Renal System Disorders Renal System Disorders Renal System Disorders Renal System Disorders

Renal System Disorders
Nio C. Noveno,
Noveno, RN
RN,, MAN
The Human Kidney
Renal Disorders nionoveno@hotmail.com 2

The Nephron

Functions of the Renal System
Excretion of waste
Regulation of acid-base balance
Formation of erythropoietin
Regulation of fluid and electrolyte balance

(RAAS)
Regulation of phosphate and calcium

Classification of Renal Disorders
Obstructive disorders
Acute renal failure
Chronic renal failure

Obstructive disorders
Can occur anywhere in the urinary
tract
Signs and symptoms depend on the

site of location and size of
obstruction

Causes
of urinary tract obstruction
Lower urinary tract Ureteral obstruction
Bladder neoplasms Calculi
Urethral strictures Trauma
Calculi Enlarged lymph nodes

Congenital anomalies
Tumors
Benign prostatic
hypertrophy Kidney
Calculi
Polycystic kidney disease

Renal stones
Crystallization of minerals around an
organic matrix (blood, pus,
devitalization tissue)
Usually idiopathic:
– Infection

SITES OF STONE FORMATION

Composition of renal stones
Calcium (oxalate and phosphate) Uric acid
Hypercalcemia High purine diet
Hyperthyroidism Gout
Vitamin D intoxication Chemotherapy
Immobilization
Cystine
Tumors
Genetic disorder
Renal tubular acidosis
Intake of steroids Struvite
Infection related

Renal Stones
Diagnostics
Urinalysis
KUB-UTZ
KUB-IVP
CT scan
Cystoscopy
BUN, Creatinine
Clinical manifestations
Pain
Hematuria

Diagnostic Procedures

Medical management
Medications
Pain medications
Medications to Ca & PO4 content
– Ascorbic acid
Medications to uric acid formation
– Sodium bicarbonate
– Allopurinol
Surgery
Extracorporeal shockwave lithotripsy
Percutaneous lithotripsy

EXTRACORPOREAL
SHOCKWAVE LITHOTRIPSY

Nursing management
Administer medications as
ordered
Strain urine to detect passage

of stones
Monitor I & O
Encourage to increase OFI

>3 L/day
Instruct client on infection

prevention
Bladder carcinoma
Most common among 60-70 years old
Males>females
Predisposing factors:
– Cigarette smoking
– Exposure to rubber dyes
– Abuse of phenacetin-containing
analgesics
– Recurrent UTI
– Recurrent nephrolithiasis
Bladder carcinoma
Clinical manifestations
– Gross painless hematuria
– Dysuria
– Frequent urination
Diagnostics
– Urinalysis
– IVP
– Cystoscopy with biopsy
– CT scan
Bladder carcinoma
Medical Management Nursing management
Surgical treatment Encourage to:

Radiation – Increase OFI
Chemotherapy – Quit smoking
Assess for presence

of UTI

Bladder carcinoma
Care of the STOMA Teach patient on stoma
Immediate post-OP: care
Color of drainage is bright Opening should be
red/pink no more than 2-3
mm larger than the
Report: gray or black stoma
discoloration Change every 3-5
Position pouch at the side of days
bed for drainage
Monitor urine output daily
Report signs of UTI
Monitor for signs of peritonitis
– Cloudy urine
Abdominal pain, – Hematuria
distention, fever – Strong odor
– Fever
– Flank pain
Benign Prostatic Hyperplasia (BPH)
Most common
problem of adult male
reproductive organ
Cause is not
completely
understood
Not a predisposing
factor for prostatic
carcinoma
Clinical manifestations Diagnostics

Dribbling Digital rectal exam
Hesitancy Urinalysis
Diminution in caliber BUN/Creatinine
and force of urinary Cystourethroscopy
stream PSA
Feeling of incomplete
emptying
Irritative symptoms


