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GOODPASTURE SYNDROME
°Nursing and
collaborative management:
Goodpasture syndrome
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NEPHROTIC SYNDROME
° Etiology and clinical manifestations
° Collaborative care
° Nursing management: Nephrotic syndrome

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URINARY TRACT CALCULI
° Types
Endourologic procedure
Lithotripsy
Surgical therapy
Nutritional therapy
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NURSING MANAGEMENT
RENAL CALCULI
° Nursing assessment
° Nursing diagnoses
° Planning
° Nursing implementation
° Evaluation
° Clots, stones and strictures can obstruct
renal system backing up urine causing
toxicity cuz it is held in renal pelvis and
introduced back to bloodstream.
° KIDNEY STONES ARE VERY PAINFUL!!
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STRICTURES
° Ureteral strictures
° Urethral stricture
° Manifestation of Kidney stones:
° Unilateral PAIN!
° Dx by X-ray
° Tx: break it up, increased fluids collect
stones to identify source, do this by
straining urine.
° Staghorn or round shaped stones, staghorn
not passed easily, surgical removal.
° Hemorrhage post surgery can occur. Watch
for decreased BP.
° Drug of choice for pain during passing is IV
Morphine.
° If uric acid stone, avoid sardines, organ
meats, chicken, salmon, crab. See boxP1171
(purine)
° Tx: Extracorpeal shock-wave lithotripsy:P1172
° To help avoid recurrence of renal stones increase
fluid to 000 mL per day.

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° Kidneys need to be profussed or adequate removal of waste will not
occur!
NEPHROSCLEROSIS:
Only Sx will be Hypertension P1175
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° Cysts cause blockages and do not allow proper function of kidneys it
is decrased.
° Any drugs including NSAID·s, that are metabolized in Liver should
be avoided.
° Tx is Kidney Transplant

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POLYCYSTIC KIDNEY DISEASE

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KIDNEY CANCER
° Clinical manifestations and diagnostic studies
° Nursing and collaborative management:
Kidney cancer
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BLADDER CANCER
° Clinical manifestations and
diagnostic studies
° Nursing and collaborative
management: Bladder cancer
Surgical therapy
Radiation therapy and chemotherapy
Intravesical therapy
Risk factors:
Hair dyes, cigarette smoking, chronic
abuse of analgesics.
'
° Hematuria is Sx,
° Tx for Bladder cancer:
° Transurethral resection with fulguration P 1179
° If passing clots post surgery, have them come in

ASAP!
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URINARY INCONTINENCE
AND RETENTION
° Collaborative care: Urinary incontinence
Drug therapy
Surgical therapy
Types:
Stress incontinence: when you cough or
sneeze, you pee your pants ´
Tx: Drug therapy with Ditropan,
Kegel exercises
Diagnostic studies for urinary retention:
Bladder scan to estimate how many mL pt.
has in bladder ')
NURSING MANAGEMENT
URINARY INCONTINENCE
° Collaborative care: Urinary retention
Drug therapy
Surgical therapy
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INSTRUMENTATION
° Urethral catheterization
° Ureteral catheters
° Suprapubic catheters
° Nephrostomy tubes
° Intermittent catheterization
° Wash catheter with soap and water

after each use.
° Catheter can be used for up to 1
week.
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RENAL AND URETERAL SURGERY
° Preoperative management
° Postoperative management
Urine output
Respiratory status
Abdominal distention
° Laparoscopic nephrectomy
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URINARY DIVERSION
° Incontinent urinary diversion: making a
fake bladder out of Colon, watch for hitting
vagal nerve!P1180
° Continent urinary diversions
° Orthotropic bladder substitution
° Ostomy is an option, so urine is diverted to

