Renal disorders

Nursing management of patients
with renal disorders
Prepared By
Dr. Zuhair Rushdi Mustafaa
Lecturer at University of Duhok/ College of Nursing

 Assessment of urinary function
The alterations in the function of the urinary tract can be:
1. Pain
2. Changes in voiding
3. Gastrointestinal symptoms.
I. Pain: Sites of pain
Renal pain:
* dull ache in costovertebral angle
* a sharp, colicky pain felt in the flank area that radiates to the
groin or testicle.

2. Ureteral Pain:
Back pain radiating to the abdomen,
upper thigh, testis and labium.
3. Bladder Pain:
Lower abdominal pain or over
the suprapubic area.
4.Urethral meatus pain. It is due to
infection or trauma, or foreign body
in the lower urinary tract.
Pain increase with voiding.

5. Scrotal Pain: Due to inflammatory swelling of
epididymis or testicle, torsion of the testicle, or scrotal
infection.
6. Back and leg pain: It is due to metastasis of cancer
of the prostate to the pelvic bones.
7. Pain in the glans penis: It is due to prostatitis.
8- Testicular pain—due to injury, mumps, orchitis,
torsion of spermatic cord, testes.
9- Perineal or rectal discomfort—due to acute or
chronic prostatitis, prostatic abscess, or trauma.

II. Changes in Voiding (Micturition):
A- Changes in Amount or Colour of Urine:
1-Hematuria:- blood in the urine
a- Dark, rusty urine.
b- Bright red bloody urine
c- Microscopic hematuria.
d- Painless hematuria may indicate neoplasm in the
urinary tract.
2- Polyuria:- large volume of urine voided in given
time.
3- Oliguria:-small volume of urine.
a- Output between 100 and 500 mL/24 hours.

4- Anuria:-absence of urine output.
A- Output less than 50 mL/24 hours.
B- Symptoms Related to Irritation of
the Lower Urinary Tract:
1-Dysuria:-painful or difficult urination.
2-Frequency:- Voiding that occurs more often than usual (normally
from 5 to 6 times/day plus once occasionally at night).
3-Urgency—strong desire to urinate that is difficult to postpone.
4-Nocturia:- urination at night, which interrupts sleep.

7. Urinary incontinence: Involuntary loss of urine caused by:
a. An injury of the external urinary sphincter
5- Enuresis: Involuntary voiding during sleep.
C- Symptoms Related to Obstruction of the Lower Urinary
Tract
1- Weak stream:-decreased force of stream when compared to
usual stream of urine when voiding.
2-Hesitancy:- undue delay and difficulty in initiating voiding.
3-Terminal dribbling:-prolonged dribbling or urine from the
meatus after urination is complete.

4-Incomplete emptying:- feeling that the bladder is still full
even after urination.
5- Urinary retention:-inability to void.
III. Gastrointestinal Symptoms:
 nausea
 diarrhoea
 abdominal discomfort
 paralytic ileus
 vomiting
Diagnostic Tests of Urinary Dysfunction
1- Urinalysis

Lab NL Findings Deviations & Causes
Color/ appearance Clear, yellow,
straw
Dark-amber urine suggests dehydration.
Yellow-brown to green urine indicates excessive Bilirubin.
colorless urine is seen with a large fluid intake or diabetes insipidus.
Odor of urine Aromatic Foul smelling in infection. a fruity odor In diabetic ketoacidosis,
pH 4.6–8.0 pH below 4.6 is seen with metabolic and respiratory acidosis.
pH above 8.0 indicates alkalosis
Specific gravity 1.005-1.030 Low indicates excessive fluid intake or diabetes insipidus.
High specific gravity is seen with dehydration.
Osmolality 300-900 mOsm/kg Increase indicates dehydration, decrease fluid overload
Protein 2-8 mg/dL
Increase indicates decrease renal function.
Glucose None
Glucose in the urine indicates diabetes mellitus, excessive glucose
intake.
Ketones None Ketones in the urine indicate DM with ketonuria or starvation from
breakdown of body fats into ketones