Medical Management Non-surgical

procedures
Pharmacologic
Thermotherapy
treatment
Prostatic balloon
Anti-androgens device
– Finasteride Stents/coils
– Alpha-adrenergic TULIP (transurethral
blockers ultrasound-guided
laser prostatectomy)
– Terazosin
Surgical procedures

Nursing management:
1. Provide medications as ordered
2. Maintain patency of 3-way Foley
• Observe aseptic technique
• Irrigate with NSS (as ordered)
3. Control & treat bladder spasms
• Short, frequent walks
• Decrease frequency of bladder irrigation
• Administer anti-cholinergics and anti-
spasmodics
4. Prevent hemorrhage
• Prevent straining (heavy lifting, constipation),
prolonged periods of travel, sexual activity
until doctor approves so.
• Avoid rectal procedures.
5. Provide for bladder training after Foley
catheter removal
• Perineal exercise
• Limit fluid intake in the evening
• Restrict intake of caffeine-containing
compounds
• Withhold anti-cholinergics and anti-
spasmodics if permitted
5. Provide health teaching on:

• Increasing OFI
• Signs of UTI and report once noted
• Avoidance of heavy lifting, straining and
prolonged travel.
• Possible impotence

Prostate cancer
Highest incidence in African-American over
age 60
Adenocarcinoma; growth related to presence
of androgens
Clinical manifestations:
– Same as BPH
– Hard, nodular, fixed mass upon rectal exam
Laboratory diagnostics:
– Elevated PSA, acid & alkaline phosphatase
– Bone scan
Prostate cancer

Prostate cancer
Medical management: Nursing interventions:
1. Administer prescribed
Drug therapy:
medications
Estrogens, 2. If with radiotherapy:
chemotherapeutic • Double flush the toilet
agents after use.
Radiation therapy • Advise to avoid placing
children on their lap.
Surgery: Perineal
• Avoid sexual intercourse
prostatectomy for the whole duration of
therapy.
3. Provide care post-
prostatectomy

Acute renal failure (ARF)
Sudden cessation of kidney function; reversible

Acute renal failure (ARF)
Sudden cessation of kidney function; reversible
Causes:
1. Ischemic (pre-renal)
• Dehydration 3. Obstruction (post-renal)
• Blood loss (surgery, trauma) • Stones
• Cardiac failure • Tumors
• Shock • Strictures/stenosis
2. Toxic substance (renal)

• Solvents (carbon 4. Other causes:
tetrachloride, methanol, • Acute
ethylene glycol) glomerulonephritis
• Heavy metals (lead, arsenic,
mercury) • Malignant
hypertension
• Antibiotics
(aminoglycosides, • Hemolysis
amphotericin B)
• Pesticides
• Mushrooms

Physiologic effect Findings Symptoms
Drowsiness, Confusion, Coma
Oliguric ↑ BUN, Crea
GI bleeding
Inability to excrete wastes Asterixis
Pericarditis
Cardiac dysrhythmias
↑ K+, ↓ Na+, acidosis
Inability to regulate electrolytes Kusmaull’s breathing
Coma
CHF
Fluid overload
Inability to excrete fluid loads Pulmonary edema
Hypertension
Urine output of 4-5 L/day
Hypotension
Hypovolemia Tachycardia
Improving mental alertness
Diuretic ↓ Na+ Weight loss
↓ K+ Dry mucous membranes
Muscle weakness
Constipation
Recovery Return to normal

Nursing management:
Medical management:
Supportive
Dialysis
Nursing management:
1. Maintain F & E balance
• Accurate I & O
• Weigh daily
• Maintain fluid restrictions
• Assess for signs of fluid overload
2. Maintain nutrition
• Moderate CHON, low K+, high CHO, high fat
• Measures to relieve nausea

Nursing management:
3. Maintain rest-activity balance
• Provide assistance in ADL
• Maintain strict bed rest in acute phase
4. Prevent injury
• Keep side rails elevated (pad if necessary)
• Protect from bleeding
5. Prevent infection
• Maintain asepsis
• Reverse isolate
• Turn frequently
• Meticulous skin care
• Relieve pruritus