constantly drain into Ostomy Bag.P1190
° Will not make new pouch if bladder needs to rest, or
diverticuli in colon prevents use.
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NURSING MANAGEMENT
URINARY DIVERSION
° Preoperative management
° Postoperative management
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ACUTE RENAL FAILURE:
KIDNEYS RAPIDLY LOSING ABILITY TO FX
° Clinical course
Initiating phase
Oliguric phase
° Urinary changes
° Fluid volume excess
° Metabolic acidosis
° Sodium balance
° Potassium excess
° Hematologic disorders
° Calcium deficit and phosphate excess
° Waste product accumulation
° Neurologic disorders
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ACUTE RENAL FAILURE (CONT·D)
° Clinical course (cont·d)
Diuretic phase
Recovery phase
Nutritional therapy
Causes: (pre renal): shock
Tumor in kidney, chemicals,
liver failure«
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NURSING MANAGEMENT
ACUTE RENAL FAILURE P1197
° Nursing assessment
° Nursing diagnoses
° Planning
° Nursing implementation
Health promotion
Acute intervention
Ambulatory and home care
° Evaluation
° Fluid Volume decrease occurs in which stage?
° Metabolic Acidosis can occur
° Peak T waves on EKG, QRS affected how?
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° Monitir BUN Creatinin levels and watch for
SHOCK!
° Can take up to 12 mos to stabalize.
Tx: cardiac output! And make sure adequate flow to

kidneys.
° Put pt. on restriction of fluids.
° Drug Therapy can be used to Tx.
° Hyperkalemia can be treated with glucose and P1201
° Pt. on low Protein diet according to Pt. status. Increase carbs and
fats to prevent

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Clinical manifestations Table P1201
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CHRONIC KIDNEY DISEASE (CKD)
° Involves progressive, irreversible loss of kidney
function
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CHRONIC KIDNEY DISEASE (CONT·D)
° Defined as either presence of
Kidney damage
° Pathologic abnormalities
° Markers of damage
° Blood, urine, imaging tests
Glomerular filtration rate (GFR)

° 60 ml/min for months or longer

° Disease staging based on decrease in GFR
Normal GFR 125 ml/min, which is reflected by urine
creatinine clearance
Last stage of kidney failure
° End-stage renal disease (ESRD) occurs when GFR 15
ml/min

° Up to 80% of GFR may be lost with few changes
in functioning of body
° Remaining nephrons hypertrophy to compensate
° Result is a systemic disease involving every

organ

° Each year 70,000 people die from causes related
to renal failure
° 40 million Americans are at risk
for CKD
° Number of patients with ESRD is expected to
reach 660,000 by 2010
'
° Leading causes of ESRD
Diabetes
Hypertension
"
° Result of retained substances
Urea
Creatinine
Phenols
Hormones
Electrolytes
Water
Other substances
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° Uremia
Syndrome that incorporates all signs and symptoms
seen in various systems throughout the body

MANIFESTATIONS OF CHRONIC UREMIA
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Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved.
URINARY SYSTEM
° Polyuria
Results from inability of kidneys to concentrate urine
Occurs most often at night
Specific gravity fixed around 1.010
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URINARY SYSTEM (CONT·D)
° Oliguria
Occurs as CKD worsens
° Anuria
Urine output 40 ml per 24 hours

METABOLIC DISTURBANCES
° Waste product accumulation

As GFR Ņ, BUN Ń and serum creatinine levels Ń
° BUN Ń
° Not only by kidney failure but by protein intake, fever,
corticosteroids, and catabolism

° N/V, lethargy, fatigue, impaired thought processes, and
headaches occur
^
° Waste product accumulation (cont·d)