Lab NL Findings Deviations & Causes (conteniu)
Bilirubin None Bilirubin in the urine indicates liver disorders causing jaundice
Nitrite Negative Nitrites in the urine indicate infection in the urine.
Leukocyte
esterase
Negative leukocyte esterase in the urine indicates infection in the urine
Red blood
cells
1-2 hpf (high-power
field)
Blood in the urine may be caused by kidney stones, infection, cancer,
renal disease, or trauma.
White blood
cells
3-4 hpf WBCs in the urine indicate infection or inflammation in the urinary tract.
Casts Negative Increase with upper urinary tract infections.
Crystals Few/negative Increase indicates presence of renal stones

2- Renal Function Tests
A- Serum Creatinine: Creatinine is end product of
muscle energy metabolism (normal: 0.6 to 1.2 mg/dL).
B- blood urea nitrogen [BUN]): Urea is the nitrogenous
end-product of protein metabolism. (BUN; normal: 8
to 25 mg/dL).
C- Uric acid is an end product of purine metabolism
and the breakdown of body proteins (normal: 2 to 7
mg/dL).

3- Radiological Studies
Procedure Significance of Abnormal (Noninvasive)
Renal Ultrasound or
Ultrasonography
• used to help diagnose congenital disorders of the kidney, renal abscesses,
hydronephrosis, kidney stones, or tumors.
• The images identify enlargement of the kidneys, and changes of renal structures with
chronic infection.
Bladder Ultrasound • The bladder is scanned for residual urine volume, bladder wall thickness, bladder calculi,
and tumors.
Kidney-Ureter-
Bladder X-ray (KUB)
• May help to discover renal calculi, kidney size, or masses in the kidney.
Computed
Tomographic
(CT) Scan
The kidneys, ureters, bladder, abdominal and pelvic organs can be evaluated for
kidney size, tumors, abscesses, malignant masses, metastases, or lymph node
enlargement.
• Cysts or abscesses can be identified.
• Other uses include identification of renal stones, obstructions, and infections.
Magnetic Resonance
Imaging (MRI)
Identify stages of cancers of the kidney, bladder, and prostate.

Procedure Significance of Abnormal (invasive)
Intravenous Pyelogram
(IVP)
During the test, a radiopaque dye is injected into a large vein.
The dye outlines the renal system and identifies: Abnormal size or shape
of kidneys; Absent kidneys; Polycystic kidney disease; Tumors;
Hydronephrosis
Renal Angiography
or Arteriogram
Is useful if renal insufficiency is caused by renal vascular disease.
The test reveals hypervascular tumors, renal cysts, renal artery stenosis,
pyelonephritis, obstructions, renal infarction, and evaluates renal trauma.
Renal Biopsy Biopsy is used to diagnose benign and malignant masses, causes of renal
failure.
Cystoscopy Allows diagnostic inspection of the urinary tract for urinary calculi,
infection, vesicoureteral reflux, prostatic obstruction, bladder tumors and
urethral strictures.

Urinary Tract Infections(UTIs)
UTIs are caused by pathogenic microorganisms in the urinary
tract.
UTIs are the most common bacterial infections in all patients
and are a significant source of morbidity.
They are more common in women than in men.
In the hospital, UTIs are the most common nosocomial
infections (40%).
In most of these hospital-acquired UTIs, instrumentation of the
urinary tract or catheterization is the precipitating cause.

Classification of UTIs.
Lower UTIs:
 cystitis
 prostatitis
 urethritis
Upper UTIs:
 acute or chronic pyelonephritis
 interstitial nephritis
 renal abscesses.
 Perirenal abscess
Uncomplicated UTIs : community-acquired infection; common in young women and not
usually recurrent.
Complicated: are Often nosocomial (acquired in the hospital) and related to catheterization;
occur in patients with urologic abnormalities, pregnancy, immunosuppression, DM, and
obstructions and are often recurrent.

Reflux
An obstruction to free-flowing urine is a condition known as
urethrovesical reflux, which is the reflux (backward flow) of
urine from the urethra into the bladder.
Ureterovesical reflux refers to the backward flow of urine
from the bladder into one or both ureters.

Uropathogenic Bacteria
 Bacteriuria - >10 5 colonies of bacteria per millimeter of urine.
 Community-acquired UTIs are among the most common
bacterial infections especially in women.
 Common E.coli from lower GIT
 In males and catheterized patients gradually pseudomonas
and enterococcus are the main causes.

