MANAGEMENT OF PATIENT WITH RENAL DISORDER

Chapter 44

Management of Patients With
Renal Disorders

Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins

Renal Disorders
• Fluid and electrolyte imbalances
• Most accurate indicator of fluid loss or gain in an acutely
ill patient is weight


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.


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
• Vascular disorders
• Medications or toxic agents

Glomerular Diseases
• An inflammation of the glomerular capillaries
• Acute nephritic syndrome
• Chronic glomerulonephritis
• Nephrotic syndrome


Acute Nephritic Syndrome
• 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—
antibiotics, corticosteroids, and immunosuppressants


Nursing Management: Acute Nephritic
Syndrome
• Patient assessment
• Maintain fluid balance
• Fluid and dietary restrictions
• Patient education
• Follow-up care


Chronic Glomerulonephritis
• Causes include repeated episodes of acute glomerular
nephritis, hypertensive nephrosclerosis, hyperlipidemia,
and other causes of glomerular damage.
• Symptoms vary; may be asymptomatic for years, as
glomerular damage increases, before signs and
symptoms develop of renal insufficiency/failure.
• Abnormal laboratory tests include urine with fixed
specific gravity, casts, and proteinuria; and electrolyte
imbalances and hypoalbuminemia.
• Medical management is determined by symptoms.


Nursing Management Chronic
Glomerulonephritis
• Assessment
• Potential fluid and electrolyte imbalances
• Cardiac status
• Neurologic status
• Emotional support
• Teaching self-care


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 erythmatosus, multiple myeloma, and
renal vein thrombosis.
• Medical management includes drug and dietary therapy


Sequence of Events in Nephrotic
Syndrome


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 GFR and oliguria
• Chronic renal failure (ESRD) is a progressive, irreversible
deterioration of renal function that results in azotemia


Nursing Process: The Care of the Patient
with Renal Failure—Assessment
• Fluid status
• Nutritional status
• Patient knowledge
• Activity tolerance
• Self-esteem
• Potential complications


with Renal Failure—Diagnoses
• Excess fluid volume
• Imbalanced nutrition
• Deficient knowledge
• Risk for situational low self-esteem


Collaborative Problems/Potential
Complications
• Hyperkalemia
• Pericarditis
• Pericardial effusion
• Pericardial tamponade
• Hypertension
• Anemia
• Bone disease and metastatic calcifications


with Renal Failure—Planning
• Goals may include maintaining of IBW without excess
fluid, maintenance of adequate nutritional intake,
increased knowledge, participation of activity within
tolerance improved self-esteem, and absence of
complications.


Excess Fluid Volume
• Assess for signs and symptoms of fluid volume excess,
and keep accurate I&O and daily weights
• Limit fluid to prescribe amounts
• Identify sources of fluid
• Explain to patient and family the rationale for the
restriction
• Assist patient to cope with the fluid restriction
• Provide or encourage frequent oral hygiene


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, eg, stomatitis or
anorexia
• Adjust medication times related to meals


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


Hemodialysis System


Hemodialysis Catheter


Internal Arteriovenous Fistula and Graft


Peritoneal Dialysis


Question
Is the following statement True or False?

Failure of the temporary dialysis access accounts for most
hospital admissions of patients undergoing chronic
hemodialysis.


Answer
False

Failure of the permanent, not the temporary, dialysis
access accounts for most hospital admissions of patients
undergoing chronic hemodialysis.


Nursing Management of the Hospitalized
Patient on Dialysis (1 of 2)
• Protection of vascular access; assess site for patency and
signs of potential infection, and do not use for blood
pressure or blood draws.
• Monitor fluid balance indicators and monitor IV therapy
carefully; accurate I&O, IV administration pump.
• Assess for signs and symptoms of uremia and electrolyte
imbalance; regularly check lab data.
• Monitor cardiac and respiratory status carefully.
• Hypertension: monitor blood pressure,
antihypertensive agents must be held on dialysis
days to avoid hypotension.

Nursing Management of the Hospitalized
Patient on Dialysis (2 of 2)
• Monitor all medications and medication dosages carefully.
Avoid medications containing potassium and magnesium.
• Address pain and discomfort.
• Stringent infection control measures.
• Dietary considerations: sodium, potassium, protein, and
fluid; address individual nutritional needs.
• Skin care: pruritis is a common problem; keep skin clean
and well moisturized, and trim nails and avoid scratching.
• CAPD catheter care.


Kidney Surgery
• Preoperative considerations
• Perioperative concerns
• Postoperative management
– Potential hemorrhage and shock
– Potential abdominal distention and paralytic ileus
– 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
• 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
• Use strict asepsis with catheter and appropriate
technique in providing all care
• Monitor for signs and symptoms of bleeding
• Encourage leg exercises, early ambulation, and monitor
for signs of DVT


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


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