Disorders of the Kidneys and Ureters

Chapter 64

Overview pg 1124

The most common urologic disorders are infectious and inflammatory conditions.Those that affect the kidneys are extremely dangerous because damage to the nephrons can result in permanent renal dysfunction.

Pyelonephritis pg 1124

An acute or chronic bacterial infection of the kidney and the lining of the collecting system (kidney pelvis).Acute phelonephritis presents with moderate to severe symptoms that usually last 1 to 2 weeks.If the treatment of acute pyelonephritis is not successful and the infection recurs, it is termed chronic pyelonephritis.

Patho

Bacteria ascend to the kidney and kidney pelvis by way of the bladder and urethra.Normal fecal flora such as E. coli, is the most common bacteria that cause acute pyelonephritis.E. Coli accounts for about 85% of infections.

Patho

In acute pyelonephritis, the inflammation causes the kidneys to grossly enlarge.Chronic pyelonephritis occurs after recurrent episodes of acute pyelonephritis.The kidneys develop irreversible degenerative changes and become small and atrophic.

Patho

If extensive numbers of nephrons are destroyed, renal failure develops.Renal dysfunction may not occur for 20 or more years after the onset of the disease.About 10 to 15% of clients with chronic pyelonephritis require dialysis.

Pyelonephritis S/S pg 1124

Flank pain or tendernessChills, fever, and malaiseFrequency and burning on urination if there is an accompanying cystitis (bladder inf)Some with chronic are asymptomaticOthers have a low-grade fever and vague GI complaints.Polyuria and nocturia develop when the tubules of the nephrons fail to reabsorb water efficiently.

Medical Management

Tx includes relieving the fever and pain and prescribing antimicrobial drugs such as Septra or Cipro for 14 days.Antispasmodics and anticholinergics such as Ditropan & Pro-Banthine relax smooth muscles of the ureters and bladder, promote comfort, and increase bladder capacity. 4 weeks of drug therapy is prescribed

Nursing Management pg 1125

Obtain a complete medical, drug, & allergy history.V/S ( temp or BP)Any s/s of fluid retention such as peripheral edema and SOB.Collect a clean-catch urine specimen for urinalysis and urine culture.Measure I & O

Nursing Management

Provide a liberal fluid intake of approx. 2,000 to 3,000 mL to flush the infectious microorganisms from the urinary tract.LAB TEST: BUN, creatinine, serum electrolytes, and urine culture

Family Teaching pg 1126 Box 64-1

Suggest consuming acid-forming foods such as meat, fish, poultry, eggs, grains, corn, lentils, cranberries, prune, plums, and their juices to prevent calcium and magnesium phosphate stone formation. Recommend avoiding alcohol and caffeine products if bladder spasms are present or until a clinical response to therapy is verified.

Acute Glomerulonephritis pg 1126

The term nephritis describes a group of inflammatory but NONINFECTIOUS disease characterized by wide-spread kidney damage. Glomerulonephritis is a type of nephritis that occurs most frequently in children and young adults; however, it can affect individuals at any age.

Patho

Symptoms of acute glomerulonephritis appear about 1 to 2 weeks after a group A beta-hemolytic streptococci upper respiratory infection.The relationship between the infection & acute glomerulonephritis is not clear; microorganisms are not present in the kidney when symptoms appear, but the glomeruli are acutely inflamed.

Acute Glomerulonephritis S/S

About 50% are symptom free.Occasionally the onset is sudden with pronounced symptoms such as fever, nausea, malaise, headache, generalized edema, or periorbital edema, puffiness around the eyes.In some instances, the disorder is discovered during a routine physical examination.

Acute Glomerulonephritis S/S

More often, the client or family notices that the person’s face is pale and puffy and that slight ankle edema occurs in the evening.Many other vague symptoms….read on your own

Diagnostic Findings

Gross or microscopic hematuria gives the urine a dark, smoky, or frankly bloody appearance.