Routes of Infection
Bacteria enter the urinary tract in three ways:
1- transurethral route (the most common route).
2- bloodstream (hematogenous spread).
3- by means of a fistula from the intestine (direct extension).

Risk Factors for UTIs
Predisposing factors for UTIs include the following:
1- Inability or failure to empty the bladder completely.
2- Obstructed urinary flow caused by:
a- Congenital abnormalities
b- Urethral strictures
c- Calculi (stones) in the ureters or kidneys
d- Compression of the ureters
3- Decreased natural host defenses or immunosuppression.
4- Instrumentation of the urinary tract (eg, catheterization, cystoscopic
procedures).
6- Contributing conditions such as:
a- Diabetes mellitus.
b- Pregnancy
c- Neurologic disorders causing urinary stasis
d- Gout

UPPER URINARY TRACT INFECTION:
ACUTE PYELONEPHRITIS
Pyelonephritis is a bacterial infection of the renal pelvis,
tubules, and interstitial tissue of one or both kidneys.
Causes involve either the upward spread of pathogenic
bacteria from the bladder or spread from systemic sources
reaching the kidney via the bloodstream

 Clinical Manifestations
1- chills
2- fever 13-urgency
3-leukocytosis 14-frequency
4-bacteriuria
5-pyuria
6-Low back pain
7-flank pain
8-nausea and vomiting
9-headache
10-malaise
11-pain and tenderness in the area of the costovertebral angle
12-painful urination

Assessment and Diagnostic Findings
1- An ultrasound study or a CT scan may be performed to
locate any obstruction in the urinary tract.
2- An IV pyelogram may be indicated if functional and
structural renal abnormalities are suspected.
3- Urine culture and sensitivity tests.

Medical management
1- For severe infections, inpatient antibiotic therapy is
recommended.
A- penicillin plus aminoglycoside I.V are given.
B- An oral antibiotic may be started 24 hours after fever has
resolved.
2- Hydration with oral or parenteral fluids is essential in all
patients with UTIs.
3- Antipyretic is given for fever and analgesic for pain
control.
4- Repeat urine cultures should be performed after the
completion of therapy.

CHRONIC PYELONEPHRITIS
Repeated bouts of acute pyelonephritis may lead to
chronic pyelonephritis.
Clinical Manifestations
no symptoms of infection unless an acute exacerbation
occurs.
1- fatigue
2- headache
3- poor appetite
4- polyuria
5-excessive thirst
6-weight loss.

Assessment and Diagnostic Findings
1- IV urogram to assess the extent of the disease.
2- creatinine levels
3-blood urea nitrogen
Complications
1- end-stage renal disease
2- hypertension
3-formation of kidney stones.
Medical Management
Long-term use of prophylactic antimicrobial therapy may help
limit recurrence of infections and renal scarring.

Nursing Management
For hospitalized patient:
1-Assess vital signs frequently
2- monitor intake and output
3-administer antiemetic medications.
4- assesses the patient’s temperature every 4 hours and
administers antipyretic and antibiotic agents as prescribed.
5- Use cold compress
6- 3 to 4 L of fluids per day is encouraged.
7- Monitor CBC, blood cultures, and urine studies for
resolving infection.
8- Patient teaching regarding consuming adequate fluids,
emptying the bladder regularly, and performing
recommended perineal hygiene.

Lower urinary tract infections
Cystitis
Cystitis is inflammation and infection of the bladder wall.
Causes bacteria, viruses, fungi, or parasites.
Fungal infections can occur during long-term antibiotic therapy.
About 90% of UTIs are caused by Escherichia coli.
In most cases, the causative organisms first grow in the perineal area
and then ascend into the bladder.
Catheters are the most common predisposing factor for UTIs in the
hospital setting.

Clinical Manifestation
1- dysuria
2- frequency
3- urgency
4- cloudy urine.
5- WBCs, bacteria, and sometimes red blood cells (RBCs) in
the specimen.
Medical Management
1- for uncomplicated cystitis, combination of sulfa medication,
such as sulfamethoxazole and trimethoprim (Bactrim).
2- Complicated cystitis is often treated with ciprofloxacin
(Cipro).
3- Other antibiotics may be prescribed depending on the
results of the urine culture and sensitivity.

