1. Chapter 54 Management of Patients With Kidney Disorders

2. Kidney Disorders Fluid and electrolyte imbalances
Most accurate indicator of fluid loss or gain, in an acutely ill patient, is weight
Refer to Table 54-1

3. Question
Is the following statement true or false? The most accurate indicator of fluid loss or gain in an acutely ill patient is weight.

4. 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.

5. Causes of Acute Kidney Failure
Hypovolemia
Hypotension
Reduced cardiac output and heart failure
Obstruction of the kidney or lower urinary tract
Obstruction of renal arteries or veins

6. Causes of Chronic Kidney Failure
Diabetes mellitus
Hypertension
Chronic glomerulonephritis
Pyelonephritis or other infections
Obstruction of urinary tract
Hereditary lesions
Vascular disorders
Medications or toxic agents

7. Glomerular Diseases Inflammation of the glomerular capillaries
Acute nephritic syndrome
Chronic glomerulonephritis
Nephrotic syndrome

8. Acute Nephritic Syndrome
A type of renal failure with glomerular inflammation
Postinfectious glomerulonephritis, rapidly progressive glomerulonephritis, and membranous glomerulonephritis
Manifestations include hematuria, edema, azotemia (abnormal nitrogenous wastes), proteinuria, and hypertension
May be mild or may progress to acute renal failure or death
Medical management includes supportive care and dietary modifications; treat cause if appropriate— antibiotics, corticosteroids, and immunosuppressants

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

10. Chronic Glomerulonephritis
Inflammation of the glomerular capillaries
Repeated acute glomerular nephritis, hypertensive nephrosclerosis, hyperlipidemia, and other causes of glomerular damage
Renal insufficiency or failure: asymptomatic for years as glomerular damage increases before signs and symptoms develop
Abnormal laboratory test results: urine with fixed specific gravity, casts, proteinuria, electrolyte imbalances and hypoalbuminemia
Medical management determined by symptoms

11. Nursing Process Assessment Potential fluid and electrolyte imbalances
Cardiac status
Neurologic status
Emotional support
Education in self-care

12. Nephrotic Syndrome
Type of renal failure with increased glomerular permeability and massive proteinuria
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 (proteins that form in tissues and organs), lupus erythematosus, multiple myeloma, and renal vein thrombosis
Medical management includes drug and dietary therapy

13. Kidney 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 glomerular filtration rate and oliguria
Chronic renal failure (ESRD) is a progressive, irreversible deterioration of renal function that results in azotemia

14. Nursing Process: The Care of Patients With Chronic Kidney Disease and Acute Kidney Injury—Assessment
Fluid status
Nutritional status
Patient knowledge
Activity tolerance
Self-esteem
Potential complications

15. Nursing Process: The Care of Patients With Chronic Kidney Disease and Acute Kidney Injury—Diagnosis
Excess fluid volume
Imbalanced nutrition
Deficient knowledge
Risk for situational low self-esteem

16. Collaborative Problems and Complications
Hyperkalemia
Pericarditis
Pericardial effusion
Pericardial tamponade (pressure on heart from fluid buildup around the heart)
Hypertension
Anemia
Bone disease and metastatic calcifications

17. Nursing Process: The Care of Patients With Chronic Kidney Disease and Acute Kidney Injury—Planning
Goals may include maintaining of IBW (ideal body weight) without excess fluid, maintenance of adequate nutritional intake, increased knowledge, participation of activity within tolerance improved self-esteem, and absence of complications.

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

19. Imbalanced Nutrition: Assessment
Nutritional status; weight changes, laboratory data
Nutritional patterns, history, preferences
Provide food preferences within restrictions
Encourage high-quality nutritional foods while maintaining nutritional restrictions
Stomatitis or anorexia: modify intake related to factors that contribute to alterations
Adjust medication times related to meals

20. 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

21. Hemodialysis System

22. Hemodialysis Catheter

23. Internal Arteriovenous Fistula and Graft

24. Peritoneal Dialysis

25. Peritoneal Dialysis

26. Question
Is the following statement true or false? Failure of the temporary dialysis access accounts for most hospital admissions of patients undergoing chronic hemodialysis.

27. Answer
False Failure of the permanent dialysis access accounts for most hospital admissions of patients undergoing chronic hemodialysis.

28. Nursing Process: The Care of the Hospitalized Patient on Dialysis—Assessment
Protect vascular access; assess site for patency, signs of potential infection, do not use for blood pressure or blood draws
Carefully monitor fluid balance, IV therapy, accurate I&O, IV administration pump
s/s of uremia and electrolyte imbalance, regularly check lab data
Monitor cardiac/respiratory status carefully
Cardiovascular medications must be held prior to dialysis

29. Nursing Process: The Care of the Hospitalized Patient on Dialysis—Interventions
Monitor all medications and medication dosages carefully
Address pain and discomfort
Stringent infection control measures
Dietary considerations: sodium, potassium, protein, fluid, individual nutritional needs
Skin care: pruritus, keep skin clean and well moisturized, trim nails, and avoid scratching
CAPD catheter care

30. Kidney Surgery Preoperative considerations Perioperative concerns
Postoperative management
Potential hemorrhage and shock
Potential abdominal distention and paralytic ileus (obstruction of intestine caused by paralysis of part of intestinal muscles, aka pseudo-obstruction)
Potential infection
Potential thromboembolism

31. Positioning and Incisional Approaches

32. Kidney Transplantation

33. 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

34. Postoperative Interventions
Pain relief measures, analgesic medications
Promote airway clearance and effective breathing pattern, turn, cough, deep breathe, incentive spirometry, positioning
Monitor UO and maintain patency of urinary drainage systems
Use strict asepsis with catheter
Monitor for signs and symptoms of bleeding
Encourage leg exercises, early ambulation, and monitor for signs of DVT

35. Patient Education 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