Care of the Patient With Renal and Urinary Disorders - Handout Nursing IV - Medical Surgical Component Classroom Objectives • Discuss the pathophysiology and clinical manifestations of renal failure • Interpret the results of laboratory data & diagnostic tests associated with renal failure. • Discuss three treatment modalities used in the collaborative management of chronic renal failure. Classroom Objectives Cont. • Describe the kidney donor selection process. • Discuss the drug therapy used to prevent transplant rejection.
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Care of the Patient With Renal and Urinary Disorders -
HandoutNursing IV - Medical Surgical
Component
Classroom Objectives
• Discuss the pathophysiology and clinical manifestations of renal failure
• Interpret the results of laboratory data & diagnostic tests associated with renal failure.
• Discuss three treatment modalities used in the collaborative management of chronic renal failure.
Classroom Objectives Cont.
• Describe the kidney donor selection process.
• Discuss the drug therapy used to prevent transplant rejection.
Continued
• Use Maslow’s hierarchy to prioritize assessments in the patient with CRF undergoing various treatment modalities.
• State four nursing diagnoses (NANDA)commonly associated with a patient in end-stage renal disease.
Classroom Objectives Cont.
• List four corresponding nursing outcomes (NOC) associated with the diagnoses generated for the patient in end-stage renal disease.
• Discuss appropriate NIC based nursing interventions for the patient undergoing dialysis or renal transplant.
•
Continued
• Discuss the nursing management of the end-stage renal patient at home and the use of community resources
Slide 72.1
Anatomic Location of the Organs of the Renal/Urinary System
Bisection of the Kidney Showing Major Structures of the Kidney
Slide 72.4
Anatomy of the Nephron
Sodium and Water Reabsorbtion by the Tubules of a Cortical Nephron
• K+ increases• Phosphate increases• Sodium - normal or decreased• Magnesium increases• Calcium decreases • Metabolic acidosis
The Effects of Renal Failure on Phosphate and Calcium Balance
Slide 75.1
Focused Assessment for Care Clients with Chronic Renal Failure (Acute Care Too)*
Assess renal status, including
• Amount, frequency, and appearance of urine (anuric clients)
• Presence of bone pain
• Presence of hyperglycemia secondary to diabetes
Slide 75.19
Focused Assessment for Care Clients with Chronic Renal Failure*
Assess cardiovascular and respiratory status, including
• Vital signs, with special attention to blood pressure
• Presence of S3 and/or pericardial friction rub
• Presence of chest pain
Slide 75.18
Assessment Continued*
• Presence of edema (periorbital, pretibial, sacral)
• Jugular vein distension• Presence of dyspnea• Presence of crackles, beginning at the
bases, and extending upward
Continued*
Assess hematologic status, including• Presence of petechiae, purpura,
ecchymoses• Presence of fatigue or shortness of breathAssess gastrointestinal status, including• Presence of stomatitis• Presence of melena
Assessment Continued*
Assess integumentary status, including• Skin integrity• Presence of pruritis• Presence of skin discoloration
Review - Focused Assessment for Clients with Chronic Renal Failure
Assess NEUROLOGIC status, including• Changes in mental status• Presence of seizure activity• Presence of sensory changes• Presence of lower extremity weakness
Assess NUTRITIONAL status, including
• Weight gain or loss• Presence of anorexia, nausea, or vomiting
Case Study-End Stage Renal Disease
NURSING DIAGNOSES CRF
Nursing Diagnoses for CRF Patient*
• Fluid Vol. deficit of Fluid Vol Excess rt. impaired Renal function
• Altered Nutrition less than Body Requirements rt anorexia, nausea
• Fatigue rt. anemia & altered metabolic state
• Risk for Impaired Skin Integrity
• Knowledge Deficit rt. disease process & treatment
• Risk for Ineffective Management of Therapeutic Regime
• Risk for Ineffective Family Coping-Financial - *80% fed. Gov
Nsg. Diagnoses Continued*
• Activity Intolerance rt. Effects of Anemia
• Impaired Comfort : puritis
• Chronic Sorrow rt. Chronic Illness
• Fatigue rt. Altered Body Chemistry
• Risk for Injury rt. bone changes, muscle weakness
• Decreased Cardiac Output rt. elevated K+ levels
Medical Goals of CRF
• Preservation of Renal Function• Delay of need for Dialysis or transplant • Improvement of Body Chemistry• Alleviation of Extrarenal effects• Provide optimal quality of life
Dietary Restrictions*
• Fluid• Protein –on dialysis – high quality protein
– not limited on hemodialysis• Potassium 60-70 mEg./day• Sodium• Phosphorus
• Initially assess hemorrhage, infection, edema. elevate arm
• No B/P, venipunctures, I.V.s in access arm• assess function of fistula - bruit & thrill• assess distal pulse circulation• Allen’s test• no carrying heavy objects etc.