Nursing Process for the Patient with UTIs.
Assessment/Data Collection
The patient is asked about:
1- pain on urination
2- pain in the lower abdomen, flank, or costovertebral angle
3- general symptoms of infection such as fever, chills, and
malaise.
4- Urinary frequency, burning.
5- presence of a catheter, recent instrumentation, surgery.
6- The urine is examined for volume, color, concentration,
cloudiness, blood, or foul odor.
7- Urinalysis and culture results are examined.

Nursing Diagnosis
Acute pain related to inflammation of the urethra,
bladder, and other urinary structures.
Nursing Implementation
1- Encourage fluids 2 to 3 L per day.
2- Give antimicrobial therapy.
3- Teach patient to finish all prescribed medications.
4- Give antispasmodic agents.
5- Administer antipyretics.
6- Encourage voiding every 3 hours..

7- Teach to avoid cola, coffee, tea, alcohol.
8- Suggest cranberry juice or vitamin C 500 to 1000 mg per.
9- Apply heat to suprapubic area to relieve discomfort.
10-Empty bladder as soon as urge is felt and after sexual
intercourse to flush bacteria out of the body.
11- Teach to practice good perineal hygiene, and to wipe front
to back.
12- Teach to wear cotton underwear to reduce perineal
moisture.

Nursing diagnosis (continued)
Impaired urinary elimination: frequency, nocturia, dysuria, and
incontinence.
Implementation
1- Monitor urinary elimination including frequency, consistency,
volume, and color to identify signs and symptoms.
2- Administer antimicrobial drugs as ordered.
3- Teach patient signs and symptoms of UTI.
4- Encourage adequate fluids to prevent infection and
dehydration.
5- Women should be encouraged to void after sexual
intercourse to flush bacteria out of the urethra.

Evaluation
1-patient verbalizes relief of pain and discomfort
2- returns to previous voiding patterns.
3- free from injury related to sepsis, renal failure, or recurrent
infection.

 Patient Teaching to Prevent Urinary Tract Infection
1. Void frequently—at least every 3 hours while awake.
2. Drink up to 3000 mL of fluid a day. Preferably, drink water.
3. Drink one glass of cranberry juice per day.
4. Take showers; avoid tub baths.
5. Wipe perineum from the front to the back after toileting.
6. Urinate after intercourse.
7. Take medication exactly as prescribed.
8- Avoid coffee, tea, colas, alcohol, and other fluids that are
urinary tract irritants.

NEPHROLITHIASIS AND UROLITHIASIS
Nephrolithiasis refers to renal stone disease.
Urolithiasis refers to the presence of stones in the urinary
system.
Stones, or calculi, are formed in the urinary tract from the
kidney to bladder by the crystallization of substances
excreted in the urine.
About half of patients with a single renal stone have another
episode within 5 years.

Pathophysiology and Etiology
1- Most stones (75%) are composed mainly of calcium
oxalate crystals.
The rest are composed of calcium phosphate salts, uric
acid, struvite (magnesium, ammonium, and phosphate), or
the amino acid cystine.
2- Causes and predisposing factors:
 Hypercalcemia and hypercalciuria.
 Chronic dehydration, poor fluid intake, and immobility
 Diet high in purines and abnormal purine metabolism
(hyperuricemia and gout)
 Genetic predisposition for urolithiasis .

 Chronic infection with urea-splitting bacteria (Proteus
vulgaris)
 Chronic obstruction with stasis of urine.
 Excessive oxalate absorption in inflammatory bowel
disease and bowel resection or ileostomyts
 Excessive amount of calcium in some geographical
areas.
3- Stones may be found anywhere in the urinary.
4- One out of three patients with stones are men.
5- In both sexes, the peak age of onset is between ages 40 to
60.