Medical Management pg 1127

No specific treatment exists for acute glomerulonephritis and treatment is guided by the symptoms and their underlying abnormality.Treatment may consist of bed rest, a sodium-restricted diet (if edema or HTN is present), and antimicrobial drugs to prevent a superimposed infection in the already inflamed kidney.

Medical Management

The client is not considered cured until the urine is free of protein and red blood cells for 6 months.Return to full activity usually is not permitted until the urine is free of protein for 1 month.

Nursing Management

Maintain bed rest when the blood pressure is elevated and edema is presentCollect daily urine specimens to assist with evaluating the client’s response to TX.Assess the BP q 4 hours or prnEncourage adequate fluid intake and measure I & O.Encourage carbohydrate intake to prevent the catabolism of body protein stores (may be restricted in sodium and protein)

Chronic Glomerulonephritis pg 1127

A slowly progressive disease characterized by inflammation of the glomeruli that causes irreversible damage to the kidney nephrons.Some live for years with only occasional symptomatic episodes or none at all, or the disease may be rapidly fatal unless renal failure is treated with dialysis.

Patho

The chronic inflammation leads to ever-increasing bands of scar tissue that replace nephrons, the vital functioning units of the kidney.Decreased glomerular filtration can eventually lead to renal failure.Chronic glomerulonephritis accounts for approx. 40% of people on dialysis.

Chronic S/S

Some experience no symptoms of this disorder until renal damage is severe.Generalized edema known as ANASARCA is a common finding.Anasarca is due to the shift of fluid from the intravascular space to interstitial and intracellular fluid locations.The fluid shift is due to depletion of serum proteins, albumin in particular, which is lost in the urine.

S/S

Clients remain markedly edematous for months or years. The client may feel relatively well, but the kidney continues to excrete albumin.The fluid burden and subsequent renal failure contribute to fatigue, headache, hypertension, dyspnea, and visual disturbances.

Diagnostic Findings

Azotemia, accumulation of nitrogen waste products in the blood, is evidenced by elevated BUN, serum creatinine, and uric acid levels.The urine contains protein (albumin), sediment, cast (deposits of minerals that break loose from the walls of the tubules), and red and white blood cells.

Medical Management

Treatment is nonspecific and symptomaticManagement goals include (1) controlling HTN with medications and sodium restriction (2) correcting fluid and electrolyte imbalance, (3) reducing edema with diuretic therapy (4) preventing congestive heart failure (5) eliminating urinary tract infections with antimicrobials.May necessitate dialysis or kidney transplantation

Nursing ManagementFluid Volume Excess

Weigh daily at the same time on the same scale while wearing similar clothing.Measure I & OMonitor BP, HR, lung and heart sounds each shiftAssess for pitting edema, tight rings or shoes, clothes that do not fit comfortablyEducate on low sodium restrictionAdminister prescribed diuretics

Nursing ManagementFatigue & Activity Intolerance

Avoid clustering nursing tasks and physical activitiesProvide periods of rest and promote uninterrupted sleep at nightEliminate any activities of daily living that are not necessary.Assist the client with activities when evidence of tachycardia or dyspnea is present.

Polycystic Disease pg 1129

A congenital kidney disorder that has a familial tendency.2 forms: the infantile and adult forms1. The infantile form is rare. It may cause fetal death (before delivery), early neonatal death, or renal failure during childhood.2. The adult form has its onset between 30 to 50 years of age and insidiously progresses to renal insufficiency.

Polycystic Disease

Once renal failure develops, polycystic disease is usually fatal within 4 years, unless the client receives dialysis treatment or organ transplant.

Patho

Adult polycystic kidney disease is the result of autosomal dominant inheritance.This means that the gene for the disease is passed from an affected parent to his or her children.Each child has a 50:50 chance of acquiring the defective gene

Patho

As the name implies, this disorder is characterized by the formation of multiple bilateral kidney cysts. Fig 64-4 pg 1130.The cysts interfere with kidney function and eventually lead to renal failure.The fluid-filled cysts cause enormous enlargement of the kidneys from normal fist size to as much as the size of a football.