A Surgically Created Venous Fistula
Slide 75.7
Native Arteriovenous (AV) Fistula
• the preferred type of vascular access for patients with end stage renal disease.
• AV fistulae result in significantly lower rates of complication (such as infection and clotting), longer patency, fewer hospitalizations, lower patient morbidity, and significantly lower costs compared to other accesses
Dialysis - Nursing Care*
• Prior to Dialysis• During Dialysis
KB – Dialysis at 10AM
• Meds: Atacand, Lasix, Regular insullin, Digoxin, Tums – What do you give?
• Other Nsg. Duties?• Nausea, hypertensive,
The Client Undergoing Hemodialysis
• Weigh the client before and after dialysis.
• Know the client's dry weight.
• Decide whether any of the client's meds should be withheld until after dialysis.
• Be aware of events that occurred during the dialysis treatment.
• Measure blood pressure, pulse rate, respirations, and temperature..
Slide 75.17
Continued• Assess for symptoms of orthostatic hypotension.
• Assess the vascular access site.
• Observe for bleeding.
• Assess the client's level of consciousness and assess for headache, nausea, and vomiting.
Post- Dialysis Nsg. Management*
• Disequilibrium syndrome• Monitor for bleeding, hematoma & patency• Neuro assessment, LOC
Peritoneal Dialysis*
• Osmosis• Diffusion • Dialysate Concentrations• Dwell time
Manual Peritoneal Dialysis Via Implanted Abdominal Catheter (Tenckhoff Catheter)
Slide 75.13
Nursing Management of Peritoneal Dialysis*
• installations and dwell periods• dialysate• outflow times
• Automated Peritoneal Dialysis (ADP) can be run at different time intervals -
• Two forms of ADP 1. (CCPD) continuous cyclic with 3 cycles at noc and one 8 hr. in morning -2.(IPD)intermittent 10-14 hrs/ 3-4 x wk., NPD nightly peritoneal dialysis 8-12 hrs at noc.
The used Dialysis Bags are 'Clinical Waste'. The Renal Unit will contact the local authority for you and arrange
for free yellow coloured clinical waste bags to be delivered to your home (usually four a week. You will
need only two bags but they need to be double wrapped). They will also arrange for a free weekly
collection of the full bags.
Flatten your cardboard boxes (see diagram on the box) and put out for your regular rubbish collection.
Please click on the links below for further CAPD info.Weight & Fluid Balance | Clean Procedures : Infection |
• Hyperglycemic & hyperosmolar states Esp. with high glucose dialysate
• Cath. Displacement• Abd. Discomfort• Lack of compliance when self dialysing
Assess laboratory data, including
• BUN & Creatinine• Creatinine clearance• CBC• ElectrolyteAssess psychosocial
status, including• Presence of anxiety• Presence of maladaptive
behaviorSlide 75.20
Nsg. Management of ESRD at Home
MonitoringCommunity Resources
Kidney Transplant*• Living Related• Living Unrelated• Cadaver• United Network for Organ Sharing, Richmond Va.• National kidney transplant waiting list - 38,760 • First successful transplant -1954 - Dr. Jos. Murray,
Brigham & Women’s Hospital Boston MA.
Kidney Donor
Selection Process
Hand-assisted Laproscopic Donor Nephrectomy
• www.or-live.com/meritcare/1145/• www.matchingdonors.com• 3-5 incisions in donor abdomen• Full recovery in up to 6 weeks
Placement of a Transplanted Kidney to the Right Iliac Fossa
Slide 75.16
Nursing Responsibilities
Post Transplant
Renal Transplant Complications*
• Graft rejection -hyperacute, acute, or chronic
• Other complications: infection, disease recurrence, complications of drug therapy, ulcers, HTN, steroid-induced diabetes etc.
Hyperacute Rejection*
Hyperacute RejectionOnset• Within 48 hr after surgery
Clinical Manifestations• Increased temperature• Increased blood pressure• Pain at transplant site
Treatment• Immediate removal of the transplanted
kidneyBUN = blood urea nitrogen.
