Urinary Chapter 58 - Caring for Clients with Disorders of the Kidneys and Ureters

Secondary glomerulonephritis

inflammation of the glomeruli of the kidneys that results from other chronic conditions, such as lupus erythematosus or diabetes.

Peritonitis

inflammation of the peritoneum, the serous sac lining the abdominal cavity.

Explain why a client with an indwelling catheter is at risk for acute pyelonephritis.

A client who has an indwelling catheter is at risk for the introduction of pathogens to the urinary tract secondary to improper catheterization technique or improper catheter care. Strict asepsis is essential to prevent urinary tract infections in these clients.

Glomerulonephritis

inflammatory renal disorder that occurs most frequently in children and young adults that is preceded by an upper respiratory infection with group A beta-hemolytic streptococci; impetigo (skin infection); or viral infections such as mumps, hepatitis B, or HIV.

A client is admitted with a possible diagnosis of acute glomerulonephritis. When the nurse admits the client, which of the following signs is indicative of acute glomerulonephritis? Blood pressure 100/60 mm Hg Periorbital edema Polyuria Temperature 37.2° C

. Answer: 2. Rationale: Edema, and particularly periorbital edema, are common signs in clients with acute glomerulonephritis. Blood pressure is typically elevated over 140/90 mm Hg, and urine output is decreased. Clients may be febrile.

1 Discuss the nursing management of a client with a nephrostomy tube

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10 Discuss nursing assessments performed when caring for clients undergoing dialysis

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2 Describe conditions that cause a ureteral stricture

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2 Name problems the nurse manages when caring for clients with glomerulonephritis

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3 Explain the classic triad of symptoms associated with renal cancer

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3 Explain the pathophysiology and associated renal complications of polycystic disease

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4 Discuss problems the nurse manages when caring for a client with a nephrectomy

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4 Give examples of conditions that predispose to renal calculi

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5 Differentiate acute and chronic renal failure

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5 Identify methods for eliminating small renal calculi and larger stones

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6 Explain pathophysiologic problems associated with chronic renal failure

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7 Describe sources of organs for kidney transplantation

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8 Identify nursing methods for managing pruritus

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9 Explain the purposes and methods of dialysis

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Assessment findings of Polycystic Kidney Disease: Hypertension is present in approximately 75% of affected clients at the time of diagnosis. Other symptoms, such as pain from retroperitoneal bleeding, lumbar discomfort, and abdominal tenderness are caused by the size and effects of the cysts. The client may experience colic (acute spasmodic pain) when there is ureteral passage of clots or calculi. Many clients with this disorder also have hematuria because of UTIs and ruptured cysts. Renal stones are also common. Many clients also experience headache and increased abdominal girth.

A family history of affected members is a presumptive diagnostic indicator. Urinalysis shows mild proteinuria, hematuria, and pyuria. A complete blood count may show decreased or increased RBCs and hematocrit; an increase is seen because erythropoietin production sometimes is accelerated. Abdominal ultrasound, CT scan, magnetic resonance imaging (MRI), and IVP reveal enlarged kidneys with indentations caused by cysts. Laboratory tests such as BUN and serum creatinine indicate the degree of current kidney dysfunction.

Gerontologic considerations for Acute Glomerulonephritis?

Acute glomerulonephritis in the older adult usually occurs in those with preexisting chronic glomerulonephritis, often caused by streptococcus or gram-negative bacteria. Glomerulonephritis may occur as immunity declines; as an immunologic reaction to another system disease, such as lupus (lupus erythematosus); or as the result of unknown causes. Symptoms in the older adult are subtle and nonspecific (e.g., nausea, malaise, arthralgia, exacerbation of preexisting illness) and therefore may go undetected. Heart or renal failure symptoms may accompany the presentation. Thorough documentation promotes careful consideration of subtle changes in older adults.

Acute nephritic syndrome:

Acute nephritic syndrome: term used to describe the clinical manifestations of glomerular inflammation caused by various disorders.

A client has trimethoprim-sulfamethoxazole (Bactrim) ordered when diagnosed with pyelonephritis. A week later, the client has a follow-up appointment. Which of the following findings indicates the client adhered to the treatment regimen? Bacteria are not present on the urine culture. Client reports that the flank pain has resolved. Client states that he or she is voiding large amounts. The red blood cell count is 4.8 million cells/mm3.