Chronic renal failure (CRF)
Causes:
Chronic systemic disease

DM, HTN
Polycystic kidney disease
Long standing obstruction
Chronic glomerulonephritis
Recurrent infections

Stages of CRF
1. Decreased renal reserve (renal
impairment) 4. End-stage renal disease
• GFR: 40-50% • GFR: <10%
• BUN & crea are normal • BUN & crea severely
• Asymptomaitc increased
• Signs of CHF
2. Renal insufficiency
• GFR: 20-40% • Hypocalcemia,
hyperphosphatemia,
• BUN & crea begins to rise hyperkalemia,
• Mild anemia, mild azotemia hyponatremia
• Polyuria, nocturia • Fractures, joint pains
3. Renal failure • Infertility, amenorrhea
• GFR: 10-20% • Uremia
• BUN & crea increase
• Anemia, azotemia,
metabolic acidosis

Stages of CRF
Decreased renal
reserve
Renal insufficiency
Renal failure
End-stage renal
disease
Diagnostics: Anemia
Blood chemistry – Epoieitin alfa
Urinalysis
– Iron
KUB-TUZ
– Folate and Vitamin B12
Medical management: – Blood transfusion
Conservative TX
Fluid and electrolyte control Hypertension
– Hyperkalemia
Diet
Dialysis Dialysis
Exchange resins
– Hypocalcemia/
hyperphosphatemia Renal transplant
Phosphate binders
Diet
Vitamin D

Peritoneal Dialysis

Peritoneal Dialysis
Intermittent:
8-12 H x 3-5x/week
Ambulatory:
3-5 passes/day
Continuous cycling:
3-7x during sleep

Peritoneal dialysis
Must consider:
(+) pink-tinged effluent
– Explaining or presence of small
procedure strings is normal
– Monitor VS (+ Blood is normal for

weight) several days
– Note for signs of With ascites from other

source, substitute a
infection lower concentration of
dialysate
– Assess skin
integrity
Hemodialysis
AV Fistulas
– Internal AVF
– Internal Graft AVF
– Internal AV Graft
with external
access device
Complications
– Thrombosis
– Local infections
– Aneurysms
– Steal syndrome
Hemodialysis

HEMODIALYSIS PERITONEAL DIALYSIS
AVF
ACCESS Subclavian vein Peritoneum
Arteriovenous graft
DURATION 2-4 H 36 H
Disequilibrium syndrome Exit site infection

Hypotension Peritonitis
COMPLICATIONS Bleeding Hernias
Sepsis Pulmonary complications
Hepatitis Protein loss
Monitor for VS and changes in

Weigh before and after HD behavior
VS q 15 mins Check patency of catheter
Monitor I & O, signs of DE May procaine HCl in the
NURSING INTERVENTIONS WOF signs of bleeding dialysate to minimize
Do NOT use the AVF other than for discomfort
dialysis Observe for signs of peritonitis
Provide diversional activities Maintain aseptic technique
Renal Disorders nionoveno@hotmail.com during insertion of trochanter.
46
Nursing management:
Maintain F & E balance
– I & O q 80
– Weigh daily
– Assess edema
Auscultate breath sounds
V/S q 80
Assess LOC q 80
High CHO diet, within prescribed Na+, K+, and
CHON limits
Administer medications as ordered
Renal Transplant

Renal Transplant

Nursing management cont…:
Prevent infection and injury
– Promote meticulous skin care
– Protect from infectious agent
– Protect confused person
– Maintain asepsis
– Avoid aspirin products
– Encourage use of soft bristle toothbrush
Promote comfort
– Give anti-pruritics
– Use emolient baths, keep skin moist
– Provide good oral hygiene

ACID-BASE DISORDERS
Disorder Clinical manifestation Compensation
↑Paco2, ↑ or normal Kidneys eliminate H+

Respiratory acidosis
HCO3-, ↓ pH and retain HCO3-
↓ Paco2, ↓ or normal Kidneys conserve H+

