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Renal and Urinary Disorders NCLEX
Undergraduate 2

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Functions of kidneys

1. Maintain acid-base balance

2. Excrete end products of body metabolism

3. Control fluid and electrolyte balance

4. Excrete bacterial toxins, water-soluble drugs, and drug metabolites

5. Secrete renin to regulate the blood pressure and erythropoietin to stimulate the bone marrow to produce red blood cells.

6. Synthesize vitamin D for calcium absorption and regulation of the parathyroid hormones.

Homeostasis of water

1. Antidiuretic hormone (ADH) is primarily responsible for the reabsorption of water by the kidneys.

2. ADH is produced by the hypothalamus and secreted from the posterior lobe of the pituitary gland.

3. Secretion of ADH is stimulated by dehydration or high sodium intake and by a decrease in blood volume.

4. ADH makes the distal convoluted tubules and collecting duct permeable to water.

5. Water is drawn out of the tubules by osmosis and returns to the blood; concentrated urine remains in the tubule to be excreted.

6. When ADH is lacking, the client develops diabetes insipidus (DI).

7. Clients with DI produce large amounts of dilute urine; treatment is necessary because the client cannot drink sufficient water to survive.

Homeostasis of sodium

1. When the amount of sodium increases, extra water is retained to preserve osmotic pressure.

2. An increase in sodium and water produces an increase in blood volume and blood pressure (BP).

3. When the BP increases, glomerular filtration increases, and extra water and sodium are lost; blood volume is reduced, returning the BP to normal.

4. Reabsorption of sodium in the distal convoluted tubules is controlled by the renin-angiotensin system.

5. Renin, an enzyme, is released from the nephron when the BP or fluid concentration in the distal convoluted tubule is low.

6. Renin catalyzes the splitting of angiotensin I from angiotensinogen; angiotensin I converts to angiotensin II as blood flows through the lung.

7. Angiotensin II, a potent vasoconstrictor, stimulates the secretion of aldosterone.

8. Aldosterone stimulates the distal convoluted tubules to reabsorb sodium and secrete potassium.

9. The additional sodium increases water reabsorption and increases blood volume and BP, returning the BP to normal; the stimulus for the secretion of renin then is removed.

Homeostasis of potassium

1. Increases in the serum potassium level stimulate the secretion of aldosterone.

2. Aldosterone stimulates the distal convoluted tubules to secrete potassium; this action returns the serum potassium concentration to normal.

Homeostasis of acidity (pH)

1. Blood pH is controlled by maintaining the concentration of buffer systems.

2. Carbonic acid and sodium bicarbonate form the most important buffers for neutralizing acids in the plasma.

3. The concentration of carbonic acid is controlled by the respiratory system.

4. The concentration of sodium bicarbonate is controlled by the kidneys.

5. Normal arterial pH is 7.35 to 7.45, maintained by keeping the ratio of concentrations of sodium bicarbonate to carbon dioxide constant at 20:1.

6. Strong acids are neutralized by sodium bicarbonate to produce carbonic acid and the sodium salts of the strong acid; this process quickly restores the ratio and thus blood pH.

7. The carbonic acid dissociates into carbon dioxide and water; because the concentration of carbon dioxide is maintained at a constant level by the respiratory system, the excess carbonic acid is rapidly excreted.

8. Sodium combined with the strong acid is actively reabsorbed in the distal convoluted tubules in exchange for hydrogen or potassium ions. The strong acid is neutralized by ammonia and is excreted as ammonia or potassium salts.

