1. Management of Patients with Renal Disorders

2. Glomerular Diseases Acute Glomerulonephritis
Chronic Glomerulonephritis
Nephrotic Syndrome

3. Glomerulonephritis

4. Acute Glomerulonephritis
Preceded (10 days) by an infection
Assess for:
Lesions
Signs of circulatory overload
Change in urine color and amount
Mild to moderate hypertension
Interventions:
Treat cause: antibiotics, corticosteroids, immunosuppressants
Restrict sodium, water, potassium, protein
Dialysis, plasmapheresis
Client education
Three types: postinfectious, rapidly progressive glomerulonephritis, and membranous glomerulonephritis
Manifestations: hematuria, edema, azotemia, proteinuria, and hypertension
May be mild or progress to acute renal failure. Usually recover quickly and comletely.
Medical management is supportive and focuses on treatment of underlying cause.

5. Nursing Management- Acute Glomerulonephritis
Patient assessment
Maintain fluid balance
Fluid and dietary restrictions
Patient education
Follow-up care

6. Chronic Glomerulonephritis
years to develop
Diagnostics:
Urine with fixed specific gravity, casts, and proteinuria
Electrolyte imbalances
hypoalbuminemia
Causes:
Repeated episodes of acute glomerulonephritis, hypertensive nephrosclerosis, hyperlipidemia,
Manifestations:
Mild proteinuria and hematuria, hypertension, and occasional edema

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

8. Nephrotic Syndrome Increased glomerular permeability
Severe loss of protein into urine
Treatment:
Immunosuppresive agents
ACE Inhibitors
Heparin
Diet changes
Mild diuretics

9. Nephrotic Syndrome

10. Nephrosclerosis
Narrowing of vessel lumen from thickening in blood vessels of the nephron
Occurs with hypertension, atherosclerosis and diabetes mellitus
Collaborative management:
Control hypertension
Preserve renal function

11. Renal Failure
Results when kidney’s cannot remove wastes or perform regulatory functions
Systemic disorder resulting from many different causes
Acute renal failure- reversible syndrome that results in decreased GFR and oliguria
Chronic renal failure- progressive; irreversible deterioration of renal function resulting in azotemia

12. Acute Renal Failure Pathophysiology
Types of acute renal failure include:
Prerenal
Intrarenal
Postrenal

13. Phases of Acute Renal Failure
Phases of rapid decrease in renal function lead to the collection of metabolic wastes in the body.
Phases include:
Onset
Diuretic
Oliguric
Recovery
Acute syndrome may be reversible with prompt intervention.

14. Assessment History Clinical manifestations Laboratory assessment
Radiographic assessment
Other diagnostic assessments such as renal biopsy

15. Drug Therapy Cardioglycides Vitamins and minerals
Biologic response modifiers
Phosphate binders
Stool softeners and laxatives
Monitor fluids
Diuretics
Calcium channel blockers
Not parallel

16. Treatment Diet therapy Dialysis therapies Hemodialysis
Peritoneal dialysis

17. Renal Replacement Therapy
Standard treatment
Dialysate solution
Vascular access
Continuous arteriovenous hemofiltration
Continuous venovenous hemofiltration

18. Posthospital Care
If renal failure is resolving, follow-up care may be required.
There may be permanent renal damage and the need for chronic dialysis or even transplantation.
Temporary dialysis is appropriate for some clients.
S&P

19. Chronic Renal Failure
Progressive, irreversible kidney injury; kidney function does not recover
Azotemia
Uremia
Uremic syndrome

20. Stages of Chronic Renal Failure
Diminished renal reserve
Renal insufficiency
End-stage renal disease

23. Changes R/T CRF Kidney Metabolic Electrolytes Acid-base balance
Urea and creatinine
Electrolytes
Sodium
Potassium
Acid-base balance
Calcium and phosphorus
(Continued)

24. Changes R/T CRF (Continued)
Cardiac
Hypertension
Hyperlipidemia
Congestive heart failure
Uremic pericarditis
Hematologic
Gastrointestinal

25. Clinical Manifestations
Neurologic
Cardiovascular
Respiratory
Hematologic
Gastrointestinal
Urinary
Skin

26. Imbalanced Nutrition: Less Than Body Requirements
Interventions include:
Dietary evaluation for:
Protein
Fluid
Potassium
Sodium
Phosphorus
Vitamin supplementation

27. Excess Fluid Volume Interventions: Monitor client’s intake and output.
Promote fluid balance.
Assess for manifestations of volume excess:
Crackles in the bases of the lungs
Edema
Distended neck veins
Drug therapy includes diuretics.