5- Most stones migrate downward and are discovered in the
lower ureter.
Spontaneous stone passage can be anticipated in 80% to 90%
of patients with calculus less than 5 mm in size.
6- Some stones may lodge in the renal pelvis, ureters, or
bladder neck, causing obstruction, edema, secondary
infection and, in some cases, nephron damage.
7- Those with stones for the first time have a 50% risk of
recurrence within the next 7 to 10 years.

1- Excruciating flank pain and renal colic may radiate to lower
abdomen, groin, scrotum or labia. Pain relief is immediate after
stone passage.
2- hematuria.
3- dysuria, frequency, urgency, and enuresis.
4- GI symptoms include nausea, vomiting, diarrhea, abdominal
discomfort.
5- Obstruction—stones blocking the flow of urine will produce
symptoms of colic, chills, and fever.
6- Bladder stones may be asymptomatic or produce symptoms
similar to cystitis.

Diagnostic Evaluation
1- Kidney, ureters, and bladder (KUB) radiography may show
stone.
2- An intravenous urography (IVU). To determine site and
evaluate degree of obstruction.
3- Renal ultrasound may be done to identify a stone in the
renal pelvis, calyx, or ureter.
4- Urinalysis may indicate gross or microscopic hematuria
and could indicate abrasion of the urinary tract. pH less
than 5.5 indicates uric acid stone; more than 7.5 indicates
struvite stone.
5- CT scan and MRI show stones.

Treatment
If patients experience severe renal colic, they are admitted to
the hospital.
1- Provide pain relief:
• narcotics such as morphine
• nonsteroidal anti-inflammatory drugs .
2- Administer antispasmodics for pain control (Hyoscine).
3- Increase fluid intake to flush through the urinary tract.
4- Lithotripsy—shock waves are used to break the stone into
very small fragments that can pass or remove more easily.
Forms of lithotripsy include extracorporeal shockwave
lithotripsy (ESWL), electrohydraulic lithotripsy, laser
lithotripsy, and percutaneous ultrasonic lithotripsy.

Extracorporeal shockwave lithotripsy (ESWL)

5- Ureteroscopy: inserting a ureteroscope into the ureter and
then inserting a laser.
A stent may be inserted (double J) and left in place for 48
hours or more after the procedure to allow free flow of urine
and passage of small stones or stone pieces.
6- Surgical removal of stone. This indicated for only 1% to 2%
of all stones., rarely performed.

Percutaneous ultrasonic lithotripsy

NURSING DIAGNOSIS
Acute pain related to the presence of, obstruction, or movement
of a stone within the urinary system.
PLANNING AND IMPLEMENTATION
1- Ask severity, location, and duration of pain using pain scale.
2- Monitor patency of drains, and catheters in preoperative and
postoperative patients.
3- Encourage fluid intake unless contraindicated.
4- Administer pain medication as ordered to promote comfort.
5- Apply heat to flank area to reduce pain and promote
comfort.

6- Monitor vital signs and blood pressure; observe for bleeding
in preoperative and postoperative patients.
7- Strain urine through gauze or filter paper to collect passed
stones fragments.
8- Monitor urine amount, color, clarity, and odor to ensure
patency of urinary system or tubes. Foul smelling or cloudy
urine may indicate an infection.
9- Ambulate if possible to facilitate the passage of the stone
through the urinary system.
10- Limit calcium intake for calcium stones.

Nursing Diagnosis
Risk for infection related to the introduction of bacteria from
obstructed urinary flow and instrumentation.
Implementation
1- Monitor urine amount, color, clarity, and odor to ensure
patency of urinary system or tubes. Foul smelling or cloudy
urine may indicate an infection.
2- Assess for elevation in temperature, chills, cloudy, foul-
smelling urine as indicators of infection.
3- Encourage fluids to flush bacteria and stones, and prevent
further stone formation.

Nursing Diagnosis
Deficient knowledge related to lack of knowledge about
prevention of recurrence, diet, and symptoms of renal
calculi.
Implementation
1- Teach the patient the importance of maintaining a fluid
balance of 3000 mL per day.
2- Teach patient about medications used to prevent
recurrence of renal stones.
3- Antibiotics are used to prevent chronic UTIs which may
precede renal calculus formation.