Risk Factors Associated with Renal Disorders

■ Chemical or environmental toxin exposure

■ Contact sports

■ Diabetes mellitus

■ Family history of renal disease

■ Frequent urinary tract infections

■ Heart failure

■ High-sodium diet

■ Hypertension

■ Medications

■ Trauma

■ Urolithiasis or nephrolithiasis 

Normal Renal Function Values

■ Blood urea nitrogen level, 8 to 25 mg/dL

■ Serum creatinine level, 0.6 to 1.3 mg/dL

■ Serum uric acid level, 2.5 to 8.0 mg/dL 

Urine culture and sensitivity testing

1. Description: A urine test that identifies the presence of microorganisms (culture) and determines the specific antibiotics to treat the existing microorganism (sensitivity) appropriately

2. Interventions

a. Clean the perineal area and urinary meatus with a bacteriostatic solution.

b. Collect the midstream sample in a sterile container.

c. Send the collected specimen to the laboratory immediately.

d. Identify any sources of potential contaminants during the collection of the specimen, such as the hands, skin, clothing, hair, or vaginal or rectal secretions.

e. Urine from the client who drank a very large amount of fluids may be too dilute to provide a positive culture

Creatinine clearance test

1. Description

a. The creatinine clearance test evaluates how well the kidneys remove creatinine from the blood.

b. The test includes obtaining a blood sample and timed urine specimens.

c. Blood is drawn when the urine specimen collection is complete.

d. The urine specimen for the creatinine clearance is usually collected for 24 hours, but shorter periods such as 8 or 12 hours could be prescribed.

The creatinine clearance test provides the best estimate of the glomerular filtration rate (GFR); the normal GFR is 125 mL/minute.

2. Interventions

a. Encourage fluids before and during the test.

b. Instruct the client to avoid caffeinated beverages during testing.

c. Check with the health care provider (HCP) regarding the administration of any prescribed medications during testing.

d. Instruct the client about the urine collection.

e. At the start time, ask the client to void (or empty the tubing and drainage bag if the client has a Foley catheter) and discard the first sample.

f. Collect all urine for the prescribed time.

g. Keep the urine specimen on ice or refrigerated and check with the laboratory regarding adding a preservative to the specimen during collection.

h. At the end of the prescribed time, ask the client to empty the bladder (or empty the tubing and drainage bag if the client has a Foley catheter) and add that final urine to the collection container.

i. Send the labeled urine specimen to the laboratory in a biohazard bag along with the requisition.

j. Document specimen collection, time started and completed, and pertinent assessments.


Vanillylmandelic acid (VMA) test

1. Description

a. The test is a 24-hour urine collection to diagnose pheochromocytoma, a tumor of the adrenal gland.

b. The test determines catecholamine levels in the urine.

2. Interventions

a. Check with the laboratory regarding medication restrictions.

b. Instruct the client to avoid foods such as caffeine, cocoa, vanilla, cheese, gelatin, licorice, and fruits for at least 2 days before and during urine collection and to check with the HCP regarding the administration of any prescribed medications before or during testing.

c. Instruct the client to avoid stress; encourage adequate food and fluid intake during the test.

d. Follow the same procedure for urine collection as for the creatinine clearance test.

Intravenous urography

1. Description: An x-ray procedure in which an intravenous injection of a radiopaque dye is used to visualize and identify abnormalities in the renal system.

2. Preprocedure interventions

a. Obtain an informed consent.

b. Assess the client for allergies to iodine, seafood, and radiopaque dyes.

c. Withhold food and fluids after midnight on the night before the test.

d. Administer laxatives if prescribed.

e. Inform the client about possible throat irritation, flushing of the face, warmth, or a salty or metallic taste during the test.

3. Postprocedure interventions

a. Monitor vital signs.

b. Instruct the client to drink at least 1 L of fluid unless contraindicated.

c. Assess the venipuncture site for bleeding.

d. Monitor urinary output.

e. Monitor for signs of a possible allergic reaction to the dye used during the test and instruct the client to notify the HCP if any signs of an allergic reaction occur.

f. Contrast dye is potentially damaging to kidneys; the risk is greater in older clients and those experiencing dehydration.

The dye used in intravenous urography may be nephrotoxic; therefore encourage increased fluids unless contraindicated and monitor urinary output.

Renography (kidney scan)

1. Description: An intravenous (IV) injection of a radioisotope for visual imaging of renal blood flow, glomerular filtration, tubular function, and excretion

2. Preprocedure interventions

a. Obtain an informed consent.

b. Assess for allergies.

c. Inform the client that the test requires no dietary or activity restrictions.

d. Assist with administering the radioisotope as necessary.

e. Instruct the client to remain motionless during the test.

f. Instruct the client that imaging may be repeated at various intervals before the test is complete.