28. Decreased Cardiac Output
Interventions:
Control hypertension with calcium channel blockers, ACE inhibitors, alpha- and beta-adrenergic blockers, and vasodilators.
Instruct client and family to monitor blood pressure, client’s weight, diet, and drug therapy.

29. Risk for Infection Interventions include: Meticulous skin care
Preventive skin care
Inspection of vascular access site for infection
Monitoring of vital signs for manifestations of infection

30. Risk for Injury Interventions include: Drug therapy
Education to prevent fall or injury, pathologic fractures, bleeding, and toxic effects of prescribed drugs
S&P

31. Fatigue Interventions:
Assess for vitamin deficiency, anemia, and buildup of urea.
Administer vitamin and mineral supplements.
Administer erythropoietin therapy for bone marrow production.
Give iron supplements as needed.
S&P

32. Anxiety Interventions include: Health care team involvement
Client and family education
Continuity of care
Encouragement of client to ask questions and discuss fears about the diagnosis of renal failure
S&P

33. Potential for Pulmonary Edema
Interventions:
Assess the client for early signs of pulmonary edema.
Monitor serum electrolyte levels, vital signs, oxygen saturation levels, hypertension.

34. Hemodialysis Client selection Dialysis settings
Works using passive transfer of toxins by diffusion
Anticoagulation needed, usually heparin treatment
S&P

35. Vascular Access
Arteriovenous fistula, or arteriovenous graft for long-term permanent access
Hemodialysis catheter, dual or triple lumen, or arteriovenous shunt for temporary access
Precautions
Complications

36. Permanent Vascular Access

37. Hemodialysis Nursing Care
Postdialysis care:
Monitor for complications such as hypotension, headache, nausea, malaise, vomiting, dizziness, and muscle cramps.
Monitor vital signs and weight.
Avoid invasive procedures 4 to 6 hours after dialysis.
Continually monitor for hemorrhage.

38. Complications of Hemodialysis
Dialysis disequilibrium syndrome
Infectious diseases
Hepatitis B and C infections
HIV exposure—poses some risk for clients undergoing dialysis
S&P

39. Peritoneal Dialysis
Procedure involves siliconized rubber catheter placed into the abdominal cavity for infusion of dialysate.
Types of peritoneal dialysis:
Continuous ambulatory peritoneal
Automated peritoneal
Intermittent peritoneal
Continuous-cycle peritoneal

40. Complications Peritonitis Pain Exit site and tunnel infections
Poor dialysate flow
Dialysate leakage
Other complications

41. Nursing Care During Peritoneal Dialysis
Before treating, evaluate baseline vital signs, weight, and laboratory tests.
Continually monitor the client for respiratory distress, pain, and discomfort.
Monitor prescribed dwell time and initiate outflow.
Observe the outflow amount and pattern of fluid.

42. Nursing Management of Hospitalized Client on Dialysis
Protect vascular access
Monitor fluid balance indicators
Monitor IV carefully
Assess for s/s uremia
Monitor cardiopulmonary status carefully
Monitor BP
Monitor medications
Address pain and discomfort
Infection control measures
Monitor dietary e-lytes and fluids
Skin care
CAPD catheter care if appropriate

43. Renal Transplantation
Candidate selection criteria
Donors
Preoperative care
Immunologic studies
Surgical team
Operative procedure

44. Postoperative Care Assessment Urologic management Complications
all body systems
Pain
Fluid and electrolyte status
Urologic management
Assessment of system patency
Assessment of urine output hourly for 48 hours.
Complications
Rejection
Acute tubular necrosis
Thrombosis
Renal artery stenosis
Other complications
Immunosuppressive drug therapy
Psychosocial preparation

45. Post-transplantation Intervetions
Pain relief measures and analgesics
Promote airway clearance and effective breathing pattern
Strict asepsis
Monitor for signs/symptoms of bleeding
Encourage leg exercises, early ambulation, and monitor for signs of DVT

46. Renal Cell Carcinoma
Healthy kidney tissue damaged and replaced by cancer cells
Paraneoplastic syndrome:
Anemia
Erythrocytosis
Hypercalcemia
Liver dysfuntion
Hormonal effects
Increased sedimentation rate
Hypertension

47. Renal Cell Carcinoma Management
Nonsurgical
Radiofrequency ablation
Chemotherapy
Biological response modifiers and tumor necrosis factor lengthen survival time
Renal artery embolization
Surgical
Pre-op care
Nephrectomy
Post-op care:
Monitoring for hemorrhage and adrenal insufficiency
Pain management
Prevention of complications

48. Renal Trauma Minor injuries: Major injuries: Nonsurgical management:
Contusions, small lacerations
Major injuries:
Lacerations to cortex, medulla, or branches or renal artery
Nonsurgical management:
Drug and fluid therapy
Surgical management:
Nephrectomy or partial nephrectomy