Answer: 1. Rationale: The absence of bacteria on a urine culture indicates that the antibiotic has been effective. Although absence of pain indicates that the infection has improved, it is not an indicator for the effectiveness of an antibiotic. Antibiotics do not impact urine output or the red blood cell levels

Patho and Etiology of Polycystic Kidney Disease: Adult polycystic kidney disease is inherited as an autosomal dominant trait, which means that an affected parent passes the gene for the disease to his or her children. Each child has a 50:50 chance of acquiring the defective gene (Fig. 58-3). This is opposed to autosomal recessive inheritance, in which a child has a 25% chance of being affected.

As the name implies, this disorder is characterized by the formation of multiple bilateral kidney cysts (Fig. 58-4). The cysts interfere with kidney function and eventually lead to renal failure. The fluid-filled cysts cause great enlargement of the kidneys, from their normal size of a fist to that of a football. As the cysts enlarge, they compress the renal blood vessels and cause chronic hypertension. Bleeding into cysts causes flank pain. People with polycystic disease are much more susceptible to kidney infections and kidney stones. Besides renal failure, other complications include cysts on the pancreas and liver, an enlarged heart, mitral valve prolapse, and brain aneurysm.

Assessment Findings of Pyelonephritis: Signs and Symptoms: ***Flank pain, CVA tenderness - tenderness in the costovertebral angle - u can palpate it Flank pain or tenderness, chills, fever, and malaise occur in clients with acute pyelonephritis. Frequency and burning on urination are present if there is accompanying cystitis (bladder infection). Some clients with chronic pyelonephritis are asymptomatic; others have a low-grade fever and vague gastrointestinal complaints. Polyuria and nocturia develop when the tubules of the nephrons fail to reabsorb water efficiently. *** Fever, chills, flank pain, colony forming units more than 100,000 on urine culture. CFU > 100,000

Assessment Findings of Pyelonephritis: Diagnostics: Urinalysis - most common and urine culture to isolate the bug A urinalysis demonstrates multiple abnormalities. The chief abnormality is pyuria, or pus (a combination of bacteria and leukocytes) in the urine (Box 58-2). A urine culture identifies the causative microorganism. The physician initially may perform an ultrasound or computed tomography (CT) scan to determine if there is obstruction in the urinary tract. A cystoscopy, or intravenous pyelogram (IVP) or retrograde pyelogram, demonstrates obstruction or damage to structures of the urinary tract. An IVP is not usually done if acute pyelonephritis is suspected because the IVP is generally unremarkable in 75% of clients (Smeltzer et al., 2010). An x-ray of the kidneys, ureters, and bladder may reveal calculi, cysts, or tumors in the kidney or other urinary structures. The diagnosis of chronic pyelonephritis is based on a history of repeated acute pyelonephritis. Serum creatinine and blood urea nitrogen (BUN) levels, if elevated, indicate impaired renal function. An ultrasound may be done to ascertain if there are any obstructions in the urinary tract.

The teaching plan for the client with acute pyelonephritis includes the following recommendations: Review information about the disease, its cause, related risk factors, treatment, and preventive measures. Read about the purpose, dosage, side effects, and toxic effects of all prescribed medications. Complete the entire regimen of antimicrobial therapy as indicated, even if symptoms abate. Drink a large volume of oral fluids daily.

Avoid alcohol and caffeine products if bladder spasms are present or until a clinical response to therapy is verified. Demonstrate how to collect a clean-catch midstream urine specimen for subsequent medical follow-up at 2 weeks and 3 months after treatment. Have your blood pressure monitored intermittently. Consult the primary care provider if you experience signs of recurring or worsening pyelonephritis or lower UTI (frequency, urgency, burning, cloudy urine, and fever). Practice methods to prevent reinfection—women should wipe from front to back after defecation and wear cotton undergarments. Void every 2-3 hours when awake and before and after intercourse.

Assessment Findings of Chronic Glomerulonephritis: Diagnostic findings: Low RBC volume is detected through complete blood counts. Its underlying cause is the excretion of erythrocytes in the urine and reduced production of erythropoietin. 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, casts, (deposits of minerals that break loose from the walls of the tubules), and red and white blood cells. The urinary creatinine clearance is reduced. Serum electrolyte changes indicate nephron dysfunction, including hyperkalemia (elevated potassium), increased phosphorus levels related to decreased renal excretion of phosphorus, and related decreased calcium levels (calcium binds to phosphorus to compensate for increased serum phosphorus levels).