3. Postprocedure interventions

a. Encourage fluid intake unless contraindicated.

b. Assess the client for signs of delayed allergic reaction such as itching and hives.

c. The radioisotope is eliminated in 24 hours; wear gloves for excretion precautions.

d. Follow standard precautions when caring for incontinent clients and double-bag client linens per agency policy.

e. If captopril (Capoten) was administered during the procedure, the client’s BP should be checked frequently.

Cystoscopy and biopsy of the bladder

1. Description: The bladder mucosa is examined for inflammation, calculi, or tumors by means of a cystoscope; a sample for biopsy may be obtained.

2. Preprocedure interventions

a. Obtain an informed consent.

b. If a biopsy is planned, withhold food and fluids after midnight the night before the test.

c. If a cystoscopy alone is planned, no special preparation is necessary, and the procedure may be performed in the HCP’s office; postprocedure interventions include increasing fluid intake.

3. Postprocedure interventions following biopsy

a. Monitor vital signs.

b. Increase fluid intake as prescribed.

c. Monitor intake and output.

d. Encourage deep-breathing exercises to relieve bladder spasms.

e. Administer analgesics as prescribed.

f. Administer sitz or tub baths for back and abdominal pain.

g. Note that leg cramps are common because of the lithotomy position maintained during the procedure.

h. Assess the urine for color and consistency.

i. Inform the client that burning on urination, pink-tinged or tea-colored urine, and urinary frequency are common after cystoscopy and resolve in a few days.

j. Monitor for bright red urine or clots, and notify the HCP if a fever (with or without chills) occurs; an increase in white blood cell (WBC) count suggests infection.

Renal biopsy

1. Description: Insertion of a needle into the kidney to obtain a sample of tissue for examination; usually done percutaneously

2. Preprocedure interventions

a. Assess vital signs.

b. Assess baseline coagulation studies; notify the HCP if abnormal results are noted.

c. Obtain an informed consent.

d. Withhold food and fluids 4 to 6 hours before the procedure.

3. Interventions during the procedure: Position the client prone with a pillow under the abdomen and shoulders.

4. Postprocedure interventions

a. Monitor vital signs, especially for hypotension and tachycardia, which could indicate bleeding.

b. Provide pressure to the biopsy site for 30 minutes.

c. Monitor the hemoglobin and hematocrit levels for decreases, which could indicate bleeding.

d. Place the client on strict bed rest in the supine position with a back roll for additional support for 2 to 6 hours after the biopsy.

e. Check the biopsy site and under the client for bleeding.

f. Encourage fluid intake of 1500 to 2000 mL as prescribed.

g. Observe the urine for gross and microscopic bleeding.

h. Instruct the client to avoid heavy lifting and strenuous activity for 1 to 2 weeks.

i. Instruct the client to notify the HCP if either a temperature greater than 100° F or hematuria occurs after the first 24 hours postprocedure.

Acute Kidney Injury

A. Description

1. Acute kidney injury (AKI) is the rapid loss of kidney function from renal cell damage.

2. Occurs abruptly and can be reversible

3. AKI leads to cell hypoperfusion, cell death, and decompensation of renal function.

4. The prognosis depends on the cause and the condition of the client.

5. Near-normal or normal kidney function may resume gradually.

B. Causes

1. Prerenal: Outside the kidney; caused by intravascular volume depletion, dehydration, decreased cardiac output, decreased peripheral vascular resistance, decreased renovascular blood flow, and prerenal infection or obstruction.

2. Intrarenal: Within the parenchyma of the kidney; caused by tubular necrosis, prolonged prerenal ischemia, intrarenal infection or obstruction, and nephrotoxicity

3. Postrenal: Between the kidney and urethral meatus, such as bladder neck obstruction, bladder cancer, calculi, and postrenal infection.