Patho

As the cysts enlarge, they compress the renal blood vessels and cause chronic hypertension.Bleeding into cysts causes flank pain

Polycystic Disease S/S

Hypertension is present in approx 75% of affected individuals at the time of diagnosis.Other symptoms, such as pain from retroperitoneal bleeding, lumbar discomfort, and abdominal tenderness, are due to the size and effects of the cysts.Colic (acute spasmodic pain) is experienced when there is ureteral passage of clots or calculi.

Medical Management

Has no cure, but some interventions reduce the rate of progression.HTN --- antihypertensive drugs, diuretic med and sodium restrictionUTI—promptly with antibioticsLow RBC count—iron supplements, injections of erythropoietin (Epogen) or blood transfusions

Medical Management

NEPHROTOXIC MEDICATIONS, SUCH AS NONSTEROIDAL ANTI-INFLAMMATORY DRUGS AND CEPHALOSPORIN ANTIBIOTICS, ARE AVOIDED AT ALL COSTS.Dialysis substitutes for kidney function when renal failure occurs and while the client awaits an organ transplant

Nursing Management

Assess V/S especially BPObserve the urine for signs of bleeding or infectionMeasure I & OReport any decrease in or absence of urine output.

Obstructive Disorders pg 1130

KIDNEY AND URETRERAL STONES:A stone (calculus) is a precipitate of mineral salts that ordinarily remain dissolved in urine.About 80% of renal calculi in the US are composed of calcium oxalate.Stones may be smooth, jagged, or staghorn shaped fig 64-5 pg 1131

Kidney & Ureteral Stones Pg. 1130

Calculi can occur anywhere in the urinary tract from the kidney pelvis and beyond.When a stone forms, the condition is called urolithiasis.Nephrolithiasis refers to the presence of a kidney stone, the size of which may range form microscopic to several centimeters in diameter.Ureterolithiaisis is a stone within the ureter. Ureteral stones are usually small –some may be no larger than a grain of sand.

Patho

Predisposing factors:Calciuria, excessive calcium in the urine (hyperparathyroid dx, calcium-based antacids, and excessive intake of vitamin D)Dehydration Osteoporosis in which bone is demineralizedObstructive disorders (enlarged prostate)ImmobilityUTI

Patho

Calculi traumatize the walls of the urinary tract and irritate the cellular lining, causing pain as violent contractions of the ureter develop to pass the stone along.But the ureteral spasms may just as easily hold a stone in place.If a stone totally or partially obstructs the passage of urine beyond its location, pressure increases in the area above the stone.

S/S

Small stones may pass unnoticedHowever, sudden, sharp, severe flank pain that travels to the suprapubic region and external genitalia is the classic symptom of urinary calculi.The pain comes in waves that radiate to the inguinal ring, the inner aspect of the thigh, and to the testicle or tip of the penis in men , or the urinary meatus or labia in women.

Medical Management 1132

Small calculi are passed naturally with no specific interventions.If the stone is 5 mm or less in diameter, moving, the pain is tolerable, and no obstruction is present, the client is managed medically with vigorous hydration, analgesics, antimicrobial therapy, and drugs that dissolve calculi or eventually alter conditions that promote their formation (Table 64-1 pg 1132)

Medical Management

For larger stones, extracorporeal shock wave lithotripsy (ESWL), a procedure that uses 800 to 2,400 shock waves aimed from outside the body toward dense stones may be used (fig 64-6) pg 1133The stones are shattered into smaller particles that are passed from the urinary tract

Medical Management

ESWL is administered with the client in a water bath or surrounded by a soft cushion while under light anesthesia or sedation.Stones can also be pulverized with laser lithotripsy.--- to do so, a fine wire, through which the laser beam passes, is inserted into the ureter by means of a cystoscope. Repeated bursts of the laser reduces the stone to a fine powder, which is then passed in the urine.