Chest x-rays and echocardiograms demonstrate cardiac size because cardiac enlargement is common. An electrocardiogram (ECG) may indicate left ventricular hypertrophy related to hypertension and signs of hyperkalemia (tall, peaked T waves). A percutaneous kidney biopsy may be performed in the early stage to confirm the diagnosis and to determine the severity of the disorder. In late stages, the kidneys are too small to safely perform a biopsy.

Medical and Surgical Management of Polycystic Kidney Disease: Polycystic disease has no cure, but some interventions reduce the rate of progression. Hypertension is treated with antihypertensive drugs, diuretic medications, and sodium restriction. Despite these interventions, the hypertension is difficult to control. When and if urinary infections develop, they are treated promptly with antibiotics. Low RBC counts are treated with iron supplements, injections of erythropoietin (Epogen), or blood transfusions. Nephrotoxic medications, such as nonsteroidal anti-inflammatory drugs (NSAIDs) 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. Surgical removal of one or both kidneys may be required. Animal research is being conducted using the antineoplastic drug, paclitaxel (Taxol); steroids such as methylprednisolone (Depo-Medrol); and an antihyperlipidemic agent, lovastatin (Mevacor), to evaluate if these drugs slow the rate of disease progression.

CHRONIC GLOMERULONEPHRITIS The nurse teaches the client and family as follows: Follow the diet and fluid regimen recommended by the physician and as outlined by the dietitian. Take medications exactly as directed on the container label. Do not omit or discontinue any medication unless ordered to do so by the physician. Do not take nonprescription drugs unless a physician approves their use. Monitor and record temperature and weight daily. (In some instances, clients may be asked to monitor their blood pressure.)

Follow the physician's recommendations as to physical activity and exercise. Take frequent rest periods if fatigue occurs. Contact the physician if there are questions about medications; if symptoms become worse; or if fever, chills, blood in the urine, weight gain, swelling of the arms or legs or periorbital edema, difficulty in breathing, difficulty in thinking, severe fatigue, excessive sleepiness, constipation, loss of appetite, or an upper respiratory infection occurs. Emphasize that frequent follow-up visits and laboratory tests are necessary to monitor response to treatment.

1 Differentiate pyelonephritis and glomerulonephritis Pyelonephritis: acute or chronic bacterial infection of the kidney and the lining of the collecting system (kidney pelvis). Acute pyelonephritis presents with moderate-to-severe symptoms that usually last 1 to 2 weeks. If the treatment of acute pyelonephritis is unsuccessful and the infection recurs, it is termed chronic pyelonephritis.

Glomerulonephritis: inflammatory renal disorder that occurs most frequently in children and young adults that is preceded by an upper respiratory infection with group A beta-hemolytic streptococci; impetigo (skin infection); or viral infections such as mumps, hepatitis B, or HIV.

INFECTIOUS AND INFLAMMATORY DISORDERS OF THE KIDNEY ACUTE GLOMERULONEPHRITIS: Glomerulonephritis:

Glomerulonephritis: inflammatory renal disorder that occurs most frequently in children and young adults that is preceded by an upper respiratory infection with group A beta-hemolytic streptococci; impetigo (skin infection); or viral infections such as mumps, hepatitis B, or HIV.

Oliguria

low urine output of less than 500 mL/day.

Disequilibrium syndrome

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 dialysis.

INFECTIOUS AND INFLAMMATORY DISORDERS OF THE KIDNEY Infectious and inflammatory disorders of the kidney affect structures such as the renal pelvis, the nephrons, or both. Pyelonephritis: acute or chronic bacterial infection of the kidney and the lining of the collecting system (kidney pelvis). (***Infection of the renal pelvis ***) - more common in females - mostly due to E. Coli - Risk factors: Sexual intercourse, UTI, DM Patho and Etiology for Pyelonephritis: Bacteria ascend to the kidney and kidney pelves by way of the bladder and urethra. Normal fecal flora such as Escherichia coli, Klebsiella pneumoniae, Proteus mirabilis, Streptococcus fecalis, Pseudomonas aeruginosa, and Staphylococcus aureus are the most common bacteria that cause acute pyelonephritis. E. coli accounts for about 85% of infections. Additional risk factors for chronic pyelonephritis, such as urinary obstruction and reflux