° Serum creatinine and creatinine clearance are more
accurate indicators of kidney function than BUN
^
METABOLIC DISTURBANCES (CONT·D)
° Defective carbohydrate metabolism
Caused by impaired glucose use
° From cellular insensitivity to the normal action of insulin
^
° Defective carbohydrate metabolism (cont·d)
Patients with diabetes who become uremic may
require less insulin than before onset of CKD
Insulin dependent on kidneys for excretion
^'
METABOLIC DISTURBANCES (CONT·D)
° Elevated triglycerides
Hyperinsulinemia stimulates hepatic production of
triglycerides
Altered lipid metabolism
° Ņ Levels of enzyme lipoprotein lipase
Important in breakdown of lipoproteins
^"
ELECTROLYTE/ACID²BASE IMBALANCES
° Potassium
Hyperkalemia
° Most serious electrolyte disorder in kidney disease
° Fatal dysrhythmias
^)
° Potassium
Hyperkalemia (cont·d)
° Results from decreased excretion by kidneys, breakdown of
cellular protein, bleeding metabolic acidosis, food intake,
medications
^
(CONT·D)
° Sodium
May be normal or low
Because of impaired excretion, sodium is retained
° Water is retained
° Edema
° Hypertension
° CHF
^^
Clinical Manifestations
Electrolyte/Acid²Base Imbalances
(Cont·d)
° Calcium and phosphate alterations
° Magnesium alterations
û
Clinical Manifestations
Electrolyte/Acid²Base Imbalances
(Cont·d)
Results from
° Inability of kidneys to excrete acid load (primary ammonia)
° Defective reabsorption/regeneration of bicarbonate
^
Hematologic System
° Anemia
Due to Ņ production of erythropoietin
° From Ņ of functioning renal tubular cells
° Bleeding tendencies
Defect in platelet function
u
Hematologic System (cont·d)
° Infection
Changes in leukocyte function
Altered immune response and function
Diminished inflammatory response
u
Hematologic System (cont·d)
° Increased incidence of cancer
Lung
Breast
Uterus
Colon
Prostate
Skin
u
Cardiovascular System
° Hypertension
° Heart failure
° Left ventricular hypertrophy
° Peripheral edema
° Dysrhythmias
° Uremic pericarditis
u'
Respiratory System
° Kussmaul respiration
° Dyspnea
° Pulmonary edema
° Uremic pleuritis
u"
Respiratory System (cont·d)
° Pleural effusion
° Predisposition to respiratory infections
° Depressed cough reflex
° Úremic lungµ
u)
Gastrointestinal System
° Every part of GI is affected
Due to excessive urea
° Mucosal ulcerations
° Stomatitis
u
Gastrointestinal System (cont·d)

° Every part of GI is affected (cont·d)
Due to excessive urea (cont·d)
° Uremic fetor (urinous odor of breath)
° GI bleeding
° Anorexia
° N/V
u^
Neurologic System
° Expected as renal failure progresses
Attributed to
° nitrogenous waste products
° Electrolyte imbalances
° Axonal atrophy
° Demyelination of nerve fibers
uu
Neurologic System (cont·d)
° Altered mental ability
° Seizures
° Coma
° Dialysis encephalopathy
° Peripheral neuropathy
u
Neurologic System (cont·d)
° Restless leg syndrome
° Muscle twitching
° Irritability
° Decreased ability to concentrate

Musculoskeletal System
° Renal osteodystrophy
Syndrome of skeletal changes
Result of alterations in calcium and phosphate
metabolism
° Weaken bones, increase fracture risk
Two types associated with ESRD:
° Osteomalacia
° Osteitis fibrosa

Musculoskeletal System (cont·d)
° Metastatic calcifications
Muscles, lungs, skin, GI tract, eyes

RENAL OSTEODYSTROPHY
O '
Integumentary System
° Most noticeable change
Yellow-gray discoloration of the skin
° Due to absorption/retention of urinary pigments
° Pruritus
° Uremic frost
° Dry, pale skin
"
Integumentary System (cont·d)
° Dry, brittle hair
° Thin nails
° Petechiae
° Ecchymoses
)
Reproductive System
° Infertility
Experienced by both sexes
° Decreased libido
° Low sperm counts
° Sexual dysfunction

Endocrine System
° Manifestations of hypothyroidism
° Thyroid function may yield low to low-normal

levels of T and T4
^
° Psychologic changes
° Personality and behavioral changes
° Emotional ability
° Withdrawal
° Depression
u
DIAGNOSTIC STUDIES
° History and physical examination
° Laboratory tests
BUN
Serum creatinine
Creatinine clearance
Serum electrolytes
Protein-creatinine ratio (first morning void)

DIAGNOSTIC STUDIES
° Laboratory tests (cont·d)
Urinalysis
Urine culture
Hematocrit
Hemoglobin
° Renal ultrasound
° Renal scan

° Renal scan
° CT scan
° Renal biopsy

COLLABORATIVE CARE
° Conservative therapy
° Correction of extracellular fluid volume overload
or deficit
° Nutritional therapy
° Erythropoietin therapy
° Calcium supplementation, phosphate binders

