Objectives At the end of this session students will be able to: Describe the nursing management of patients with acute and chronic renal failure.Describe the nursing management of the renal transplant.Develop a postoperative plan of nursing care and teaching plan for the patient undergoing kidney surgery and transplantation

Kidney

GlomerulusThis is the only place in the system where the blood is actually filtered.Blood pressure is used to push plasma through capillary walls and into the Bowmans capsule.

Proximal tubuleNutrients (salts, vitamins, etc.) are moved out of the tubule through active transport.Water follows the nutrients by osmosis.

Functions of kidneyExcretion ~ remove nitrogenous waste i.e. urea, salts, water, heat, toxic substanceOsmoregulation ~ controlling amount of water in body ~ maintain osmotic potential

QuestionIs the following statement True or False?

The most accurate indicator of fluid loss or gain in an acutely ill patient is weight.

AnswerTrue

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.

Definition Acute Renal Failure is defined as sudden, rapid, potentially reversible deterioration of renal function.Chronic Renal Failure is the end result of progressive, irreversible loss of functioning renal tissue.

Causes of Acute Renal FailureHypovolemiaHypotensionReduced cardiac output and heart failure Obstruction of the kidney or lower urinary tractObstruction of renal arteries or veins

Causes of Chronic Renal FailureDiabetes mellitusHypertensionChronic glomerulonephritis, Pyelonephritis or other infectionsObstruction of urinary tractHereditary lesions

Causes of Chronic Renal FailureVascular disordersMedications or toxic agents

Collaborative Problems/Potential ComplicationsHyperkalemiaPericarditisPericardial effusionPericardial tamponadeHypertensionAnemiaBone disease and metastatic calcifications

The Care of the Patient with Renal FailureAssessmentFluid statusNutritional statusPatient knowledgeActivity toleranceSelf-esteemPotential complications

Nursing ManagementInspect neck veins for engorgement, and extremites abdomen, sacrum,and eyelids for oedema.Administer prescribed medication which may include antibiotics, calcium supplements Assess for infection, especially of the respiratory and urinary tracts

Nursing ManagementMonitor vital signsWeigh patient dailyAssess for signs and symptoms of fluid volume excess, and keep accurate I&O

Nursing ManagementExplain to patient and family the rationale for the fluid restriction Assist patient to cope with the fluid restrictionProvide or encourage frequent oral hygiene

Nursing ManagementAssess nutritional status; weight changes and lab dataAssess patient nutritional patterns and history; note food preferencesEncourage high-quality nutritional foods while maintaining nutritional restrictions

Nursing ManagementAssess and modify intake related to factors that contribute to altered nutritional intake, eg, stomatitis or anorexiaAdjust medication times related to meals Encourage high calorie, low-protein, low-sodium and low potassium snacks between meals

Nursing ManagementAssess for evidence of inadequate protein intake: edema, delayed wound healing and decreased serum albumin levelsProvide patient with food preferences within dietary restrictionsAssist patient to cope with the discomforts resulting from fluid restrictions

Nursing ManagementMonitor urinary output and urine specific gravity.Monitor for signs of hypervolemia and hypovolemia because the regulating capacity of the kidneys are inadequate.Instruct patient about the importance of following prescribed diet and avoiding foods high in potassium.

Risk for Situational Low Self EsteemAssess patient and family responses to illness and treatmentAssess relationships and coping patternsEncourage open discussion about changes and concerns

Risk for Situational Low Self EsteemExplore alternate ways of sexual expressionDiscuss role of giving and receiving love, warmth, and affection

Acute GlomerulonephritisRefers to a group of kidney diseases in which there is an inflammatory reaction in the glomeruli

Clinical Manifestations

tea coloured urineOliguriaFatigue and anorexiaHypertensionAnemiaPossible headachePuffiness of faceEdema of extremities

Nursing ManagementMonitor vital signs, intake and output and maintain dietary restrictionsEncourage restAdminister medications as ordered and evaluate patients response to antihypertensives, diuretics and antibiotics.

Nursing ManagementMonitor for signs of heart failure, distended neck veins, tachycardia, enlarged and tender liver

Observe for hypertensive encephalopathy and any evidence of seizure activity.