C. Phases of AKI and interventions



1. Onset: Begins with precipitating event

2. Oliguric phase

a. For some clients, oliguria does not occur and the urine output is normal; otherwise the duration of oliguria is 8 to 15 days; the longer the duration, the less chance of recovery.

b. Sudden decrease in urine output; urine output is less than 400 mL/day.

c. Signs of excess fluid volume: Hypertension, edema, pleural and pericardial effusions, dysrhythmias, heart failure (HF), and pulmonary edema

d. Signs of uremia: Anorexia, nausea, vomiting, and pruritus

e. Signs of metabolic acidosis: Kussmaul’s respirations

f. Signs of neurological changes: Tingling of extremities, drowsiness progressing to disorientation, and then coma

g. Signs of pericarditis: Friction rub, chest pain with inspiration, and low-grade fever

h. Laboratory analysis (see Box 62-4)

i. Restrict fluid intake; if hypertension is present, daily fluid allowances may be 400 mL to 1000 mL plus the measured urinary output.

j. Administer medications as prescribed, such as diuretics (furosemide [Lasix]), to increase renal blood flow and diuresis.

3. Diuretic phase

a. Urine output rises slowly, followed by diuresis (4 to 5 L/day).

b. Excessive urine output indicates that damaged nephrons are recovering their ability to excrete wastes.

c. Dehydration, hypovolemia, hypotension, and tachycardia can occur.

d. Level of consciousness improves.

e. Laboratory analysis (see Box 62-4)

f. Administer IV fluids as prescribed, which may contain electrolytes to replace losses.

4. Recovery phase (convalescent)

a. Recovery is a slow process; complete recovery may take 1 to 2 years.

b. Urine volume returns to normal.

c. Memory improves.

d. Strength increases.

e. The older adult is less likely than a younger adult to regain full kidney function.

f. Laboratory analysis (see Box 62-4)

g. AKI can progress to chronic kidney disease (CKD).

The signs and symptoms of acute kidney injury are primarily caused by the retention of nitrogenous wastes, the retention of fluids, and the inability of the kidneys to regulate electrolytes.

D. Assessment: Assess objective and subjective data noted in the phases of AKI (see Box 62-4).

E. Other interventions

1. Monitor vital signs, especially for signs of hypertension, tachycardia, tachypnea, and an irregular heart rate.

2. Monitor urine and intake and output (hourly in AKI) and urine color and characteristics.

3. Monitor daily weight (same scale, same clothes, same time of day), noting that an increase of 1/2 to 1 lb/day indicates fluid retention.

4. Monitor for changes in the BUN, serum creatinine, and serum electrolyte levels.

5. Monitor for acidosis (may be treated with sodium bicarbonate).

6. Monitor urinalysis for protein level, hematuria, casts, and specific gravity.

7. Monitor for altered level of consciousness caused by uremia.

8. Monitor for signs of infection because the client may not exhibit an elevated temperature or an increased white blood cell count.

9. Monitor the lungs for wheezes and rhonchi and monitor for edema, which can indicate fluid overload.

10. Administer a prescribed diet, which is usually a low- to moderate-protein (to decrease the workload on the kidneys) and high-carbohydrate diet.

11. Restrict potassium and sodium intake as prescribed based on the electrolyte level.

12. Administer medications as prescribed; be alert to the mechanism for metabolism and excretion of all prescribed medications.

13. Be alert to nephrotoxic medications, which may be prescribed (see Box 62-3).

14. Be alert to the health care provider’s adjustment of medication dosages for kidney injury.

15. Prepare the client for dialysis if prescribed; continuous renal replacement therapy may be used in AKI to treat fluid volume overload or rapidly developing azotemia and metabolic acidosis.

16. Provide emotional support by allowing opportunities for the client to express concerns and fears and by encouraging family interactions.