° Antihypertensive therapy
° Measures to lower potassium
° Adjustment of drug dosages to degree of renal

function
'
Drug Therapy
° Hyperkalemia
IV insulin
° IV glucose to manage hypoglycemia
IV 10% calcium gluconate
Sodium bicarbonate
° Shift potassium into cells
° Correct acidosis
"
COLLABORATIVE CARE
Drug Therapy (cont·d)
° Hyperkalemia (cont·d)
Sodium polystyrene sulfonate (Kayexalate)
° Cation-exchange resin
° Resin in bowel exchanges potassium for sodium
)
COLLABORATIVE CARE
° Hyperkalemia (cont·d)
Sodium polystyrene sulfonate (Kayexalate) (cont·d)
° Evacuates potassium-rich stool from body
° Educate patient that diarrhea may occur due to laxative in
preparation

Drug Therapy
° Hypertension
Weight loss
Lifestyle changes
Diet recommendations
Sodium and fluid restriction
^
COLLABORATIVE CARE
° Hypertension (cont·d)
Antihypertensive drugs
° Diuretics
° ǃ-Adrenergic blockers
° Calcium channel blockers
u
COLLABORATIVE CARE
° Hypertension (cont·d)
Antihypertensive drugs (cont·d)
° Angiotensin-converting enzyme (ACE) inhibitors
° Angiotensin receptor blocker agents

COLLABORATIVE CARE
° Renal osteodystrophy
Phosphate intake restricted to
1000 mg/day

COLLABORATIVE CARE
° Renal osteodystrophy (cont·d)
Phosphate binders
° Calcium carbonate (Tums)
° Bind phosphate in bowel and excreted
° Sevelamer hydrochloride (Renagel)
° Lowers cholesterol and LDLs

COLLABORATIVE CARE
Phosphate binders (cont·d)
° Should be administered with each meal
° Side effect: Constipation

COLLABORATIVE CARE
Supplementing vitamin D
° Calcitriol (Rocaltrol)
° Serum phosphate level must be lowered before
administering calcium or vitamin D
'
COLLABORATIVE CARE
Controlling secondary hyperparathyroidism
° Calcimimetic agents
° Cinacalcet (Sensipar)
Ń Sensitivity of calcium receptors in parathyroid glands

° Subtotal parathyroidectomy
"
Drug Therapy
° Anemia
Erythropoietin
° Epoetin alfa (Epogen, Procrit)
° Administered IV or subcutaneously
° Increased hemoglobin and hematocrit in 2 to weeks

° Side effect: Hypertension
)
COLLABORATIVE CARE
° Anemia (cont·d)
Iron supplements
° If plasma ferritin 100 ng/ml
° Side effect: Gastric irritation,
constipation
° May make stool dark in color

COLLABORATIVE CARE
° Anemia (cont·d)
Folic acid supplements
° Needed for RBC formation
° Removed by dialysis
Avoid blood transfusions
^
Drug Therapy
° Dyslipidemia
Goal
° Lowering LDL below 100 mg/dl
° Triglyceride level below 200 mg/dl
Statins
° HMG-CoA reductase inhibitors
° Most effective for lowering LDL
u
COLLABORATIVE CARE
° Dyslipidemia (cont·d)
Fibrates
° Fibric acid derivatives
° Most effective for lowering triglycerides
° Can also decrease HDLs

Drug Therapy
° Complications
Drug toxicity
° Digitalis
° Antibiotics
° Pain medication (Demerol, NSAIDs)

Nutritional Therapy
° Protein restriction
0.6 to 0.8 g/kg body weight/day
° Water restriction
Intake depends on daily urine output

Nutritional Therapy
° Sodium restriction
Diets vary from 2 to 4 g depending on

degree of edema and hypertension
Sodium and salt should not be equated
Patient should be instructed to avoid
high-sodium foods
Salt substitutes should not be used
because they contain potassium chloride