In acute pyelonephritis, the inflammation causes the kidneys to grossly enlarge. The cortex and medulla develop multiple abscesses. The renal calyces and pelves also can become involved. Resolution of the inflammation results in fibrosis and scarring. Chronic pyelonephritis develops after recurrent episodes of acute pyelonephritis. The kidneys manifest irreversible degenerative changes and become small and atrophic. If destruction of nephrons is extensive, 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. Gerontologic considerations: Urinary obstruction is the most common cause of pyelonephritis in the older adult. When present, the older adult may not experience the fever and difficulty voiding common in younger adults. Accurate assessment of urine volume is critical.

CONGENITAL KIDNEY DISORDERS: POLYCYSTIC DISEASE:

Individuals may be born with various malformations of renal structures. Most of these are unpredictable because they are the result of errors in fetal development. Polycystic disease, however, is the result of a hereditary trait. The two manifestations of polycystic disease are the infantile and adult forms. The infantile form is rare. It may cause fetal death (before delivery), early neonatal death, or renal failure during childhood. The adult form generally has its onset between 30 and 40 years of age, but it can occur at any age. It insidiously progresses to renal insufficiency. Once renal failure develops, polycystic disease usually is fatal within 4 years, unless the client receives dialysis treatment or an organ transplant. The kidneys are the primary organs involved, but the polycysts can also occur in the liver or other organs. Women and men are affected equally. Death usually results from renal failure or the complications of hypertensive cardiovascular disease.

Drugs used to treat Pyelonephritis: (youtube) Aminoglycosides: gentamicin Fluoroquinolones: ciprofloxacin, levofloxacin Trimethoprims/sulfamethoxazole - bactrim

Leukocyte count 19400/mm3 - WBC count Band 15% - sign of infection Bands are neutrophils Platelet 239000/mm3 Next step in management: Blood culture and urinalysis

Drugs used to treat Pyelonephritis: Oral Antibiotics: Trimethoprim-sulfamethoxazole (Bactrim, Septra) ciprofloxacin (Cipro) levofloxacin What are their mechanisms of action? What are their side effects? What are some nursing considerations?

Mech. Inhibit bacterial growth and destroy microorganisms Side effects: Dizziness, drowsiness, blurred vision, dry mouth, constipation, increased heart rate, delirium. sulfa drugs may leave a metal aftertaste in the mouth Nurs. consid: Clients should complete the entire course of drug therapy and report any further symptoms, continuing or worsening. Drugs can be used for up to 14 days. Clients do not require hospitalization unless nausea, vomiting, or signs of septicemia develop.

Drugs used to treat Pyelonephritis: Antispasmodics: Oxybutynin chloride (Ditropan) flavoxate (Urispas) belladonna and opium suppositories What are their mechanisms of action? What are their side effects? What are some nursing considerations?

Mech. of action: Inhibit the action of acetylcholine and relax smooth muscle of the ureters and bladder Side effects: Dizziness, drowsiness, blurred vision, dry mouth, constipation, increased heart rate, delirium Nursing consid: Do not administer to clients with closed-angle glaucoma or hypotension

Drugs used to treat Pyelonephritis: Antispasmodics With Anticholinergic Properties: Propantheline (Pro-Banthine) hyoscyamine (Levsinex) tincture of belladonna What are their mechanisms of action? What are their side effects? What are some nursing considerations?

Mech: Reduce spasms and smooth muscle contractions by inhibiting the effects of acetylcholine, thereby increasing bladder capacity Side effects: Dizziness, drowsiness, blurred vision, dry mouth, constipation, increased heart rate, delirium Nurs. consid: Do not administer to clients with closed-angle glaucoma or hypotension

Patho and physio for Acute glomerulonephritis: Acute glomerulonephritis usually occurs as a result of bacterial infections, which include group A beta-hemolytic streptococcal infections, bacterial endocarditis, or impetigo (skin infection). Viral infections such as hepatitis B or C, HIV, varicella-zoster virus, or Epstein-Barr virus can also cause glomerulonephritis. The relationship between the infection and acute glomerulonephritis is not clear. Microorganisms are not present in the kidney when symptoms appear, but the glomeruli are acutely inflamed.