17. Promote consistency in caregivers.

18. Also refer to Section IV,E in this chapter (Special Problems in Kidney Disease and Interventions).

Acute Kidney Injury: Phases and Laboratory Findings


■ Begins with precipitating event

Oliguric Phase

■ Elevated blood urea nitrogen and serum creatinine levels

■ Decreased urine specific gravity (prerenal causes) or normal (intrarenal causes)

■ Decreased glomerular filtration rate and creatinine clearance

■ Hyperkalemia

■ Normal or decreased serum sodium level

■ Hypervolemia

■ Hypocalcemia

■ Hyperphosphatemia

Diuretic Phase

■ Gradual decline in blood urea nitrogen and serum creatinine levels, but still elevated

■ Continued low creatinine clearance with improving glomerular filtration rate

■ Hypokalemia

■ Hyponatremia

■ Hypovolemia

Recovery Phase (Convalescent)

■ Increased glomerular filtration rate

■ Stabilization or continual decline in blood urea nitrogen and serum creatinine levels toward normal

■ Complete recovery (may take 1 to 2 years)

Chronic Kidney Disease

A. Description

1. CKD is a slow, progressive, irreversible loss in kidney function, with a GFR less than or equal to 60 mL/minute for 3 months or longer.

2. It occurs in stages and results in uremia or end-stage kidney disease


3. Hypervolemia can occur because of the kidneys’ inability to excrete sodium and water; hypovolemia can occur because of the kidneys’ inability to conserve sodium and water.

Chronic kidney disease affects all major body systems and requires dialysis or kidney transplantation to maintain life.

B. Primary causes

1. May follow AKI

2. Diabetes mellitus and other metabolic disorders

3. Hypertension

4. Chronic urinary obstruction

5. Recurrent infections

6. Renal artery occlusion

7. Autoimmune disorders

C. Assessment

1. Assess body systems for the manifestations of CKD

2. Assess psychological changes, which could include emotional lability, withdrawal, depression, anxiety, suicidal behavior, denial, dependence-independence conflict, and changes in body image.

D. Interventions

1. Same as the interventions for AKD.

2. Administer a prescribed diet, which is usually a moderate-protein (to decrease the workload on the kidneys) and high-carbohydrate, low-potassium, and low phosphorus diet.

3. Provide oral care to prevent stomatitis and reduce discomfort from mouth sores.

4. Provide skin care to prevent pruritus.

5. Teach the client about fluid and dietary restrictions and the importance of daily weights.

6. Provide support to promote acceptance of the chronic illness and prepare the client for longterm dialysis and transplantation, or explain to the client about his or her choice to decline dialysis or transplantation.

1. Activity intolerance and insomnia

a. Fatigue results from anemia and the buildup of wastes from the diseased kidneys.

b. Provide adequate rest periods.

c. Teach the client to plan activities to avoid fatigue.

d. Administer mild central nervous system depressants as prescribed to promote rest.

2. Anemia

a. Anemia results from the decreased secretion of erythropoietin by damaged nephrons, resulting in decreased production of red blood cells.

b. Monitor for decreased hemoglobin and hematocrit levels.

c. Administer epoetin alfa (Epogen, Procrit) or darbepoetin alfa (Aranesp), hematopoietics, as prescribed to promote maturity of the red blood cells.

d. Administer folic acid (vitamin B9) as prescribed.

e. Administer iron orally as prescribed, but not at the same time as phosphate binders.

f. Administer stool softeners as prescribed because of the constipating effects of iron.

g. Note that oral iron is not well absorbed by the gastrointestinal tract in CKD and causes nausea and vomiting; parenteral iron (iron sucrose [Venofer] or sodium ferric gluconate complex [Ferrlecit]) may be used if iron deficiencies persist despite folic acid or oral iron administration.

h. Administer blood transfusions if prescribed; blood transfusions are prescribed only when necessary (acute blood loss, symptomatic anemia) because they decrease the stimulus to produce red blood cells; note that certain clients (e.g., Jehovah’s Witnesses) may refuse blood and blood products because of their religious beliefs.

i. Blood transfusions also cause the development of antibodies against human tissues, which can make matching for organ transplantation difficult.

3. Gastrointestinal bleeding

a. Urea is broken down by the intestinal bacteria to ammonia; ammonia irritates the gastrointestinal mucosa, causing ulceration and bleeding.

b. Monitor for decreasing hemoglobin and hematocrit levels.

c. Monitor stools for occult blood.

d. Instruct the client to use a soft toothbrush.

e. Avoid the administration of acetylsalicylic acid (aspirin) because it is excreted by the kidneys; if administered, aspirin toxicity can occur and prolong the bleeding time.

