1. Chapter 44 Management of Patients With Renal Disorders

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

3. 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

4. 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

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

6. 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

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

8. 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.

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

10. 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

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

12. Nursing Process: The Care of the Patient with Renal Failure—Diagnoses
Excess fluid volume
Imbalanced nutrition
Deficient knowledge
Risk for situational low self-esteem

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

14. Nursing Process: The Care of the Patient 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.

15. 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

16. 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

17. 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

18. Hemodialysis System

19. Hemodialysis Catheter

20. Internal Arteriovenous Fistula and Graft

21. Peritoneal Dialysis

22. Peritoneal Dialysis

23. 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.

24. 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.

25. Kidney Surgery Preoperative considerations Perioperative concerns
Postoperative management
Potential hemorrhage and shock
Potential abdominal distention and paralytic ileus
Potential infection
Potential thromboembolism

26. Patient Positioning and Incisional Approaches

27. Renal Transplantation

28. 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

29. 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

30. 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