Respiratory alkalosis
HCO3-, ↑ pH and eliminate HCO3-
↓ or normal Paco2, Lungs eliminate CO2

Metabolic acidosis
↓HCO3-, ↓ pH and conserve HCO3-
Lungs hypoventilate to
↑ or normal Paco2, ↑ Paco2, kidneys
Metabolic alkalosis
↑HCO3-, ↑ pH conserve H+ excrete
HCO3-
Causes of Acid-Base Disorders
Nursing management:
Metabolic acidosis
Administer sodium
Causes:
bicarbonate
DKA, uremia,
starvation, diarrhea, Monitor for signs of
severe infections hyperkalemia
Provide alkaline
Manifestations: mouthwash
Headache, nausea Lubricate lips to prevent
and vomiting dryness
Signs of hyperkalemia I & O
Seizures, coma, Institute seizure precaution
hyperventilation
Monitor ABG & electrolyte
losses
Metabolic alkalosis
Causes: Nursing management:
Severe vomiting, NGT Decreased
suctioning, diuretic respirations
therapy, excessive Replace fluids nad
ingestion of NaHCO3, electrolytes losses
biliary drainage I&O
Assess for signs of
Manifestations: hypokalemia
Nausea and vomiting Monitor ABG &
Signs and symptoms electrolytes
of hypokalemia
Respiratory acidosis
Causes:
Hypoventilation: COPD, Nursing management:
barbiturate or sedative Semi-Fowler’s
overdose, acute airway
obstruction, Patent airway
neuromuscular disorders Turn, cough, deep-
breath
Manifestations: Administer fluids
Headache, weakness, O2 therapy
visual disturbances, rapid
respirations, confusion, Monitor ABG
drowsiness, tachycardia,
coma
Respiratory alkalosis
Causes: Nursing management:
Hyperventilation,
mechanical Offer reassurance
overventilation, Encourage breathing
encephalitis into a paper bag
Manifestations:
Provide sedation as
Numbness and tingling of
mouth and extremities ordered
Inability to concentrate Monitor mechanical
Rapid respirations, dry ventilation and ABG
mouth, coma

Interpretation
UC PC FC
pH ↓ or ↑ ↓ or ↑ normal
↓ or ↑
HCO3- ↓ or ↑ ↓ or ↑
normal
↓ or ↑
Paco2 ↓ or ↑ ↓ or ↑
normal
Renal System Disorders
Nio C. Noveno, USRN, MAN

Renal System Disorders Renal System Disorders Renal System Disorders Renal System Disorders

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Renal System Disorders

Renal Disorders nionoveno@hotmail.com 2

Renal Disorders nionoveno@hotmail.com 3

Regulation of acid-base balance

Regulation of fluid and electrolyte balance

Regulation of phosphate and calcium

Renal Disorders nionoveno@hotmail.com 4

Acute renal failure

Chronic renal failure

Renal Disorders nionoveno@hotmail.com 5

Signs and symptoms depend on the

Renal Disorders nionoveno@hotmail.com 6

Calculi Enlarged lymph nodes

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Renal Disorders nionoveno@hotmail.com 14

Strain urine to detect passage

Encourage to increase OFI

Instruct client on infection

Surgical treatment Encourage to:

Assess for presence

Renal Disorders nionoveno@hotmail.com 18

Clinical manifestations Diagnostics

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Medical Management Non-surgical

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5. Provide health teaching on:

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2. Toxic substance (renal)

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Recovery Return to normal

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Chronic systemic disease

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– Monitor VS (+ Blood is normal for

– Note for signs of With ascites from other

Renal Disorders nionoveno@hotmail.com 45

Disequilibrium syndrome Exit site infection

Monitor for VS and changes in

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Renal Disorders nionoveno@hotmail.com 50

↑Paco2, ↑ or normal Kidneys eliminate H+

↓ Paco2, ↓ or normal Kidneys conserve H+

↓ or normal Paco2, Lungs eliminate CO2

Renal Disorders nionoveno@hotmail.com 55

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