Medical Management

Other stone removal procedures are performed with ureteroscopic approaches in which the endoscope is inserted from the urethra into the upper urinary tract under anesthesia to grasp, crush, and remove stones from the kidney pelvis or ureter.Afterward, a catheter or ureteral stent, a slender supportive device, is left in place for 3 days to splint the ureter or divert the urine past any possible tear in the ureteral wall (fig 64-7) pg 1134

Medical Management

If the stone cannot be removed, a ureteral catheter is left in place for 24 hours to dilate the ureter in the hope that the stone will pass through it or that it will be pulled into the bladder when the catheter is removed.

Surgical Management

A nephrostomy tube, is a catheter that is inserted through the skin into the renal pelvis to manage any obstruction to urine flow above the bladder.The tube is kept in place with a suture through he skin.Unlike the bladder, the kidney pelvis can only hold APPROX. 5 TO 8 ML of urine.

Surgical Management

If urinary drainage through the tube is impaired for even a short time from a blood clot or kinking or compression of the tubing, hydronephrosis and damage to surgically repaired tissue can result.The client will complain of pain if the renal pelvis becomes distended with urine.

REVIEW ON YOUR OWN

Nursing Guidelines 64-1 pg 1135 Managing a Nephrostomy Tube

Ureteral Stricture pg 1136

A stricture is a narrowing of a lumen; in this case the ureter is narrowedThe recurrent inflammation and infection cause scar tissue to accumulate within the ureter. Other conditions that can interfere with urine passing through the ureter are congenital anomalies or conditions that mechanically compress the ureter such as pregnancy and tumors within the abdomen or upper urinary tract.

S/S

Flank pain or discomfort and tenderness at the costovertebral angle (CVA) due to enlargement of the renal pelvis often develop.CVA where the last rib joins the vertebra

Medical Management pg 1137The ureter can be stretched by inserting a dilator called a filiform or urethral sound, a curved metal rod, followed by others that are sequentially larger.If the obstruction persists, the MD performs a ureteroplasty, removal of the narrowed section of ureter and reconnection of the patent portions.A ureteral stent is placed in the ureter to provide support to the walls of the ureter, relive the obstruction, and maintain the flow of urine through the ureter and into the bladder.

Nursing Management

If a ureteral catheter is inserted preoperatively, measure the urine output from the catheter hourly.Immediately report if there is no urine output from the ureteral catheter.On return from surgery, all urinary drainage tubes and catheters are connected to a closed drainage system or to the type of drainage ordered by the physician.

Nursing Management

The main complication associated with ureteral surgery is failure of the ureter to transport urine from the kidney to the bladder. Contact the MD if signs of shock appear, urinary output from the ureteral catheter is decreased or absent, or if the client complains of significant abdominal pain, which may indicate leakage of urine into the peritoneal cavity.

Nursing Management

Notify the MD if signs of a urinary tract infection develop, such as fever and chills or if the urine is cloudy or has a foul odor.

Tumors of the Kidney pg 1137

A hypernephroma (renal adenocarcinoma) is the most common malignant tumor of the kidney in adults. Squamous cells tumors are second.May be associated with carcinogenic effects of long-term cigarette smoking, environmental toxin (asbestos) or volatile solvents (gasoline)Because the kidneys are deeply protected in the body, tumors can become quite large before causing symptoms.

S/S

The classic triad of renal cancer is PAINLESS hematuria, flank pain, and the presence of a palpable mass.Additional symptoms include weight loss, malaise, and unexplained fever.Later, there is colic-like discomfort during the passage of blood clots

Medical Management

Nephrectomy, including removal of the surrounding perinephric fat, is the treatment for a malignant renal tumor.Surgery, chemotherapy, and radiation doneIf extensive metastases are found, only palliative treatment is given.

Nursing Management pg 1138

Review care plan and family teaching on your own !!!!