Kidney SurgeryPreoperative considerationsPerioperative concernsPostoperative managementPotential hemorrhage and shockPotential abdominal distention and paralytic ileus

Kidney SurgeryPotential infectionPotential thromboembolism

Patient Positioning and Incisional Approaches

Renal Transplantation

Postoperative Nursing ManagementAssessment: include all body systems, pain, fluid and electrolyte status, and patency and adequacy of urinary drainage systemDiagnoses: ineffective airway clearance, ineffective breathing pattern, acute pain, fear and anxiety, impaired urinary elimination, and risk for fluid imbalance

Postoperative Nursing ManagementComplications: bleeding , pneumonia, infection, and DVT

InterventionsPain relief measures and analgesic medicationsPromote 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

Nursing ManagementPain relief measures and analgesic medicationsPromote 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

Nursing ManagementMonitor for signs and symptoms of bleedingEncourage leg exercises, early ambulation, and monitor for signs of DVTUse strict asepsis with catheter and appropriate technique in providing all care

Patient TeachingInstruct both patient and family Drainage system care Strategies to prevent complicationsSigns and symptomsFollow-up careFluid intakeHealth promotion and health screening

Renal TransplantKidney transplantation is performed on patients with chronic kidney failure, or end-stage renal disease (ESRD). ESRD occurs when: a disease, disorder, or congenital condition damages the kidneys so that they are no longer capable of adequately removing fluids and wastes from the body

Renal Transplantor of maintaining the proper level of certain kidney-regulated chemicals in the bloodstream. Without long-term dialysis or a kidney transplant, ESRD is fatal.

Open nephrectomy

The surgical procedure to remove a kidney from a living donor is called a nephrectomy. In a traditional, open nephrectomy, the kidney donor is administered general anesthesia and a 610-in (15.225.4-cm) incision through several layers of muscle is made on the side or front of the abdomen.

Open nephrectomy

The kidney and an attached section of ureter are removed from the donor. A similar procedure is used to harvest cadaver kidneys, although both kidneys are typically removed at once, and blood and cell samples for tissue typing are also taken.

Kidney transplant

During the transplant operation, the kidney recipient is typically under general anesthesia and administered antibiotics to prevent possible infection. A catheter is placed in the bladder before surgery begins.

Kidney transplant

An incision is made in the flank of the patient, and the surgeon implants the kidney above the pelvic bone and below the existing, non-functioning kidney by suturing the kidney artery and vein to the patient's iliac artery and vein.

Kidney transplant

The ureter of the new kidney is attached directly to the kidney recipient's bladder. Once the new kidney is attached, the patient's existing, diseased kidneys may or may not be removed, depending on the circumstances surrounding the kidney failure. Barring any complications, the transplant operation takes about three to four hours.

Complications InfectionAcute rejection appears within the first 6 months after transplantation and affects approximately 15% of transplanted kidneysChronic rejection occurs more than 1 year after transplantation

Complications HypertensionRenal vein thrombosis is typically an early complication presenting as graft tenderness and edema

Class ActivityFormulate nursing interventions for the following diagnoses:

Risk for anxiety related to transplant experience, potential for rejection, and side effects of medications.

Class ActivityRisk for ineffective management of therapeutic regimen related to insufficient knowledge of prevention of infection, and dietary management.Risk for Fear related to diagnosis and anticipated surgical experience.

Patient TeachingExplain and reinforce symptoms of rejection- fever, chills, sweating, hypertension, lassitude, weight gain, decrease in urine output, peripheral oedema.Stress that follow up care after transplantation is a life long process.

Patient TeachingAdvise avoidance of contact sports for life to prevent trauma to the transplanted kidney.

Patient TeachingInstruct patient and family about prescribed immuno-suppressants and complication of therapy.Observe for symptoms of urine leak, such as sudden loss of kidney function, pain over transplant site and copious drainage of yellow fluid from the wound

Bladder CancerBladder cancer involves any one of the following cell carcinomas in the lining of the bladder: transitional, squamous, or adenocarcinoma. This is most common form of cancer associated with the urinary track. Bladder cancer is rare before the age of 50 and occurs more frequently in men than in women.

Risk FactorsCarcinogens in the workplace, such as dyes, rubber, leather, paintRecurrent bacterial infection of urinary tractSmoking Bladder stones

Risk FactorsHigh urinary PhHigh cholesterol intakeCancers arising from prostate, colon and rectum in males

Clinical ManifestationsHematuriaPain and a mass in the flankDull pain in the back from pressure produced by compression of the ureterExtension of the tumour into the perirenal area

Clinical ManifestationsHaemorrhage into the kidney tissuesColicky pains occur if mass or clot of tumour cells passes down from the ureterUnexplained weight loss

Clinical ManifestationsGross, painless hematuriaUrinary frequencyUrgencyDysuriaPelvic or back pain with metastasis

Treatment ChemotherapyThere are three main ways that chemotherapy can be used to treat muscle-invasive bladder cancer. It can be used:before radiotherapy and surgery to shrink the size of any tumours

Treatment in combination with radiotherapy before surgery (chemoradiation) to slow the spread of incurable, advanced bladder cancer .

