MANAGEMENT OF PATIENT WITH RENAL DISORDER

Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins

Chapter 44

Management of Patients With Renal Disorders

Chapter 44

Management of Patients With Renal Disorders


Renal DisordersRenal Disorders

• Fluid and electrolyte imbalances

• Most accurate indicator of fluid loss or gain in an acutely ill patient is weight


QuestionQuestion

Is the following statement True or False?

The most accurate indicator of fluid loss or gain in an acutely ill patient is weight.


AnswerAnswer

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.


Causes of Acute Renal FailureCauses 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 FailureCauses of Chronic Renal Failure

• Diabetes mellitus

• Hypertension

• Chronic glomerulonephritis,

• Pyelonephritis or other infections

• Obstruction of urinary tract

• Hereditary lesions

• Vascular disorders

• Medications or toxic agents


Glomerular DiseasesGlomerular Diseases

• An inflammation of the glomerular capillaries

• Acute nephritic syndrome

• Chronic glomerulonephritis

• Nephrotic syndrome


Acute Nephritic Syndrome Acute Nephritic Syndrome

• Postinfectious glomerulonephritis, rapidly progressive glomerulonephritis, and membranous glomerulonephritis

• Manifestations include hematuria, edema, azotemia, proteinuria, and hypertension

• May be mild, or may progress to acute renal failure

• Medical management includes supportive care and dietary modifications; treat cause if appropriate—antibiotics, corticosteroids, and immunosuppressants


Nursing Management: Acute Nephritic Syndrome Nursing Management: Acute Nephritic Syndrome

• Patient assessment

• Maintain fluid balance

• Fluid and dietary restrictions

• Patient education

• Follow-up care


Chronic GlomerulonephritisChronic Glomerulonephritis

• Causes include repeated episodes of acute glomerular nephritis, hypertensive nephrosclerosis, hyperlipidemia, and other causes of glomerular damage.

• Symptoms vary; may be asymptomatic for years, as glomerular damage increases, before signs and symptoms develop of renal insufficiency/failure.

• Abnormal laboratory tests include urine with fixed specific gravity, casts, and proteinuria; and electrolyte imbalances and hypoalbuminemia.

• Medical management is determined by symptoms.


Nursing Management Chronic GlomerulonephritisNursing Management Chronic Glomerulonephritis

• Assessment

• Potential fluid and electrolyte imbalances

• Cardiac status

• Neurologic status

• Emotional support

• Teaching self-care


Nephrotic Syndrome Nephrotic Syndrome

• Any condition that seriously damages the glomerular membrane and results in increased permeability to plasma proteins

• Results in hypoalbuminemia and edema

• Causes include chronic glomerulonephritis, diabetes mellitus with intercapillary glomerulosclerosis, amyloidosis, lupus erythmatosus, multiple myeloma, and renal vein thrombosis.

• Medical management includes drug and dietary therapy


Sequence of Events in Nephrotic SyndromeSequence of Events in Nephrotic Syndrome


Renal FailureRenal Failure

• Results when the kidneys cannot remove wastes or perform regulatory functions

• A systemic disorder that results from many different causes

• Acute renal failure is a reversible syndrome that results in decreased GFR and oliguria

• Chronic renal failure (ESRD) is a progressive, irreversible deterioration of renal function that results in azotemia


Nursing Process: The Care of the Patient with Renal Failure—AssessmentNursing Process: The Care of the Patient with Renal Failure—Assessment

• Fluid status

• Nutritional status

• Patient knowledge

• Activity tolerance

• Self-esteem

• Potential complications


Nursing Process: The Care of the Patient with Renal Failure—DiagnosesNursing Process: The Care of the Patient with Renal Failure—Diagnoses

• Excess fluid volume

• Imbalanced nutrition

• Deficient knowledge

• Risk for situational low self-esteem


Collaborative Problems/Potential ComplicationsCollaborative Problems/Potential Complications

• Hyperkalemia

• Pericarditis

• Pericardial effusion

• Pericardial tamponade

• Hypertension

• Anemia

• Bone disease and metastatic calcifications


Nursing Process: The Care of the Patient with Renal Failure—PlanningNursing Process: The Care of the Patient with Renal Failure—Planning

• Goals may include maintaining of IBW without excess fluid, maintenance of adequate nutritional intake, increased knowledge, participation of activity within tolerance improved self-esteem, and absence of complications.