COLLABORATIVE CARE
Nutritional Therapy (cont·d)
° Potassium restriction
2 to 4 g
High-potassium foods should be avoided
° Oranges
° Bananas
° Tomatoes
° Green vegetables
'
COLLABORATIVE CARE
Nutritional Therapy (cont·d)
° Phosphate restriction
1000 mg/day
Foods high in phosphate
° Dairy products
Most foods high in phosphate are also high in calcium
"
NURSING MANAGEMENT
NURSING ASSESSMENT
° Complete history of any existing renal disease,
family history
° Long-term health problems
° Dietary habits
)
NURSING MANAGEMENT
NURSING DIAGNOSES
° Excess fluid volume
° Risk for injury
° Imbalanced nutrition: Less than body

requirements
° Grieving
° Risk for infection

NURSING MANAGEMENT
PLANNING
° Overall goals
Demonstrate knowledge and ability to comply with
therapeutic regimen
Participate in decision making
Demonstrate effective coping strategies
^
NURSING MANAGEMENT
PLANNING
° Overall goals (cont·d)
Continue with activities of daily living within
psychologic limitations
u
NURSING MANAGEMENT
° Health promotion
Identify individuals at risk for CKD
° History of renal disease
° Hypertension
° Diabetes mellitus
° Repeated urinary tract infection
Regular checkups and changes in urinary

appearance, frequency, and volume should be
reported

NURSING MANAGEMENT
° Acute intervention
Daily weight
Daily BPs
Identify signs and symptoms of fluid overload
Identify signs and symptoms of hyperkalemia
Strict dietary adherence
'
NURSING MANAGEMENT
° Acute intervention (cont·d)
Medication education
Motivate patients in management of their disease
'
NURSING MANAGEMENT
° Ambulatory and home care
When conservative therapy is no longer effective, HD,
PD, and transplantation are treatment options
Patient/family need clear explanation of dialysis and
transplantation
'
NURSING MANAGEMENT
EVALUATION
° Maintenance of ideal body weight
° Acceptance of chronic disease
° No infections
° No edema
° Hematocrit, hemoglobin, and serum albumin

levels in acceptable range
''
GERONTOLOGIC CONSIDERATIONS
° About 5% of ESRD patients are
65 years of age or older
° Most common diseases leading to renal failure in
the older adult
Hypertension
Diabetes
'"
(CONT·D)
° Diminished cardiopulmonary function
° Bone loss
° Immunodeficiency
')
(CONT·D)
° Altered protein synthesis
° Impaired cognition
° Altered drug metabolism
'
(CONT·D)
° Most common cause of death in the elderly ESRD
patient
Cardiovascular disease (MI, stroke)
Withdrawal from dialysis
'^
! $&
'u
CASE STUDY
° 5-year-old male began to notice weakness with
activities such as walking distances or running
° Also began experiencing tingling all over his

body, particularly in his hands and feet
'
° Symptoms progressed over 4 months, with 10

pounds of weight lost with no decline in appetite
"
° Increased urinary output with normal frequency
° Strong thirst at night
° Sought medical help because he was afraid he

was getting diabetes
"
CASE STUDY - HISTORY
° History reveals grandmother and aunt have
diabetes with no family history of renal disease
° At 5 years of age, he was admitted to the hospital

for hematuria
Urinary protein 4+
BUN 1 mg/dl
Hb 11.6
Was diagnosed with acute glomerulonephritis
"
CASE STUDY - HISTORY
° At 11 years of age, he was admitted to the same
hospital with gross hematuria
Albuminuria 4+
BUN 10.5
Hb 15.7
Diagnosed with recurring acute glomerulonephritis
"'
CASE STUDY
° He has had no follow-up medical care after that
hospitalization until being admitted to the
hospital currently
""
° Current lab values

Potassium 6.0 mEq/L
BUN 110 mg/dl
Creatinine 12 mg/dl
Hct 20%
Hb 6 gm/dl
")
DISCUSSION QUESTIONS
1. Why would his symptoms seem similar to
diabetes?
2. Why is he developing chronic renal failure so

many years after his primary diagnosis?
"
DISCUSSION QUESTIONS (CONT·D)
. What is the priority of care for him?
4. What patient teaching should be done with him?
"^
DIALYSIS
° General principles of dialysis
"u
"^(^
"
PERITONEAL DIALYSIS
° Catheter placement
° Dialysis solutions and cycles
° Peritoneal dialysis systems