Most believe that the inflammatory response is from antigen-antibody stimulation in the glomerular capillary membrane. The disruption of membrane permeability causes red blood cells (RBCs) and protein molecules to filter from the glomeruli into Bowman's capsule and eventually become lost in the urine. Figure 58-2 outlines the sequence of events in acute glomerulonephritis.

Pharmacologic considerations with Polycystic Kidney Disease:

Nephrotoxic drugs are not administered to a client with renal disease unless the client's life is in danger and no other therapeutic agent is of value.

Medical management for Acute Glomerulonephritis: No specific treatment exists for acute glomerulonephritis. Preserving kidney function and preventing complications are the primary goals. Treatment is guided by the symptoms and the underlying abnormality. Treatment may consist of bed rest, a sodium-restricted diet (if edema or hypertension is present), and antimicrobial drugs to prevent a superimposed infection in the already inflamed kidney. Penicillin may be used to abolish any remaining streptococci from the recent infection. Diuretics to reduce edema and antihypertensive agents for severe hypertension may be necessary. Vitamins are added to the diet to improve general resistance, and oral iron supplements may be needed to counteract anemia. Corticosteroids and immunosuppressive agents may be given to treat a rapidly progressive inflammatory process. Any increase in hematuria, proteinuria, or blood pressure indicates a need for aggressive treatment. The client is not considered cured until the urine is free of protein and RBCs for 6 months. Return to full activity usually is not permitted until the urine is free of protein for 1 month.

Nursing Management for Acute Glomerulonephritis: The client must maintain bed rest when the blood pressure is elevated and edema is present. The nurse collects daily urine specimens to assist with evaluating the client's response to treatment. He or she assesses blood pressure every 4 hours or as ordered. Encouraging adequate fluid intake and measuring intake and output are important nursing interventions. Although the diet may be restricted in sodium and protein, it is necessary for the client to have adequate carbohydrate intake to prevent the catabolism of body protein stores. Client teaching aims to accomplish the following: Identify the specific amount of sodium that is allowed and sources of sodium to avoid. Explain the purpose of diuretic therapy or other prescribed medications, the dosing regimen, and side effects. Recommend regular blood pressure monitoring. Caution client to avoid contact with persons who have infections. Emphasize compliance with medical appointments and the necessity for repeated urinalyses. Advise client to contact the physician if urinary volumes diminish, there is unexplained weight gain, or headaches or nosebleeds occur.

INFECTIOUS AND INFLAMMATORY DISORDERS OF THE KIDNEY: CHRONIC GLOMERULONEPHRITIS Chronic glomerulonephritis is a slowly progressive disease characterized by inflammation of the glomeruli, causing irreversible damage to the nephrons. The course of the disease is highly variable. Some clients live for years with no or occasional symptomatic episodes. In other clients, the disease is rapidly fatal unless they receive dialysis to take care of the renal failure.

Patho and Physiology of Chronic Glomerulonephritis: A small number of those with chronic glomerulonephritis are known to have had repeated acute glomerulonephritis, but many do not have that history. Complications of autoimmune connective tissue disorders, such as lupus erythematosus (see Chap. 63) and Goodpasture's syndrome (a rare disease that includes progressive glomerulonephritis, hemoptysis, and marked RBC destruction), also may cause chronic glomerulonephritis. The chronic inflammation leads to ever-increasing bands of scar tissue that replace nephrons, the vital functioning units of the kidney. Decreased glomerular filtration eventually can lead to renal failure. Chronic glomerulonephritis accounts for approximately 40% of people on dialysis.

What is Primary glomerulonephritis: Ex. notes: Primary glomerulonephritis can progress to chronic glomerulonephritis, and there is a risk of kidney failure in some clients. occurs independently of other chronic conditions but usually is an acute postinfectious process.

Primary glomerulonephritis: inflammation of the glomeruli of the kidneys that occurs independently of other chronic conditions; usually the result of an acute infectious process.