4- As applicable, teach patient about management of
stones. Most stones pass spontaneously. There may be
pain, nausea, and vomiting.
5- Teach patient to strain all urine. Stone fragments may
continue to pass for weeks after stone crushing or
lithotripsy.
6- Teach patient to report signs of infection, pain not
relieved by medication, nausea, chills, or the appearance
of foul-smelling urine for treatment.

PATIENT EDUCATION on Preventing Kidney Stones
1- Avoid protein intake; usually protein is restricted to 60 g/day
to decrease urinary excretion of calcium and uric acid.
2- A sodium intake of 3 to 4 g/day is recommended.
3- Low-calcium diets are not generally recommended.
4- Avoid intake of oxalate-containing foods (eg, spinach,
strawberries, tea, peanuts).
5- During the day, drink fluids (ideally water) every 1 to 2 hours.

6- Drink two glasses of water at bedtime to prevent urine from
becoming too concentrated during the night.
7- Avoid activities in hot weather that may cause excessive
sweating and dehydration.

Benign Prostatic Hypertrophy (BPH)
 Is a nonmalignant growth of the prostate that gradually causes
urinary obstruction.
 Enlargement of the prostate gland is a normal process in older
men.
 Typically occurs in men older than 40 years of age.
 At 60 years of age, 50% of men have BPH.
 It affects as many as 90% of men by 85 years of age.
 BPH is the second most common cause of surgical intervention
in men older than 60 years of age.
 The cause is unknown but may be linked to hormonal changes.

Clinical manifestation
Symptoms related to obstruction include:
1- Decrease in the size or force of the urinary stream.
2- Difficulty in starting stream or pushing to start.
3- Dribbling at the end of urination.
4- Urinary retention, and a feeling that the bladder is not
empty.
5- Recurrent UTIs.
Symptoms related to irritation include:
1- Urinary frequency
2- Urgency
3- Nocturia
4- Hesitancy in starting urination

Diagnostic test
• Urography shows high volume of post-void residual urine.
• Prostate-specific antigen (PSA) may be mildly elevated.
• Prostate ultrasound shows hypertrophy.
• Digital rectal exam reveals fullness of prostate.
• Urinalysis may show microscopic hematuria.
• BUN and creatinine levels may elevate, if renal function is
impaired.

Medical Management
1- Catheterization if a patient is unable to void especially in
emergency basis.
 2- Administer alpha1-blockers for symptom relief, such as
doxazosin (Cardura) to relax the smooth muscle of the
bladder neck and prostate.
 3- Administer medications that block the action of the male
hormone in the prostate gland to prevent or shrink tissue
growth such as finasteride (Proscar).
 3- Balloon urethroplasty, laser therapy, and intraurethral
stents (Newer treatments) .

Surgical treatment
1- Transur.ethral resection of the prostate (TURP).
2- laser therapy
2- Open prostatectomy.

Nursing Process for the Patient with BPH and TURP.
Nursing Diagnosis
Acute pain related to bladder spasms, obstruction, or surgical
process.
Nursing Intervention
1- Monitor pain every 2 to 4 hours using a pain scale for first
48 hours.
2 Administer stool softeners to prevent discomfort from
constipation.
3- Give prescribed medication (analgesics, antispasmodics)
and monitor response.

4- Irrigate catheter as ordered.
5- Teach relaxation, deep breathing techniques.
6- Make sure catheter is secured to patient's thigh and tubing
is not creating traction on catheter, which will cause pain
and potential hemorrhage.
Nursing Diagnoses
Impaired Urinary Elimination related to surgical procedure
and urinary catheter.
Nursing Intervention
1- Maintain patency of urethral catheter placed after surgery.

 Monitor flow of three-way closed irrigation and drainage
system if used. Continuous irrigation helps prevent clot
formation, which can obstruct catheter, cause painful
bladder spasms, and lead to infection.
 Perform manual irrigation with 50 mL irrigating fluid using
aseptic technique.
 Avoid overdistention of bladder, which could lead to
hemorrhage.
 Administer anticholinergic medications to reduce bladder
spasms, as ordered.

A three-way system for bladder irrigation.