Automated peritoneal dialysis
Continuous ambulatory peritoneal
dialysis
)
"^(u
)
"^(
"^(
)'
"^(
)"
"^(
))
PERITONEAL DIALYSIS (CONT·D)
° Complications of peritoneal dialysis
Exit site infection
Peritonitis
Abdominal pain
Outflow problems
Hernias
Lower back problems
Bleeding
)
PERITONEAL DIALYSIS (CONT·D)
° Complications of peritoneal dialysis (cont·d)
Pulmonary complications
Protein loss
Carbohydrate and lipid abnormalities
Encapsulating sclerosing peritonitis and
loss of ultrafiltration
° Effectiveness of and adaptation to chronic
peritoneal dialysis
)^
HEMODIALYSIS
° Vascular access sites
Shunts
Internal arteriovenous fistulas
and grafts
Temporary vascular access
)u
"^('
)
"^("

"^()

HEMODIALYSIS (CONT·D)
° Dialyzers
° Procedure
Settings for hemodialysis

"^(
'
"^(^
"
HEMODIALYSIS (CONT·D)
° Complications of hemodialysis
Hypotension
Muscle cramps
Loss of blood
Hepatitis
Sepsis
Disequilibrium syndrome
° Effectiveness of and adaptation to
hemodialysis
)
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!&

"^(u
^
KIDNEY TRANSPLANTATION
° Recipient selection
° Histocompatibility studies
° Donor sources
Live donors
Deceased donors
° Surgical procedure
Live donor
Kidney transplant recipient
u
"^(

NURSING MANAGEMENT
KIDNEY TRANSPLANT RECIPIENT
° Preoperative care
° Postoperative care
Live donor
Recipient
^
KIDNEY TRANSPLANTATION (CONT·D)
° Immunosuppressive therapy
° Complications of transplantation
Rejection
Infection
Cardiovascular disease
Malignancies
Recurrence of original renal disease
Corticosteroid-related complications
^
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^

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m

° Collaborative care and drug therapy

° Can occur in upper or lower Urinary area.

° Both are of concern

° Pyelonephritis: Inflammation of renal parenchyma and

° RISK FOR SEPTIC SHOCK!!

° Pt Fluctuates temp, cool due to lack of blood flow and hot

° Cystitis (inflammation of bladder wall)

° Existing diabetes/neurologic disease

experiences one remote from a previous UTI (separated by

bloodstream or urine to kill bacteria

° Loss or leakage or urine

° Complaint of loss of urine during sleep

° Difficulty starting the urine stream

° Urine loss after completion of voiding

° Inability to empty urine from bladder

° Stains urine reddish orange

° Can be mistaken for blood and may stain underclothing

° OTC AZO can be used

° Drink Cranberry juice

° Avoid spicy foods, acidic juices etc.

° Preparations with methylene blue tint urine blue or green

° Underlying diseases (HIV, diabetes)

° Taking immunosuppressive drug or corticosteroids

° Wear cotton crotched underwear

° Wipe the right way, DUH !

° Flushes out bacteria before they can colonize

° Pass urine without urgency

° Urine free of blood

° Adequate intake of fluids

° Fungi, protozoa, or viruses infecting kidneys can

bacteremia involving gram-negative

° Pass urine without urgency

° Urine free of blood

° Adequate intake of fluids

° Symptoms began 48 hours ago

° History of recurring urinary tract infections since

° Temperature 98.6° F orally

° Blood pressure 114/64 mm Hg

1. What type of urinary tract infection does she

2. Why might she be having recurring infections?

. What is the priority of care for her?

4. What teaching should be done

° DMSO drug used to desensitize bladder therefore

° Nursing management: Nephrotic syndrome

° Transurethral resection with fulguration P 1179

° If passing clots post surgery, have them come in

° Wash catheter with soap and water

° Orthotropic bladder substitution

° Ostomy is an option, so urine is diverted to

Tx: cardiac output! And make sure adequate flow to

° Blood, urine, imaging tests

 Glomerular filtration rate (GFR)

° Result is a systemic disease involving every

° Waste product accumulation

corticosteroids, and catabolism

° Waste product accumulation (cont·d)

° Left ventricular hypertrophy

° Predisposition to respiratory infections

° Depressed cough reflex

Gastrointestinal System (cont·d)

° Demyelination of nerve fibers

° Decreased ability to concentrate

. What is the priority of care for her?

Glomerular filtration rate (GFR)

Ń Sensitivity of calcium receptors in parathyroid glands

° Increased hemoglobin and hematocrit in 2 to weeks

Avoid blood transfusions

Diets vary from 2 to 4 g depending on

Regular checkups and changes in urinary

. What is the priority of care for him?