Risk factors for Pyelonephritis: Acute Pyelonephritis: Instrumentation of the urethra and bladder (catheterization, cystoscopy, urologic surgery) Inability to empty the bladder Pregnancy Urinary stasis Urinary obstruction (tumors, strictures, calculi, prostatic hypertrophy) Diabetes mellitus Other renal disease (polycystic kidney disease) Neurogenic bladder (stroke, multiple sclerosis, spinal cord injury) Women with increased sexual activity, diaphragm, spermicide use, failure to void after intercourse, history of recent urinary infection Men who perform anal intercourse, infection with HIV

Risk factors for Pyelonephritis: Chronic Pyelonephritis: Recurrent episodes of acute pyelonephritis Chronic obstruction (e.g., strictures and stones) Reflux disorders that allow urine to flow backward up the ureters

Secondary glomerulonephritis: results from other conditions, such as lupus erythematosus or diabetes.

Secondary glomerulonephritis: inflammation of the glomeruli of the kidneys that results from other chronic conditions, such as lupus erythematosus or diabetes.

Assessment findings for Acute Glomerulonephritis: Signs and Symptoms: Many clients with glomerulonephritis have no symptoms. Early symptoms may be so slight that the client does not seek medical attention. Occasionally the onset is sudden, with pronounced symptoms such as fever, nausea, malaise, headache, generalized edema, or puffiness around the eyes. Some clients are first diagnosed from a routine urinalysis that reveals hematuria through microscopic examination. Often, clients present with the following symptoms: Pink- or cola-colored urine from RBCs being excreted in the urine (hematuria), Foamy-appearing urine from (proteinuria) (excess serum albumin excreted in the urine) Hypertension Edema with evidence of swelling in the hands, feet, abdomen, and periorbital edema Fatigue related to anemia or kidney failure

Some clients experience pain or tenderness over the kidney area and mild-to-moderate hypertension. Their appetite may be poor, nocturia (urination during the night) may be present. Irritability and shortness of breath also develop. As the condition progresses, the client develops obvious hematuria (blood in the urine), anemia (from the hematuria), convulsions associated with hypertension, congestive heart failure, oliguria (low urine output of 100 to 500 mL/day), and perhaps anuria (<100 mL of urine over 24 hours). Fluid retention and hypertension contribute to visual disturbances, often as a result of papilledema or hemorrhage in the eye, and epistaxis (nosebleeds).

Medical Management of Pyelonephritis: Treatment of acute pyelonephritis includes relieving fever and pain and prescribing antimicrobial drugs such as trimethoprim-sulfamethoxazole (TMP-SMZ; Septra), gentamycin with or without ampicillin, cephalosporin, or ciprofloxacin (Cipro) for 14 days. Two weeks after the client completes initial treatment, a follow-up urine culture is done. Antispasmodics and anticholinergics such as oxybutynin (Ditropan) and propantheline (Pro-Banthine) are additional pharmacologic interventions that relax the smooth muscles of the ureters and bladder, promote comfort, and increase bladder capacity (Drug Therapy Table 58-1). Symptoms usually disappear within a few days of antibiotic therapy. Four to 6 weeks of drug therapy are prescribed for clients with a history of frequent relapsing infections with the same microorganism.

Surgical management of Pyelonephritis: The goal of treatment for chronic pyelonephritis is to prevent progressive kidney damage. When possible, any urinary tract obstruction is relieved to save the kidney from destruction. An effort is made to improve the client's overall health. A nephrectomy, the surgical removal of a kidney, is performed if severe hypertension develops and if the other kidney has adequate function.

What are glomeruli?

The glomeruli are capillaries that filter substances from the plasma.

The most common urologic disorders are:

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. The same is true of other upper urinary tract disorders such as kidney and ureteral stones and tumors. The consequences can lead to acute or chronic renal failure

Medical Management of Chronic Glomerulonephritis: Treatment is nonspecific and symptomatic. Management goals include the following: Controlling hypertension with medications and sodium restriction Correcting fluid and electrolyte imbalance Reducing edema with diuretic therapy Preventing congestive heart failure Eliminating urinary tract infections (UTIs) with antimicrobials Renal failure eventually may necessitate dialysis or kidney transplantation, discussed later in this chapter.

The nurse evaluates the client's ability to manage home care and the availability of a support system before developing discharge plans. If the client lacks a support system from the family or extended family members, the nurse consults with the physician for a referral to a social agency or home healthcare agency. Client and Family Teaching 58-2 provides important discharge instructions.

Nursing management of Polycystic Kidney Disease: Many clients with polycystic disease are treated as outpatients by primary care physicians or nephrologists, physicians who specialize in the diagnosis and treatment of renal diseases. When hospitalization is necessary, the nurse assesses vital signs, especially blood pressure, and reports any significant elevations. He or she monitors laboratory test results for indicators of renal function.