Excess Fluid Volume Excess Fluid Volume

• Assess for signs and symptoms of fluid volume excess, and keep accurate I&O and daily weights

• Limit fluid to prescribe amounts

• Identify sources of fluid

• Explain to patient and family the rationale for the restriction

• Assist patient to cope with the fluid restriction

• Provide or encourage frequent oral hygiene


Imbalanced NutritionImbalanced Nutrition

• Assess nutritional status; weight changes and lab data

• Assess patient nutritional patterns and history; note food preferences

• Provide food preferences within restrictions

• Encourage high-quality nutritional foods while maintaining nutritional restrictions

• Assess and modify intake related to factors that contribute to altered nutritional intake, eg, stomatitis or anorexia

• Adjust medication times related to meals


Risk for Situational Low Self EsteemRisk 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

• Explore alternate ways of sexual expression

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


Hemodialysis SystemHemodialysis System


Hemodialysis CatheterHemodialysis Catheter


Internal Arteriovenous Fistula and Graft Internal Arteriovenous Fistula and Graft


Peritoneal DialysisPeritoneal Dialysis


Peritoneal DialysisPeritoneal Dialysis


QuestionQuestion

Is the following statement True or False?

Failure of the temporary dialysis access accounts for most hospital admissions of patients undergoing chronic hemodialysis.


AnswerAnswer

False

Failure of the permanent, not the temporary, dialysis access accounts for most hospital admissions of patients undergoing chronic hemodialysis.


Nursing Management of the Hospitalized Patient on Dialysis (1 of 2)Nursing Management of the Hospitalized Patient on Dialysis (1 of 2)

• Protection of vascular access; assess site for patency and signs of potential infection, and do not use for blood pressure or blood draws.

• Monitor fluid balance indicators and monitor IV therapy carefully; accurate I&O, IV administration pump.

• Assess for signs and symptoms of uremia and electrolyte imbalance; regularly check lab data.

• Monitor cardiac and respiratory status carefully.

• Hypertension: monitor blood pressure, antihypertensive agents must be held on dialysis days to avoid hypotension.


Nursing Management of the Hospitalized Patient on Dialysis (2 of 2)Nursing Management of the Hospitalized Patient on Dialysis (2 of 2)

• Monitor all medications and medication dosages carefully. Avoid medications containing potassium and magnesium.

• Address pain and discomfort.

• Stringent infection control measures.

• Dietary considerations: sodium, potassium, protein, and fluid; address individual nutritional needs.

• Skin care: pruritis is a common problem; keep skin clean and well moisturized, and trim nails and avoid scratching.

• CAPD catheter care.


Kidney SurgeryKidney Surgery

• Preoperative considerations

• Perioperative concerns

• Postoperative management

– Potential hemorrhage and shock

– Potential abdominal distention and paralytic ileus

– Potential infection

– Potential thromboembolism


Patient Positioning and Incisional ApproachesPatient Positioning and Incisional Approaches


Renal TransplantationRenal Transplantation


Postoperative Nursing ManagementPostoperative 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

• Complications: bleeding , pneumonia, infection, and DVT


InterventionsInterventions

• 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

• Use strict asepsis with catheter and appropriate technique in providing all care

• Monitor for signs and symptoms of bleeding

• Encourage leg exercises, early ambulation, and monitor for signs of DVT


Patient TeachingPatient 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

MANAGEMENT OF PATIENT WITH RENAL DISORDER

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