Renal Failure pg 1139

The inability of the nephrons within the kidneys to maintain fluid, electrolyte, and acid-base balance, excrete nitrogen waste products, and perform regulatory functions such as maintaining calcification of bones and producing erythropoietin.

Renal Failure

There are two types of renal failure: 1. Acute renal failure (ARF) is characterized by sudden and rapid decrease in renal function. ARF is potentially reversible with early, aggressive treatment of its contributing etiology.2. Chronic renal failure: (CRF) is characterized by progressive and irreversible damage to the nephrons. It may take months to years for CRF to develop.

Acute Renal Failure

Acute renal failure progresses through 4 phases:1. Initiation phase2. Oliguric phase3. Diuretic phase4. Recovery phase

Acute Renal Failure

1. Initiation Phase: begins with the onset of the contributing event.It is accompanied by a reduction in blood flow to the nephrons to the point at which there is acute tubular necrosis (ATN)ATN refers to the death of cells within the collecting tubules of the nephrons where reabsorption of water, electrolytes, and excretion of protein wastes and excess metabolic substances occurs.

Acute Renal Failure

2. Oliguric Phase: associated with the excretion of less that adequate urinary volumes.This phase begins within 48 hours after the initial cellular insult and may last for 10 to 14 days or longer.Fluid volume excess develops, which leads to edema, HTN< and cardiopulmonary complications.

Acute Renal Failure

Azotemia, marked accumulation of urea and other nitrogenous wastes such as creatinine and uric acid in the blood, creates a potential for neurologic changes such as seizures, coma, and death. Some clients excrete urinary volumes greater than 500 mL/day. However, the urine has a very low specific gravity because it lacks normal amounts of excreted substances such as excess potassium and hydrogen ions, to maintain homeostasis.

Acute Renal Failure

Consequently, hyperkalemia, metabolic acidosis, and uremia, a toxic state caused by the accumulation of nitrogen wastes, develop regardless of the excreted water volume.

Acute Renal Failure

Diuretic Phase: diuresis begins as the nephrons recover.Despite an increase in the water content of urine, the excretion of wastes and electrolytes continues to be impaired. The BUN, creatinine, potassium, and phosphate levels remain elevated in the blood.

Acute Renal Failure

Recovery Phase: it may take one or more years of recovery while normal glomerular filtration and tubular function are restored.Some clients recover completely; others develop varying degrees of permanent renal dysfunction.

Chronic Renal Failure

In CRF, the kidneys are so extensively damaged that they do not adequately remove protein by-products and electrolytes from the blood and do not maintain acid-base balance.End-stage renal disease (ESRD) is the term given for the point at which a regular course of dialysis or kidney transplantation is necessary to maintain life.

Chronic Renal Failure

Actual electrolyte imbalances include hyperkalemia, hyperphosphatemia, hypermagnesemia, and hypocalcemia.The skin becomes the excretory organ for the substances the kidney usually clears from the body.A precipitate, referred to as uremic frost, may form on the skin.

Chronic Renal Failure

Assessment: S/S—In both ARF & CRF, the client has an elevated blood pressure and weight gain.Urine output is generally decreased.Facial features appear puffy due to fluid retentionThe skin is pale; ulceration and bleeding of the GI tract may occur.

Chronic Renal Failure

The oral mucous membranes bleed, and blood may be found in the feces.Vague symptoms of lethargy, HA, anorexia, and dry mouth.The client’s breath and body may have an odor characteristic of urine.Table 64-4 lists the systemic manifestations of CRF. Pg 1141

Medical Management pg 1141

DialysisFluid and dietary restrictions that include:Low proteinHigh caloriesLow sodiumLow potassium

Medical Management

Kayexalate—an ion-exchange resin, is prescribed for oral or rectal administration to remove excess potassium when hyperkalemia occurs.An IV infusion of glucose and insulin also facilitates movement of potassium within the cell.Instead of blood transfusions to correct chronic anemia, Epogen is administered to stimulate bone marrow production of RBC’s

Surgical Management Pg 1142Some are candidates for a kidney transplantOne healthy kidney can perform the work of twoAny potential donor with a history of HTN, malignant disease, or DM is excluded form donation.When a transplant is performed, the donor kidney is inserted through an abdominal incision and the nonfunctioning kidneys are left in place unless the client is extremely hypertensive.

