management of patients with renal disorders. glomerular diseases acute glomerulonephritis acute...

Management of Management of Patients with Patients with

Renal Disorders Renal Disorders

Glomerular DiseasesGlomerular Diseases

Acute GlomerulonephritisAcute Glomerulonephritis Chronic Glomerulonephritis Chronic Glomerulonephritis Nephrotic SyndromeNephrotic Syndrome

Glomerulonephritis Glomerulonephritis

Acute Acute GlomerulonephritisGlomerulonephritis

Preceded (10 days) by an infectionPreceded (10 days) by an infection Assess for:Assess for:

LesionsLesions Signs of circulatory overloadSigns of circulatory overload Change in urine color and amountChange in urine color and amount Mild to moderate hypertensionMild to moderate hypertension

Interventions:Interventions: Treat cause: antibiotics, corticosteroids, Treat cause: antibiotics, corticosteroids,

immunosuppressants immunosuppressants Restrict sodium, water, potassium, protein Restrict sodium, water, potassium, protein Dialysis, plasmapheresisDialysis, plasmapheresis Client education Client education

Nursing Management-Nursing Management-Acute Glomerulonephritis Acute Glomerulonephritis

Patient assessmentPatient assessment Maintain fluid balanceMaintain fluid balance Fluid and dietary restrictionsFluid and dietary restrictions Patient educationPatient education Follow-up careFollow-up care

Chronic Chronic GlomerulonephritisGlomerulonephritis

20-30+ years to develop20-30+ years to develop Diagnostics: Diagnostics:

Urine with fixed specific gravity, casts, and Urine with fixed specific gravity, casts, and proteinuriaproteinuria

Electrolyte imbalancesElectrolyte imbalances hypoalbuminemiahypoalbuminemia

Causes:Causes: Repeated episodes of acute Repeated episodes of acute

glomerulonephritis, hypertensive glomerulonephritis, hypertensive nephrosclerosis, hyperlipidemia, nephrosclerosis, hyperlipidemia,

Manifestations:Manifestations: Mild proteinuria and hematuria, Mild proteinuria and hematuria,

hypertension, and occasional edemahypertension, and occasional edema

Nursing Management: Nursing Management: Chronic Glomerulonephritis Chronic Glomerulonephritis AssessmentAssessment Potential fluid and electrolyte Potential fluid and electrolyte

imbalancesimbalances Cardiac statusCardiac status Neurologic statusNeurologic status Emotional supportEmotional support Teaching self-care Teaching self-care

Nephrotic SyndromeNephrotic Syndrome

Increased glomerular permeabilityIncreased glomerular permeability Severe loss of protein into urineSevere loss of protein into urine Treatment:Treatment:

Immunosuppresive agentsImmunosuppresive agents ACE InhibitorsACE Inhibitors HeparinHeparin Diet changesDiet changes Mild diuretics Mild diuretics

Nephrotic Syndrome Nephrotic Syndrome

NephrosclerosisNephrosclerosis

Narrowing of vessel lumen from Narrowing of vessel lumen from thickening in blood vessels of the thickening in blood vessels of the nephronnephron

Occurs with hypertension, Occurs with hypertension, atherosclerosis and diabetes mellitusatherosclerosis and diabetes mellitus

Collaborative management:Collaborative management: Control hypertensionControl hypertension Preserve renal function Preserve renal function

Renal FailureRenal Failure Results when kidney’s cannot remove Results when kidney’s cannot remove

wastes or perform regulatory functionswastes or perform regulatory functions Systemic disorder resulting from many Systemic disorder resulting from many

different causesdifferent causes Acute renal failure- reversible Acute renal failure- reversible

syndrome that results in decreased syndrome that results in decreased GFR and oliguriaGFR and oliguria

Chronic renal failure- progressive; Chronic renal failure- progressive; irreversible deterioration of renal irreversible deterioration of renal function resulting in azotemia function resulting in azotemia

Acute Renal FailureAcute Renal Failure

PathophysiologyPathophysiology Types of acute renal failure include:Types of acute renal failure include:

Prerenal Prerenal Intrarenal Intrarenal Postrenal Postrenal

Phases of Acute Renal Phases of Acute Renal FailureFailure

Phases of rapid decrease in renal Phases of rapid decrease in renal function lead to the collection of function lead to the collection of metabolic wastes in the body.metabolic wastes in the body.

