VIII. RENAL A. Glomerulonephritis: FILTERING PORTION KIDNEY Acute can lead to chronic. 1. Pathophysiology: a. Inflammatory reaction in the GLOMERULUS.

b. Antibodies lodge in the glomerulus; get scarring & DECREASED filtering. c. Main cause: STREP THROAT 2. S/S: a. Sore throat b. Malaise and headache c. BUN & Creatinine INCREASED d. Sediment/protein/blood in urine HEMATURIA e. Flank pain (costovertebral angle tenderness) f. BP INCREASED g. Facial EDEMA h. UO DOWN i. Urine specific gravity INCREASED Client going into fluid volume EXCESS. 3. Tx: a. Get rid of the strep. b. Balance activity with rest. c. I & O and daily weights d. Monitor blood pressure. e. How is fluid replacement determined? Fluid replacement = 24 hour fluid loss + 500CC. Hurst Review Services 111 f. Dietary needs: Protein? DECREASED Na? DECREASED Carbs? INCREASED,GIVES ENERGY g. Dialysis h. Diuresis begins in 1 to 3 weeks after onset. i. BLOOD and protein may stay in the urine for months. j. Teach S/S of RENAL FAILURE. Malaise, headache, anorexia, nausea, vomiting, decreased output, weight gain. B. Nephrotic Syndrome: 1. Pathophysiology: Inflammatory response in the GLUMERULUS big holes form so protein starts leaking out in the urine (what do we call that? PROTENURIA) now the client is hypoalbuminemic (low albumin in the blood) without albumin you cant hold on to fluid in the vascular space so where does all the fluid in the vascular space go?

INTO THE TISSUE now the client is edematous since all the fluid is going out into the tissue what has happened to the circulating blood volume? ALDOSTERONE the kidneys sense this decreased volume and they want to help replace it reninangiotensin system kicks in aldosterone produced retention of SODIUM and WATER but is there any protein (albumin) in the vascular space to hold it? TISSUE so where does this fluid go? TISSUE Total Body Edema = ANASARCA Problems associated with protein loss: Blood CLOTS (thrombosis) Cholesterol and triglycerides will be INCREASED 112 Hurst Review Services 2. Causes: a. Bacteria or viral BACTERIA b. NSAIDs c. Cancer and predisposition. d. Systemic disease like lupus or diabetes. e. Strep 3. S/S: a. Proteinuria b. Hypoalbuminemia c. Edema (anasarca) d. Hyperlipidemia 4. Tx: a. Diuretics b. ACE INHIBITORS to block aldosterone secretion. c. Prednisone to DECREASE inflammation. Shrink holes so PROTEIN cant get out. Immunosuppressed. d. Lipid lowering drugs for hyperlipidemia. e. Na? DECREASE f. Protein? INCREASE g. Anticoagulation therapy for up to 6 months. h. Dialysis Rule: Limit protein with kidney problems except with Nephrotic Syndrome. C. Renal Failure: Requires bilateral failure. 1. Causes: BLOOD CANNOT GO TO KIDNEYS a. Pre-Renal Failure: DAMAGE cant get to the kidney. Hypotension DECREASED heart rate. (arrhythmia)

Hypovolemic Any form of SHOCK b. Intra-Renal Failure: damage has occurred INSIDE the kidney. Glomerulonephritis Nephrotic syndrome used in test such as heart cath and CT scan Drugs (Aminoglycosides, Mycins) Malignant HYPERTENTION (uncontrolled HTN) And DM cause severe KIDNEY damage. c. Post-Renal Failure DAMAGE cant get out of the kidney. Enlarged KIDNEY Kidney stone Tumors Ureter obstruction Edematous KIDNEY (Ileal conduit) NCLEX Critical Thinking Exercise: 18- month old who went to surgery for bilateral ureteral stents. After surgery you notice the UO has dropped. a. Call MD b. Turn from side to side. c. Irrigate d. Reassess in 15 minutes 2. S/S: a. Creatinine and BUN INCREASED b. Specific gravity Initially a little urine, specific gravity increases Fixed specific gravity: May lose ability to concentrate and dilute urine. Fluid challenge- bolus with 250 mLs or greater of normal saline c. Anemia Not enough erythropoietin. d. HTN Retaining WATER e. HF f. Anorexia, nausea, vomiting retaining FROSTING. g. Itching frost (Uremic frost) Good skin care h. Acid- base/fluid and electrolyte imbalances HYPERKALEMIA could cause lethal arrhythmias. Metabolic acidosis. Retain phosphorous serum calcium DECREASES calcium pulled from BONES. WATCH FOR OSTEOSPOROSIS. 3. Two phases of Acute Renal Failure:

Kidneys have been damaged by one of the causes, this damage leads to the oliguric phase. a. Oliguric phase: What has happened to UO? DECREASED UO of 100 to 400 ml/ 24 hours. DO A FLUID CHALLEGE. This client is in a fluid volume DEFICIT What do you think will happen to the K+? INCREASE. b. Diuretic phase: SUDDEN onset What is happening to the UO? INCREASE This client is in a fluid volume DEFICIT. (Shock) What do you think will happen to the K+? DECREASE. D. Dialysis: 1. Hemodialysis: a. General Information: The machine is the glomerulus. (filter) Is done 3-4 times per week; so the client has to watch what they EAT and DRINK between treatments. To prevent blood CLOTS from forming the client is given an anticoagulation during dialysis. Usually Heparin- implement what? PREVENT BLEEDING EPISODES. Depression Suicide Electrolytes and are watched constantly. Can all clients tolerate hemodialysis? NO Unstable cardiovascular system cant tolerate hemodialysis. NCLEX Critical Thinking Exercise What medications should you hold for a client going to dialysis? Select all that apply. 1. Lisinopril (Zestril) 2. Nitroglycerin (Nitro-Bid) 3. Water soluble vitamin -NO 4. Amoxicillin (Ampicillin) 5. Famotidine (Pepcid) THE NEVER SELECT ALL THAT APPLIES. b. Vascular Access: Must have a vascular access: 1) Types of Access: With hemodialysis, blood is being removed, cleansed, and then returned at a rate of 300-800 mL/min. What is vascular access?