Treatment Radiotherapy that is used to shrink tumours and achieve a cure is given by a machine that beams the radiation at the bladder (external radiotherapy).

Class activityFormulate nursing interventions for the following nursing diagnoses:

Risk for infection related to invasive procedures.

Nursing ManagementRisk for Impaired Skin Integrity related to the effects of radiation and chemotherapy, immunologic deficits, decreased nutrient intake and anemia.Risk for Sexual Dysfunction related to deficit of knowledge / skills about alternative responses to health transition, decreased function / structure, the effects of treatment.

Urinary CalculiKidney stones (renal lithiasis) are small, hard deposits that form inside your kidneys. The stones are made of mineral and acid salts. Kidney stones have many causes and can affect any part of your urinary tract from your kidneys to your bladder. Often, stones form when the urine becomes concentrated, allowing minerals to crystallize and stick together.

Risk FactorsFamily or personal history. Dehydration. Certain diets. Too much sodium in your diet increases the amount of calcium your kidneys must filter and significantly increases your risk of kidney stones.Being obese. High body mass index (BMI)

Risk FactorsDigestive diseases and surgery. Gastric bypass surgery, inflammatory bowel disease or chronic diarrhea can cause changes in the digestive process that affect your absorption of calcium and water, increasing the levels of stone-forming substances in your urine.

Clinical ManifestationsA kidney stone may not cause symptoms until it moves around within your kidney or passes into your ureter the tube connecting the kidney and bladder. At that point, these signs and symptoms may occur:

Clinical ManifestationsSevere pain in the side and back, below the ribsPain that spreads to the lower abdomen and groinPain that comes in waves and fluctuates in intensityPain on urinationPink, red or brown urine

Clinical ManifestationsCloudy or foul-smelling urineNausea and vomitingPersistent urge to urinateUrinating more often than usualFever and chills if an infection is present

Diagnostic TestsBlood tests. Blood tests may reveal too much calcium or uric acid in your blood. Urine tests. Tests of your urine, such as the 24-hour urine collection, may show that you're excreting too many stone-forming minerals or too few stone-preventing substances.

Diagnostic TestsImaging tests. Imaging tests may show kidney stones in your urinary tract. Analysis of passed stones. You may be asked to urinate through a strainer to catch stones that you pass. Lab analysis will reveal the makeup of your kidney stones.

Health Education/PromotionLifestyle changes You may reduce your risk of kidney stones if you: Drink water throughout the day. For people with a history of kidney stones, doctors usually recommend passing about 2.6 quarts (2.5 liters) of urine a day.

Health Education/PromotionEat fewer oxalate-rich foods. If you tend to form calcium oxalate stones, your doctor may recommend restricting foods rich in oxalates. These include rhubarb, beets, okra, spinach, sweet potatoes, nuts, tea, chocolate and soy products.

Health Education/PromotionContinue eating calcium-rich foods, but use caution with calcium supplements. Calcium in food doesn't have an effect on your risk of kidney stones. Continue eating calcium-rich foods unless your doctor advises otherwise.

Health Education/PromotionAsk your doctor before taking calcium supplements, as these have been linked to increased risk of kidney stones. You may reduce the risk by taking supplements with meals.

Health Education/PromotionChoose a diet low in salt and animal protein. Reduce the amount of salt you eat and choose non animal protein sources, such as legumes.

References Nachman, P.H, et al. (2008).Primary glomerular disease. In: Brenner BM. Brenner & Rector's The Kidney. 8th ed. Philadelphia, Pa.: Saunders Elsevier.Nettina. S (2010). Lippincott Manual of Nursing Practice. 9th ed. Lippincott Williams & Wilkins.

References Stoller, M.L. (2008)Urinary stone disease. In: Tanagho EA, et al. Smith's General Urology. 17th ed. New York, N.Y.: McGraw-Hill Medical.

References Watkins, R,W. (2007)Urolithiasis (kidney and bladder stones). In: Rakel D. Integrative Medicine. 2nd ed. Philadelphia, Pa.: Saunders Elsevier.Worcester EM, et al.(2008). Nephrolithiasis. Primary Care: Clinics in Office Practice. 35, 369

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