Surgical Management

The blood vessels from the donor kidney are sutured to the iliac artery and vein and the ureter is implanted in the bladder. (fig 64-11 pg 1142)

Dialysis Pg. 1143

A procedure for cleaning and filtering the blood.It provides a substitute for kidney function when the kidneys are unable to remove the nitrogenous waste products and maintain adequate fluid, electrolyte, and acid-base balance.

Dialysis

During dialysis the client’s blood is filtered by diffusion and osmosis.Substances such as urea, creatinine,and dangerously high levels of potassium, and water move FROM the blood through the semipermeable membrane TO the dialysate, the solution used during dialysis that has a composition similar to normal human plasma.

Dialysis

Dialysis is performed by hemodialysis and peritoneal dialysis.Either technique can be performed at home or in a dialysis center.Each type of dialysis has advantages and disadvantages. Table 64-5 pg. 1148

Arteriovenous Fistula

A surgical anastomosis (connection) of an artery and vein lying in close proximity. Fig 64-13 pg 1149The vessels usually joined are the cephalic vein and the radial artery or the cephalic vein and brachial artery.They require from 1 to 4 months to mature before being used.

Arteriovenous Fistula

At the time of dialysis, two venipunctures are performed at either end of the fistula The distal venipuncture is used to remove blood that is transported to the machine.The proximal needle puncture is used to return the dialyzed blood.When dialysis is completed, the needles are removed and pressure dressings are applied for several hours.

Arteriovenous Fistula

Blood samples are taken before and after dialysis.The client’s predialysis and postdialysis weights are compared. Sometimes as much as 10 lb of fluid is removed.BUN, creatinine, sodium, potassium, chlorides, and HCT are used as indicators of efficiency of dialysis.l

Arteriovenous Graft

A type of vascular access method that uses a tube of synthetic material to connect a vein and artery in the upper or lower arm Fig 64-13 pg 1149.The graft pulsates with blood flowAV grafts can be used 14 days after their insertion.Although the graft reseals after each needle puncture, the expected life of the graft is 3 to 5 years with repeated use.

Nursing Management

Assess & record vital signs before and after hemodialysis.Weigh the client and obtain blood for lab’sTo prepare for vascular access:Palpate for a THRILL (vibration) over the vascular access. Listen for a BRUIT, a loud sound caused by turbulent blood flow. IF ABSENT, POSTPONE FURTHER USE AND REPORT FINDINGS.

Nursing Management

After dialysis is completed, do not administer injections for 2 to 4 hours.This allows time for the metabolism and excretion of heparin, which is administered during dialysis, to reach safe levels.Before discharging the client, observe for disequilibrium syndrome.

Nursing Management

Disequilibrium Syndrome: a neurologic condition believed to be caused by cerebral edema.The shift in cerebral fluid volume occurs when the concentrations of solutes within the blood are lowered rapidly during dialysisDecreasing solute concentration lowers the plasma osmolality.WATER THEN FLOODS THE BRAIN TISSUE!!!

Nursing Management

This syndrome is characterized by HA, disorientation, restlessness, blurred vision, confusion, and seizures.The symptoms are self-limiting and disappear within several hours after dialysis as fluid and solute concentrations equalize.The syndrome can be prevented by slowing the dialysis process to allow time for gradual equilibration of water.

Nursing Management

Client Teaching: Avoid carrying heavy items in the arm with the fistula or graftDo not sleep on the vascular access armDo not permit venipunctures, injections, or blood pressures in the arm with the vascular access. Assess for a thrill or bruit daily!!