A site where they have access to a large blood vessel because very rapid blood flow is essential for hemodialysis. AVF (arteriovenous fistula) in forearm with an anastomosis between an artery and a vein. AVG (arteriovenous graft) a synthetic graft to join the vessels. Both require surgery, takes weeks to mature and to be ready for repeated venipunctures. During dialysis two needles are inserted into the vascular access. One needle will allow blood to be pulled from the circulation and sent to the hemo machine. The other is used to return the filtered blood to the clients circulation. The ASHCATH end of the access will remove the blood and the return is through the low pressure end. 2) Care of Access: Do not use any of the above for IV access (drawing blood, administering meds, etc.) When a client has an alternate vascular access what is the associated nursing care for that extremity? No BLOOD PRESSURES No NEEDLE sticks No CONSTRICTIONS. NO WATCHES. 3) Assessment of Access: Why? ENSURE PATENCY How? Thrill-cat purring sensation (palpate) Bruit-turbulent blood flow (auscultate) Feel a THRILLHear the BRUIT. 2. Peritoneal Dialysis: Use peritoneal membrane as a FILTER. Dialysate is warmed and infused into the peritoneal cavity by gravity via a Tenckhoff catheter. The fluid (2000-2500 ml) fills the peritoneal cavity (takes about 10 min) remains in peritoneal cavity for a prescribed amount of time. This is called the dwell time. Then the bag is lowered and the fluid along with the TOXINS, etc., are drained. And that is called the exchange. Why do we warm the fluid? Cold promotes vasoconstriction limits blood flow

We want it warm, this promotes VASODILATION, and more blood flow. What should the drainage look like? CLEAR, straw-colored cloudy = INFECTION Should be able to read a newspaper through the drainage/effluent. What type of client gets peritoneal dialysis? Someone who cant tolerate HEMODIALYSIS or someone who chooses peritoneal. What if all the fluid doesnt come out? MUST COME OUT. TOXINS MUST COME OUT. TURN SIDE TO SIDE a. Two Types of Peritoneal Dialysis: 1) CAPD (Continuous Ambulatory Peritoneal Dialysis): Must have a client that has the energy and the desire to be active in their treatment and that also has the ability to learn and follow instructions. Done 4 times a day, 7 days a week. Could a client with disc disease or arthritis do this? NO Fluid causes pressure on back. Could a client with a colostomy do this? NO High risk for INFECTION 2) CCPD (Continuous Cycle Peritoneal Dialysis): Connect their peritoneal dialysis catheter to a cycler at NIGHT and their exchange is done automatically while they sleep. Disconnected in the AM; has more freedom. b. Complications of Peritoneal Dialysis: Major complication is PERITONITIS (Cloudy effluent 1st sign) Constant sweet taste May get a HERNIA. Altered body image/sexuality Anorexia Low back pain c. Dietary Needs of the Peritoneal Client: Increase what in the diet? Fiber Have decreased peristalsis due to abdominal fluid. Protein Big holes in peritoneum and lose protein with each exchange. 3. Continuous Renal Replacement Therapy (CRRT):

Typically done in an ICU setting and is continuous so that the client doesnt have drastic fluid shifts. Never more than 80 ml of blood out of the body at one time being filtered and therefore does not stress the cardiovascular system as much. CRRT is performed on a client with: A fragile cardiovascular status and acute KIDNEY failure. E. Kidney Stones (urolithiasis, renal calculi): 1. S/S: Pain (nausea/vomiting) WBCs in . Hematuria Anytime you suspect a kidney stone get a URINE specimen ASAP and have it checked for STONES. If a kidney stone is present the client will get pain medication immediately. 2. Tx: Ketorolac (Toradol), Ondansetron (Zofran), Hydromorphone (Dilaudid) FORCE fluids. Maybe surgery Strain urine Extracorporeal shock wave lithotripsy (ESWL) 120 Hurst Review Services NCLEX Critical Thinking Exercise: The nurse is assessing a client diagnosed with kidney stones who just returned from extracorporeal shock wave therapy (lithotripsy). The client is supine in bed with a foley catheter in place. Which finding would be the best indicator that the treatment has been effective? 1. Total absence of pain. 2. The foley catheter is draining freely. 3. Rebound tenderness is absent during abdominal assessment. 4. Sand-like sediment has settled in the bottom of the foley catheter bag. NCLEX Critical Thinking Exercise: A nurse is working in the ED and assigned to care for the clients in examination rooms 1, 2, and 3. The nurse received the following report from the off going

nurse: 1. The client in Room 1 is an elderly person who has fallen and is currently in CT to rule out a subdural hematoma. 2. Client in room 2 is diagnosed with kidney stones, positive for hematuria and has 8/10 pain. 3. The client in room 3 has a blood pressure of 90/40. Let me ask you a question: which client would you go see first? ROOM 1