The nurse inspects the urine for signs of bleeding or infection. He or she measures and documents intake and output at least every 8 hours. The nurse reports any decrease in or absence of urine output. For further information about complications or advanced stages, refer to "Nursing Process for the Client With Renal Calculi" and the "Nursing Management" sections in the discussions of the client with renal failure and dialysis.

Nursing management of Pyelonephritis: The nurse obtains complete medical, drug, and allergy histories and assesses vital signs, reporting abnormal findings such as elevated temperature or blood pressure. Continued and regular monitoring of vital signs is important to detect any evidence of changes. A physical examination helps the nurse determine the location of discomfort and any signs of fluid retention such as peripheral edema or shortness of breath. The nurse observes and documents the characteristics of the client's urine. A clean-catch urine specimen is collected for urinalysis and urine culture.

The nurse measures intake and output and recommends, if not contraindicated, a liberal daily fluid intake of approximately 3000 to 4000 mL to flush infectious microorganisms from the urinary tract. The nurse also administers prescribed medications and evaluates laboratory test results such as BUN, creatinine, serum electrolytes, and urine culture to determine the client's response to therapy. If chronic pyelonephritis develops, the treatment often is lengthy. Poor health and prolonged medical therapy are discouraging. The nurse urges the client to follow the recommendations of the physician and adhere to the prescribed medication regimen.

Urinalysis Results With Pyelonephritis Acute Pyelonephritis: Bacteria and bacterial casts Leukocytes (large) Casts (leukocytes, granular, renal tubular) Red blood cells (few) Low specific gravity Slightly alkaline pH Proteinuria (minimal to mild) Urine culture: organism colony count of >100,000 organisms/mm urine

Urinalysis Results With Pyelonephritis Chronic Pyelonephritis Leukocytes (increased) Proteinuria (absent, minimal, or intermittent) Bacteria Casts (present in early stages and absent in late stages) Low specific gravity

Pharmacologic considerations when using drugs for pyelonephritis.

Use caution when giving drugs excreted by the kidney to those with renal disease. If the drug is deemed necessary, it may be given in lower than normal doses; observe the client closely for any changes in renal status if normal doses are necessary. Pay special attention to the client's urinary output because this method is a way to determine a change in renal status.

Assessment Findings of Chronic Glomerulonephritis: Signs and Symptoms: Some clients do not experience symptoms until renal damage is severe. Generalized edema, known as anasarca, is a common finding. Anasarca is caused by the shift of fluid from the intravascular space to interstitial and intracellular locations. The fluid shift results from depletion of serum proteins, particularly albumin, which are lost in the urine. Clients remain markedly edematous for months or years.

They may feel relatively well, but the kidney continues to excrete albumin. The fluid burden and subsequent renal failure contribute to fatigue, headache, dizziness, hypertension, dyspnea, and visual disturbances. Clients may also experience weight loss, digestive problems, decreased muscle strength and endurance, irritability, and increasing nocturia.

Casts

deposits of minerals that break loose from the walls of renal tubules.

Calciuria

excessive calcium in the urine.

Anasarca

generalized edema caused by the shift of fluid from the intravascular space to interstitial and intracellular fluid locations.

Azotemia

accumulation of nitrogen waste products in the blood, as evidenced by elevated BUN, serum creatinine, and uric acid levels.

Pyelonephritis

acute or chronic bacterial infection of the kidney and the lining of the collecting system (kidney pelvis).

Colic

acute spasmodic pain.

Primary glomerulonephritis

inflammation of the glomeruli of the kidneys that occurs independently of other chronic conditions; usually the result of an acute infectious process.

youtube for Glomerulonephritis: urinalysis reveals the presence of protein, admit pt, throat culture - negative, ASO titer - high, CBC essentially normal, BUN will be elevated, serum creatinine elevated, strep throat, fever, periorbital edema, edema of the hands and fingers, gross or microscopic hematuria, 24 hour urine protein analysis shows elevated protein, acute poststreptococcal glomerulonephritis, HEP C, HEP B, autoimmune conditions such as Lupus, malignancy's, certain drugs and antibiotics can cause Glomerulonephritis Acute glomerulonephritis usually occurs as a result of bacterial infections, which include group A beta-hemolytic streptococcal infections, bacterial endocarditis, or impetigo (skin infection). Viral infections such as hepatitis B or C, HIV, varicella-zoster virus, or Epstein-Barr virus can also cause glomerulonephritis

bed rest, with bathroom privileges, fluid restriction 1200ml/day, restricted sodium and protein diet if it's drug related - stop the drug if infection - use antibiotics to treat diuretics help get rid of swelling and reduce BP steroids may be used to treat Glomerulonephritis plasmapheresis - so that the toxins in your body get removed and are not able to attack the kidney - they are replaced by plasma dialysis also helps

Hematuria

blood in the urine.