Phases include:Phases include: Onset Onset Diuretic Diuretic Oliguric Oliguric Recovery Recovery

Acute syndrome may be reversible Acute syndrome may be reversible with prompt intervention.with prompt intervention.

Assessment Assessment

History History Clinical manifestationsClinical manifestations Laboratory assessmentLaboratory assessment Radiographic assessmentRadiographic assessment Other diagnostic assessments such Other diagnostic assessments such

as renal biopsyas renal biopsy

Drug TherapyDrug Therapy CardioglycidesCardioglycides Vitamins and mineralsVitamins and minerals Biologic response modifiersBiologic response modifiers Phosphate bindersPhosphate binders Stool softeners and laxativesStool softeners and laxatives Monitor fluidsMonitor fluids DiureticsDiuretics Calcium channel blockersCalcium channel blockers

TreatmentTreatment

Diet therapyDiet therapy Dialysis therapiesDialysis therapies

HemodialysisHemodialysis Peritoneal dialysisPeritoneal dialysis

Renal Replacement Renal Replacement TherapyTherapy

Standard treatment Standard treatment Dialysate solutionDialysate solution Vascular accessVascular access Continuous arteriovenous Continuous arteriovenous

hemofiltration hemofiltration Continuous venovenous Continuous venovenous

hemofiltrationhemofiltration

Posthospital CarePosthospital Care

If renal failure is resolving, follow-up If renal failure is resolving, follow-up care may be required.care may be required.

There may be permanent renal There may be permanent renal damage and the need for chronic damage and the need for chronic dialysis or even transplantation.dialysis or even transplantation.

Temporary dialysis is appropriate for Temporary dialysis is appropriate for some clients.some clients.

Chronic Renal FailureChronic Renal Failure

Progressive, irreversible kidney Progressive, irreversible kidney injury; kidney function does not injury; kidney function does not recoverrecover

AzotemiaAzotemia UremiaUremia Uremic syndromeUremic syndrome

Stages of Chronic Renal Stages of Chronic Renal FailureFailure

Diminished renal reserveDiminished renal reserve Renal insufficiencyRenal insufficiency End-stage renal diseaseEnd-stage renal disease

Changes R/T CRFChanges R/T CRF

• Kidney Kidney • Metabolic Metabolic

– Urea and creatinineUrea and creatinine

• ElectrolytesElectrolytes– Sodium Sodium – PotassiumPotassium

• Acid-base balanceAcid-base balance• Calcium and phosphorusCalcium and phosphorus

(Continued)(Continued)

Changes R/T CRFChanges R/T CRF (Continued)(Continued)

• CardiacCardiac– HypertensionHypertension– HyperlipidemiaHyperlipidemia– Congestive heart failureCongestive heart failure– Uremic pericarditisUremic pericarditis

• HematologicHematologic• GastrointestinalGastrointestinal

Clinical ManifestationsClinical Manifestations NeurologicNeurologic CardiovascularCardiovascular RespiratoryRespiratory Hematologic Hematologic GastrointestinalGastrointestinal UrinaryUrinary SkinSkin

Imbalanced Nutrition: Imbalanced Nutrition: Less Than Body Less Than Body RequirementsRequirements Interventions include:Interventions include:

Dietary evaluation for:Dietary evaluation for: ProteinProtein FluidFluid PotassiumPotassium SodiumSodium PhosphorusPhosphorus

Vitamin supplementationVitamin supplementation

Excess Fluid VolumeExcess Fluid Volume Interventions:Interventions:

Monitor client’s intake and output.Monitor client’s intake and output. Promote fluid balance.Promote fluid balance. Assess for manifestations of volume Assess for manifestations of volume

excess:excess: Crackles in the bases of the lungsCrackles in the bases of the lungs EdemaEdema Distended neck veinsDistended neck veins

Drug therapy includes diureticsDrug therapy includes diuretics..

Decreased Cardiac Decreased Cardiac OutputOutput

Interventions:Interventions: Control hypertension with calcium Control hypertension with calcium

channel blockers, ACE inhibitors, alpha- channel blockers, ACE inhibitors, alpha- and beta-adrenergic blockers, and and beta-adrenergic blockers, and vasodilators.vasodilators.