Slide 75.21
Acute Rejection*
Acute RejectionOnset• 1 wk to 2 yr postoperatively (most common
in first 2 wk)Clinical Manifestations• Oliguria or anuria• Temperature over 37.8° C (100° F)• Increased blood pressure• Enlarged, tender kidney• Lethargy• Elevated serum creatinine, Blood Urea Nitrogen, potassium levels• Fluid retention
Treatment• Increased doses of immunosuppressive drugs
BUN = blood urea nitrogen.. Slide 75.22
Chronic Rejection*
Chronic RejectionOnset• Occurs gradually during a period of
months to yearsClinical Manifestations
• Gradual increase in Blood Urea Nitrogen and serum creatinine levels
• Fluid retention• Changes in serum electrolyte level• Fatigue
Treatment• Conservative management until dialysis is
requiredSlide 75.23
Immunosuppressive therapy after Renal Transplant*
• Corticosteroids -Prednisone or methylprednisone (Solu-medrol)
• Azathioprine (Imuran, CellCept,
• Cyclosporine - used with steroids (Sandimmune or Neoral)
• FK-506 - 100 X more potent than cyclosporin
• OKT-3 - monoclonal antibody
• Antilymphocyte globulin - Atgam (ALG)
Nursing Problems rt. Immunosuppression
• increased risk of infection• bone marrow suppression• incidence of malignancy- lymphoma• c/o with steroids - gastritis & peptic ulcer
disease, bone weakness, GI bleeding, steroid induced DM, F&E imbalance
Common Types and Locations of Renal Trauma
Minor Trauma
Slide 74.7
Common Types and Locations of Renal Trauma
Pedicle Injury
Slide 74.8
Common Types and Locations of Renal Trauma
Major Trauma
Slide 74.9
Common Types and Locations of Renal Trauma
Slide 74.11
NURSING MANAGEMENT
The Patient with Bladder Cancer*
• Primary prevention: Stop Smoking – doubles the risk
• Secondary prevention: Hematuria?• Men 3X more likely• Chemicals in the workplace – dye, leather,
rubber• Whites more likely• Age – late 60’s• 53,000 new cases in 2000• 94% survival rate
Symptoms
Blood in the urine (slightly rusty to deep red in colour).
Pain during urination. Frequent urination, or feeling the need to
• Hematuria• Bladder spasms• Hemorrhage• Retropubic - care of the low ABD incision
& Suprapubic catheter• Discharge teaching
Effects of Surgery*
• Client is STERILE• Erective Dysfunction – (if pudental nerve
fx. Spared – 3-6 mos of ED ( impotence)• Urinary Incontinence – if internal &
external urinary sphincters involved.
Care Immediately after Radical Prostatectomy
• Encourage the client to use patient-controlled analgesia (PCA) as needed.The PCA device may be used through the second postoperative day.
• Keep the client on bed rest on the day of surgery. Help the client to get out of bed and ambulate for a short distance by the first postoperative day.
• Keep the client on NPO status as ordered, usually until the first or second postoperative day.
Slide 79.11
Care after Radical Prostatectomy Continued
• Maintain the sequential compression device until the client begins to ambulate. Apply antiembolic stockings until discharge.
• Monitor the client for deep vein thrombosis and pulmonary embolus.
• Keep an accurate record of intake and output, including Jackson-Pratt or other drainage device drainage.
Slide 79.11
Teaching Following Radical Prostatectomy*
You are developing a handout for patients following radical open prostatectomy . What are the
essentials?
Pt. Teaching following Radical Prostatectomy
• Keep the urinary meatus clean using soap and water.• Avoid rectal procedures or treatments.• Teach the client how to care for the urinary catheter
because he will be discharged with the catheter in place.
• Teach the client how to use a leg bag.• Emphasize the importance of not straining during
bowel movement. Advice the client to avoid suppositories or enemas.
• Remind the client about the importance of follow-up appointments with the physician to monitor progress.
Slide 79.11
Leg Bag
Discharge Teaching following Radical Prostatectomy
• Remind client about importance of follow-up appointments with M.D.
• Exercises for Urinary Incontinence :tighten perineal muscles, biofeedback
• Function – ED alternatives:prostheses, vaccum devices, viagra.
Nsg. Diagnoses Associated with Radical Prostatectomy*
• Knowledge Deficit rt Self Care & Home Maintenance
• Acute Pain rt. Bladder Spasm• Risk for Urinary Incontinence• Risk for Sexual Dysfunction – NOC
Outcomes: expresses comfort with sexual expression 1-= never demonstrated; 5 = consistently demonstrated
Potential Complications
• Sexual dysfunction with radical perineal prostatectomy