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

Glomerulus
This 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 tubule
Nutrients (salts, vitamins, etc.) are

moved out of the tubule through active

transport.
Water follows the nutrients by osmosis.

Functions of kidney
Excretion

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

Question
Is the following statement True or
False?
The most accurate indicator of fluid
loss or gain in an acutely ill patient is
weight.

Answer
True
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 Failure

Hypovolemia
Hypotension
Reduced cardiac output and heart

failure
Obstruction of the kidney or lower
urinary tract
Obstruction of renal arteries or veins

Causes of Chronic Renal Failure

Diabetes mellitus
Hypertension
Chronic glomerulonephritis,
Pyelonephritis or other infections
Obstruction of urinary tract
Hereditary lesions

Causes of Chronic Renal Failure

Vascular disorders
Medications or toxic agents

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

calcifications

The Care of the Patient with Renal Failure

Assessment
Fluid status

Nutritional status
Patient knowledge
Activity tolerance
Self-esteem
Potential complications

Nursing Management
Inspect 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 Management
Monitor vital signs
Weigh patient daily
Assess for signs and symptoms of

fluid volume excess, and keep

accurate I&O

Nursing Management
Explain to patient and family the

rationale for the fluid restriction

Assist patient to cope with the fluid
restriction
Provide or encourage frequent oral
hygiene

Nursing Management
Assess nutritional status; weight

changes and lab data

Assess patient nutritional patterns and
history; note food preferences
Encourage high-quality nutritional
foods while maintaining nutritional
restrictions

Nursing Management
Assess and modify intake related to

factors that contribute to altered

nutritional intake, eg, stomatitis or
anorexia
Adjust medication times related to meals
Encourage high calorie, low-protein,
low-sodium and low potassium snacks
between meals

Nursing Management
Assess for evidence of inadequate

protein intake: edema, delayed wound

healing and decreased serum albumin
levels
Provide patient with food preferences
within dietary restrictions
Assist patient to cope with the
discomforts resulting from fluid
restrictions

Nursing Management
Monitor 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 Esteem

Assess patient and family responses

to illness and treatment

Assess relationships and coping
patterns
Encourage open discussion about
changes and concerns

Risk for Situational Low Self Esteem

Explore alternate ways of sexual

expression
Discuss role of giving and receiving
love, warmth, and affection

Acute Glomerulonephritis
Refers to a group of kidney diseases

in which there is an inflammatory

reaction in the glomeruli

tea coloured urine

Oliguria
Fatigue and anorexia
Hypertension
Clinical
Manifestations
Anemia
Possible headache
Puffiness of face
Edema of extremities

Nursing Management
Monitor vital signs, intake and output

and maintain dietary restrictions

Encourage rest
Administer medications as ordered
and evaluate patients response to
antihypertensives, diuretics and
antibiotics.

Nursing Management
Monitor for signs of heart failure,

distended neck veins, tachycardia,

enlarged and tender liver
Observe for hypertensive

encephalopathy and any evidence of

seizure activity.

Kidney Surgery
Preoperative considerations
Perioperative concerns
Postoperative management
Potential hemorrhage and shock
Potential abdominal distention and

paralytic ileus

Kidney Surgery
Potential infection
Potential thromboembolism

Patient Positioning and Incisional

Approaches

Renal Transplantation

Postoperative Nursing Management

Assessment: include all body systems,

pain, fluid and electrolyte status, and

patency and adequacy of urinary
drainage system
Diagnoses: ineffective airway
clearance, ineffective breathing
pattern, acute pain, fear and anxiety,
impaired urinary elimination, and risk
for fluid imbalance

Postoperative Nursing Management

Complications: bleeding ,

pneumonia, infection, and DVT

Interventions
Pain relief measures and analgesic

medications
Promote airway clearance and
effective breathing pattern by
appropriate pain relief, deep breathing
coughing exercises, and incentive
spirometry and positioning
Monitor UO and maintain potency of
urinary drainage systems

Nursing Management
Pain relief measures and analgesic

medications
Promote airway clearance and
effective breathing pattern by
appropriate pain relief, deep breathing
coughing exercises, and incentive
spirometry and positioning
Monitor UO and maintain potency of
urinary drainage systems

Nursing Management
Monitor for signs and symptoms of

bleeding
Encourage leg exercises, early
ambulation, and monitor for signs of
DVT
Use strict asepsis with catheter and
appropriate technique in providing all
care

Patient Teaching
Instruct both patient and family
Drainage system care
Strategies to prevent complications
Signs and symptoms
Follow-up care
Fluid intake
Health promotion and health screening

Renal Transplant
Kidney 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 Transplant
or 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
Infection
Acute rejection appears within the first 6

months after transplantation and affects

approximately 15% of transplanted kidneys
Chronic rejection occurs more than 1 year
after transplantation

Complications
Hypertension
Renal vein thrombosis is typically an early

complication presenting as graft tenderness and

edema

Class Activity
Formulate nursing interventions for
the following diagnoses:
Risk for anxiety related to transplant

experience, potential for rejection,

and side effects of medications.

Class Activity
Risk 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 Teaching
Explain 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 Teaching
Advise avoidance of contact sports

for life to prevent trauma to the

transplanted kidney.

Patient Teaching
Instruct 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 Cancer
Bladder 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 Factors
Carcinogens in the workplace, such

as dyes, rubber, leather, paint

Recurrent bacterial infection of
urinary tract
Smoking
Bladder stones

Risk Factors
High urinary Ph
High cholesterol intake
Cancers arising from prostate, colon

and rectum in males

Clinical Manifestations
Hematuria
Pain and a mass in the flank
Dull pain in the back from pressure

produced by compression of the

ureter
Extension of the tumour into the
perirenal area

Clinical Manifestations
Haemorrhage into the kidney tissues
Colicky pains occur if mass or clot of

tumour cells passes down from the

ureter
Unexplained weight loss

Clinical Manifestations
Gross, painless hematuria
Urinary frequency
Urgency
Dysuria
Pelvic or back pain with metastasis

Treatment
Chemotherapy

There 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 activity
Formulate nursing interventions for

the following nursing diagnoses:

Risk for infection related to invasive

procedures.

Nursing Management
Risk 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 Calculi
Kidney 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 Factors
Family 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 Factors
Digestive 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 Manifestations
A 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 Manifestations
Severe pain in the side and back,

below the ribs

Pain that spreads to the lower
abdomen and groin
Pain that comes in waves and
fluctuates in intensity
Pain on urination
Pink, red or brown urine

Clinical Manifestations
Cloudy or foul-smelling urine
Nausea and vomiting
Persistent urge to urinate
Urinating more often than usual
Fever and chills if an infection is

present

Diagnostic Tests
Blood 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 Tests
Imaging 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/Promotion
Lifestyle 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/Promotion
Eat 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/Promotion
Continue 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/Promotion
Ask 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/Promotion
Choose 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