Instruct client and family to monitor Instruct client and family to monitor blood pressure, client’s weight, diet, blood pressure, client’s weight, diet, and drug therapyand drug therapy..

Risk for InfectionRisk for Infection

Interventions include:Interventions include: Meticulous skin careMeticulous skin care Preventive skin carePreventive skin care Inspection of vascular access site for Inspection of vascular access site for

infectioninfection Monitoring of vital signs for Monitoring of vital signs for

manifestations of infectionmanifestations of infection

Risk for InjuryRisk for Injury

Interventions include:Interventions include: Drug therapyDrug therapy Education to prevent fall or injury, Education to prevent fall or injury,

pathologic fractures, bleeding, and pathologic fractures, bleeding, and toxic effects of prescribed drugstoxic effects of prescribed drugs

FatigueFatigue

Interventions:Interventions: Assess for vitamin deficiency, anemia, Assess for vitamin deficiency, anemia,

and buildup of urea.and buildup of urea. Administer vitamin and mineral Administer vitamin and mineral

supplements.supplements. Administer erythropoietin therapy for Administer erythropoietin therapy for

bone marrow production.bone marrow production. Give iron supplements as neededGive iron supplements as needed..

AnxietyAnxiety

Interventions include:Interventions include: Health care team involvementHealth care team involvement Client and family educationClient and family education Continuity of careContinuity of care Encouragement of client to ask Encouragement of client to ask

questions and discuss fears about the questions and discuss fears about the diagnosis of renal failurediagnosis of renal failure

Potential for Pulmonary Potential for Pulmonary EdemaEdema

Interventions:Interventions: Assess the client for early signs of Assess the client for early signs of

pulmonary edema.pulmonary edema. Monitor serum electrolyte levels, vital Monitor serum electrolyte levels, vital

signs, oxygen saturation levels, signs, oxygen saturation levels, hypertensionhypertension..

HemodialysisHemodialysis

Client selectionClient selection Dialysis settingsDialysis settings Works using Works using

passive transfer of passive transfer of toxins by diffusiontoxins by diffusion

Anticoagulation Anticoagulation needed, usually needed, usually heparin treatmentheparin treatment

Vascular AccessVascular Access

Arteriovenous fistula, or Arteriovenous fistula, or arteriovenous graft for long-term arteriovenous graft for long-term permanent accesspermanent access

Hemodialysis catheter, dual or triple Hemodialysis catheter, dual or triple lumen, or arteriovenous shunt for lumen, or arteriovenous shunt for temporary accesstemporary access

PrecautionsPrecautions ComplicationsComplications

Permanent Vascular Permanent Vascular Access Access

Hemodialysis Nursing Hemodialysis Nursing CareCare

Postdialysis care:Postdialysis care: Monitor for complications such as Monitor for complications such as

hypotension, headache, nausea, hypotension, headache, nausea, malaise, vomiting, dizziness, and malaise, vomiting, dizziness, and muscle cramps.muscle cramps.

Monitor vital signs and weight.Monitor vital signs and weight. Avoid invasive procedures 4 to 6 hours Avoid invasive procedures 4 to 6 hours

after dialysis.after dialysis. Continually monitor for hemorrhage.Continually monitor for hemorrhage.

Complications of Complications of HemodialysisHemodialysis

Dialysis disequilibrium syndromeDialysis disequilibrium syndrome Infectious diseasesInfectious diseases Hepatitis B and C infectionsHepatitis B and C infections HIV exposure—poses some risk for HIV exposure—poses some risk for

clients undergoing dialysisclients undergoing dialysis

Peritoneal DialysisPeritoneal Dialysis

Procedure involves siliconized Procedure involves siliconized rubber catheter placed into the rubber catheter placed into the abdominal cavity for infusion of abdominal cavity for infusion of dialysate.dialysate.

Types of peritoneal dialysis:Types of peritoneal dialysis: Continuous ambulatory peritonealContinuous ambulatory peritoneal Automated peritonealAutomated peritoneal Intermittent peritonealIntermittent peritoneal Continuous-cycle peritonealContinuous-cycle peritoneal

ComplicationsComplications

PeritonitisPeritonitis PainPain Exit site and tunnel infectionsExit site and tunnel infections Poor dialysate flowPoor dialysate flow Dialysate leakageDialysate leakage Other complicationsOther complications

Nursing Care During Nursing Care During Peritoneal DialysisPeritoneal Dialysis

Before treating, evaluate baseline vital Before treating, evaluate baseline vital signs, weight, and laboratory tests.signs, weight, and laboratory tests.