2- Assess degree of hematuria and any clot formation;
drainage should become light pink within 24 hours.
 Report bright red bleeding with increased viscosity
(arterial)—may require surgical intervention
 Report increase in dark red bleeding (venous)—may
require traction of the catheter so the inflated balloon
applies pressure to prostatic fossa.
 Prepare for blood transfusion if bleeding persists.
3- Administer I.V. fluids, as ordered, and encourage oral
fluids when tolerated to ensure hydration and urine
output.

Nursing Diagnosis:
Ineffective therapeutic regimen management related to lack of
knowledge of postoperative restrictions and care.
Interventions
1- Teach patient to avoid lifting heavy objects, stair climbing,
driving, strenuous exercise, constipation, straining during
bowel movements, and sexual activities until approved by
physician (about 6 weeks).
2- Keep catheter bag secured to abdomen or thigh and below
bladder.
3- Wash catheter with soap and water once daily.

4- Report signs and symptoms of UTI to physician
immediately.
5- Encourage oral fluids.
6- Teach all patients to report bleeding that is not stopped
with resting, fever, swelling, or difficulty urinating to
physician promptly.

CHRONIC RENAL FAILURE (END-STAGE RENAL DISEASE).
Is a progressive, irreversible deterioration in renal function.
The body’s ability to maintain metabolic and fluid and electrolyte
balance fails.
Uremia or azotemia occurs.
If left untreated, the patient with uremia dies, often within weeks.
End-stage renal disease (ESRD) occurs when 90% of the nephrons
are lost
The BUN and creatinine levels are always elevated.
This is advanced stage of renal failure, which is reached when the
glumerular filtration rate (GFR) falls to 5 ml/min (normal GFR=
120 ml/min).

Etiology:
 Chronic high blood pressure causing nephrosclerosis
 DM resulting in diabetic nephropathy (leading cause).
 Chronic glomerulopathies.
 Interstitial nephritis and pyelonephritis.
 Hereditary renal disease such as polycystic disease
 obstruction of the urinary tract
 Environmental and occupational agents include lead,
mercury, and chromium.

 GIT—anorexia, nausea, vomiting, hiccups, ulceration of GI
tract, and hemorrhage, Ammonia odor to breath, Metallic
taste.
 Cardiovascular— Pitting edema (feet, hands, sacrum),
Periorbital edema, Pericarditis, Pericardial effusion,
Hyperkalemia, Hyperlipidemia.
 Respiratory—pulmonary edema, pleural effusions.
 Neuromuscular—fatigue, sleep disorders, headache,
lethargy, seizures, coma.

 Metabolic and endocrine—hyperlipidemia, sex hormone
disturbances causing decreased libido, impotence,
amenorrhea
 Dermatologic—pallor, Gray-bronze skin
colorhyperpigmentation, pruritus, ecchymoses.
 Skeletal abnormalities—renal osteodystrophy resulting in
osteomalacia
 Hematologic—anemia, defect in quality of platelets,
increased bleeding tendencies
 Psychosocial functions—personality and behavior changes,
alteration in cognitive processes.

Diagnostic Evaluation
 Complete blood count (CBC)—anemia
 Elevated serum creatinine, BUN, phosphorus
 Decreased serum calcium, bicarbonate, and proteins,
especially albumin
 Decrease in glomerular filtration rate.
 Renal ultrasound shows decrease in renal size in chronic
renal failure.

TREATMENT
1- Detection and treatment of reversible causes of renal
failure (eg, bring diabetes under control; treat
hypertension).
2- Dietary regulation— restricts potassium, phosphate,
sodium, and protein in diet.
3- Treatment of associated conditions to improve renal
dynamics
 Anemia— administer erythropoietin agents.
 Acidosis—administration of sodium bicarbonate

 Hyperkalemia—restriction of dietary potassium.
 Phosphate retention—decrease in dietary phosphorus
(chicken, milk, legumes, carbonated beverages).
4- Maintenance dialysis or kidney transplantation when
symptoms can no longer be controlled with conservative
management.

Dialysis
Dialysis is started when there is:
1- symptoms of severe fluid overload.
2- high potassium levels
3- acidosis.
4- symptoms of uremia that are life threatening.
5-It may also be used to remove medications or toxins
(poisoning or medication overdose) from the blood.