Nephrostomy tube

catheter inserted through the skin into the renal pelvis and is used to relieve an obstruction to urine flow above the bladder.

Hydronephrosis

condition in which an obstruction of urine from the ureter distends the renal pelvis.

Osteodystrophy

condition in which the bones become demineralized as a result of hypocalcemia and hyperphosphatemia.

Urolithiasis

condition of stones in the urinary tract.

Acute tubular necrosis

death of cells within the collecting tubules of the nephrons, where reabsorption of water, electrolytes, and excretion of protein wastes and excess metabolic substances occur.

Calculus

precipitate of mineral salts that ordinarily remain dissolved in urine.

Uremic frost

precipitate that sometimes forms on the skin during chronic renal failure because it becomes the excretory organ for substances the kidney usually clears from the body.

Nephrolithiasis

presence of a kidney stone, the size of which may range from microscopic to several centimeters.

Ureterolithiasis

presence of a stone within the ureter.

Dialysis

procedure for cleaning and filtering the blood that substitutes for kidney function when the kidneys cannot remove nitrogenous waste products and maintain adequate fluid, electrolyte, and acid-base balances.

Extracorporeal shock wave lithotripsy

procedure that uses shock waves to dissolve large kidney stones.

Chronic renal failure

progressive and irreversible decrease in the ability of 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.

Periorbital edema

puffiness around the eyes.

Bruit

purring or blowing sound caused by blood flowing over the rough surface of one or both carotid arteries.

Pyuria

pus (a combination of bacteria and leukocytes) in the urine.

Ureteroplasty

removal of a narrowed section of ureter and reconnection of the patent portions.

Dialyzer

semipermeable membrane filter within a machine that contains many tiny hollow fibers; during dialysis, blood moves through the hollow fibers; water and wastes from the blood move into the dialysate fluid that flows around the fibers, but protein and RBCs do not.

Ureteral stent

slender supportive device used to splint the ureter or divert urine past a possible tear in the ureteral wall.

Dialysate

solution used during dialysis that has a composition similar to normal human plasma.

End-stage renal disease

stage in chronic renal failure in which less than 10% of nephron function remains and the point at which a regular course of dialysis or kidney transplantation is necessary to maintain life.

Acute renal failure

sudden and rapid decrease in the ability of 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.

Arteriovenous fistula

surgical anastomosis (connection) of an artery and vein lying in close proximity.

Nephrectomy

surgical removal of a kidney.

Pyeloplasty

surgical repair of the ureteropelvic junction.

youtube: Glomerulonephritis: inflammation or an attack on the filters of the kidney the glomerulus one of the common causes of kidney failure

symptoms: change in urine color - red or pink - signs of blood in the urint, urine output starts to decrease, swelling/edema, high bp, protein in the urine, RBC's called a cast will be seen in the urine,

Hemodialysis

technique in which blood is transported from a client through a dialyzer, a semipermeable membrane filter within a machine that removes water and wastes from the blood.

Peritoneal dialysis

technique that uses the peritoneum, the semipermeable membrane lining of the abdomen, to filter fluid, wastes, and chemicals.

Acute nephritic syndrome

term used to describe the clinical manifestations of glomerular inflammation caused by various disorders.

Proteinuria

the presence of excess serum albumin excreted in the urine.

Uremia

toxic state caused by the accumulation of nitrogen wastes in the blood.

Arteriovenous graft

type of vascular access method that uses a tube of synthetic material or polytetrafluoroethylene to connect a vein and artery in the upper or lower arm.

Nocturia

urination during the night.

Anuria

urine output of vague, uneasy feeling, the cause of which is not readily identifiable and which is evoked when a person anticipates nonspecific danger.

Thrill

vibration.