Continually monitor the client for Continually monitor the client for respiratory distress, pain, and respiratory distress, pain, and discomfort.discomfort.

Monitor prescribed dwell time and Monitor prescribed dwell time and initiate outflow.initiate outflow.

Observe the outflow amount and Observe the outflow amount and pattern of fluid.pattern of fluid.

Nursing Management of Nursing Management of Hospitalized Client on Hospitalized Client on

Dialysis Dialysis Protect vascular Protect vascular

accessaccess Monitor fluid Monitor fluid

balance indicatorsbalance indicators Monitor IV carefullyMonitor IV carefully Assess for s/s Assess for s/s

uremiauremia Monitor Monitor

cardiopulmonary cardiopulmonary status carefullystatus carefully

Monitor BPMonitor BP

Monitor Monitor medicationsmedications

Address pain and Address pain and discomfortdiscomfort

Infection control Infection control measuresmeasures

Monitor dietary e-Monitor dietary e-lytes and fluidslytes and fluids

Skin careSkin care CAPD catheter care CAPD catheter care

if appropriate if appropriate

Renal TransplantationRenal Transplantation

Candidate selection criteriaCandidate selection criteria DonorsDonors Preoperative carePreoperative care Immunologic studiesImmunologic studies Surgical teamSurgical team Operative procedureOperative procedure

Postoperative CarePostoperative Care

AssessmentAssessment all body systemsall body systems PainPain Fluid and electrolyte Fluid and electrolyte

statusstatus Urologic Urologic

managementmanagement Assessment of system Assessment of system

patencypatency Assessment of urine Assessment of urine

output hourly for 48 output hourly for 48 hours.hours.

ComplicationsComplications RejectionRejection Acute tubular Acute tubular

necrosisnecrosis ThrombosisThrombosis Renal artery stenosis Renal artery stenosis Other complicationsOther complications Immunosuppressive Immunosuppressive

drug therapydrug therapy Psychosocial Psychosocial

preparationpreparation

Post-transplantation Post-transplantation IntervetionsIntervetions

Pain relief measures and analgesicsPain relief measures and analgesics Promote airway clearance and Promote airway clearance and

effective breathing patterneffective breathing pattern Strict asepsis Strict asepsis Monitor for signs/symptoms of Monitor for signs/symptoms of

bleedingbleeding Encourage leg exercises, early Encourage leg exercises, early

ambulation, and monitor for signs of ambulation, and monitor for signs of DVTDVT

Renal Cell CarcinomaRenal Cell Carcinoma

Healthy kidney tissue damaged and Healthy kidney tissue damaged and replaced by cancer cellsreplaced by cancer cells

Paraneoplastic syndrome: Paraneoplastic syndrome: AnemiaAnemia ErythrocytosisErythrocytosis HypercalcemiaHypercalcemia Liver dysfuntionLiver dysfuntion Hormonal effectsHormonal effects Increased sedimentation rateIncreased sedimentation rate Hypertension Hypertension

Renal Cell Carcinoma Renal Cell Carcinoma Management Management

NonsurgicalNonsurgical Radiofrequency Radiofrequency

ablationablation ChemotherapyChemotherapy Biological response Biological response

modifiers and modifiers and tumor necrosis tumor necrosis factor lengthen factor lengthen survival timesurvival time

Renal artery Renal artery embolization embolization

SurgicalSurgical Pre-op carePre-op care NephrectomyNephrectomy Post-op care:Post-op care:

Monitoring for Monitoring for hemorrhage and hemorrhage and adrenal adrenal insufficiencyinsufficiency

Pain Pain managementmanagement

Prevention of Prevention of complicationscomplications

Renal TraumaRenal Trauma

Minor injuries:Minor injuries: Contusions, small lacerationsContusions, small lacerations

Major injuries:Major injuries: Lacerations to cortex, medulla, or Lacerations to cortex, medulla, or

branches or renal arterybranches or renal artery Nonsurgical management:Nonsurgical management:

Drug and fluid therapyDrug and fluid therapy Surgical management:Surgical management:

Nephrectomy or partial nephrectomyNephrectomy or partial nephrectomy