HEMODIALYSIS
Hemodialysis involves the use of an artificial kidney to remove
waste products and excess water from the patient’s blood.
A hemodialysis treatment takes 3 to 4 hours and is done three
or four times a week.
Hemodialysis provides a rapid and efficient way to remove
waste products from the blood.
It is also an excellent means to correct excessive fluid-
overloaded states such as occur in heart failure.

Vascular Access.
Typical vascular access options are:
1- A vascular access graft.
2- An arteriovenous (AV) fistula.

Patient undergoing hemodialysis at dialysis center.

Double-lumen, cuffed hemodialysis catheter used in acute hemodialysis.

Peritoneal dialysis (PD) provides continuous dialysis
treatment and is done by the patient or family in the home.
The exchange process has three steps: filling, dwell time,
and draining.
The fill step involves instilling 1500 to 2000 mL of sterile
dialyzing solution (dialysate) into the patient’s peritoneal
cavity through the catheter.

 The solution is left to dwell in the abdomen for several hours,
allowing time for the waste products from the blood to pass
through the peritoneal membrane into the dialysate solution.
 The solution is then drained out of the body and discarded.
 Patients with diabetes or cardiovascular disease, many older
patients, and those who may be at risk for adverse effects of
systemic heparin are likely candidates for PD.

Nursing Care Plan for the Patient with Renal Failure
Nursing Diagnosis:
Excess fluid volume related to decreased urine output, dietary
excesses, and retention of sodium and water.
Nursing Interventions
1. Assess fluid and electrolyte status:
a. Serum electrolyte levels
b. Daily weight changes
c. Precise intake and output balance
d. Skin turgor and presence of edema
e. Distention of neck veins
f. Blood pressure and pulse rate and rhythm
g. Respiratory rate and effort

2. Limit fluid intake to prescribed volume.
3. Identify potential sources of fluid:
a. Medications and fluids used to take or administer
medications: oral and intravenous
b. Foods
4. Explain to patient and family rationale for fluid restriction.
5. Assist patient to cope with the discomforts resulting from
fluid restriction.
6. Provide or encourage frequent oral

Nursing Diagnosis:
Imbalanced nutrition: less than body requirements related to
anorexia, nausea, vomiting, dietary restrictions, and altered oral
mucous membranes.
Nursing Interventions
1. Assess nutritional status:
a. Weight changes
b. Laboratory values (serum electrolyte, BUN, creatinine, protein,
and iron levels)
2. Assess for factors contributing to altered nutritional intake:
a. Anorexia, nausea, or vomiting
b. Diet unpalatable to patient
c. Depression
d. Lack of understanding of dietary restrictions
e. Stomatitis

3. Provide patient’s food preferences within dietary restrictions.
4. Promote intake of high-biologic-value protein foods: eggs, dairy
products, meats.
5. Encourage high-calorie, low-protein, low-sodium, and low-
potassium snacks between meals.
6. Provide pleasant surroundings at mealtime.
7. Weigh patient daily.
8. Assess for evidence of inadequate protein intake:
a. Edema formation
b. Delayed wound healing
c. Decreased serum albumin levels

References
Burghardt, C., Lamsback,B., Robinson, J., et al. (2012). Lippincott’s review for
medical-surgical nursing certifi cation. 5th ed. Philadelphia: Lippincott Williams &
Wilkins.
DiGiulio, M., Jackson, M., and Keogh, M. (2007) Medical-Surgical
NursingDemystified. London: McGraw-Hill Companies.
Williams, L., Hopper. P. (2007) Understanding medical-surgical nursing. 3rd ed.
Philadelphia: F. A. Davis Company.
Williams, L., Hopper. P. (2003) Understanding medical-surgical nursing. 2rd ed.
Philadelphia: F. A. Davis Company.
Hillegass, E. (2007)REHAB Notes. A clinical exam pocket guide. Philadelphia: F. A.
Davis Company.
Smeltzer. S., et al. (2010)Brunner & Suddarth’s textbook of medical-surgical nursing.
12th ed. London: Lippincott Williams & Wilkins.
Nettina, S. (2010) Lippincott manual of nursing practice. 9th ed. Philadelphia:
Lippincott Williams & Wilkins.

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