7. Hypertension

a. Caused by failure of the kidneys to maintain BP homeostasis.

b. Monitor vital signs for elevated blood pressure.

c. Maintain fluid and sodium restrictions as prescribed.

d. Administer diuretics and antihypertensives as prescribed.

e. Administer propranolol (Inderal), a β-blocker, as prescribed; propranolol decreases renin release (renin causes vasoconstriction and subsequent hypertension).

8. Hypervolemia

a. Monitor vital signs for an elevated blood pressure.

b. Monitor intake and output and daily weight for indications of fluid retention.

c. Monitor for periorbital, sacral, and peripheral edema.

d. Monitor the serum electrolyte levels.

e. Monitor for hypertension and notify the health care provider for sustained elevations.

f. Monitor for signs of HF and pulmonary edema, such as restlessness, heightened anxiety, tachycardia, dyspnea, basilar lung crackles, and blood-tinged sputum; notify the HCP immediately if signs occur.

g. Maintain fluid restriction.

h. Avoid the administration of large amounts of IV fluids.

i. Administer diuretics such as furosemide (Lasix) as prescribed.

j. Teach the client to maintain a low-sodium diet.

k. Teach the client to avoid antacids, cold remedies, or other products containing sodium bicarbonate.

10. Hypovolemia

a. Monitor the vital signs for hypotension and tachycardia.

b. Monitor for decreasing intake and output and a reduction in the daily weight.

c. Monitor for dehydration.

d. Monitor electrolyte levels.

e. Provide replacement therapy based on the serum electrolyte level values.

f. Provide sodium supplements as prescribed, based on the serum electrolyte level.

11. Infection

a. The client is at risk for infection caused by a suppressed immune system, dialysis access site, and possible malnutrition.

b. Monitor for signs of infection.

c. Avoid urinary catheters when possible; if used, provide catheter care.

d. Provide strict asepsis during urinary catheter insertion and other invasive procedures.

e. Instruct the client to avoid fatigue, which decreases body resistance.

f. Instruct the client to avoid persons with infections.

g. Administer antibiotics as prescribed, monitoring for nephrotoxic effects.

12. Metabolic acidosis

a. The kidneys are unable to excrete hydrogen ions or manufacture bicarbonate, resulting in acidosis.

b. Administer alkalizers such as sodium bicarbonate as prescribed.

c. Note that clients with CKD adjust to low bicarbonate levels and as a result do not become acutely ill.

13. Muscle cramps

a. Occur from electrolyte imbalances and the effects of uremia on peripheral nerves

b. Monitor serum electrolyte levels.

c. Administer electrolyte replacements and medications to control muscle cramps as prescribed.

d. Administer heat and massage as prescribed.

14. Neurological changes

a. The buildup of active particles and fluids causes changes in the brain cells and leads to confusion and impairment in decision-making ability.

b. Peripheral neuropathy results from the effects of uremia on peripheral nerves.

c. Monitor the level of consciousness and for confusion.

d. Monitor for restless leg syndrome, which is also common during dialysis treatments.

e. Teach the client to examine areas of decreased sensation for signs of injury.

15. Ocular irritation

a. Calcium deposits in the conjunctivae cause burning and watering of the eyes.

b. Administer medications to control the calcium and phosphate levels as prescribed.

c. Administer lubricating eye drops.

d. Protect the client from injury.

e. Provide a safe and hazard-free environment.

f. Use side rails as needed (per agency policy).

16. Potential for injury

a. The client is at risk for fractures caused by alterations in the absorption of calcium, excretion of phosphate, and vitamin D metabolism.

b. Provide for a safe environment.

c. Avoid injury; tissue breakdown causes increased serum potassium levels.

17. Pruritus

a. To rid the body of excess wastes, urate crystals are excreted through the skin, causing pruritus.

b. The deposit of urate crystals (uremic frost) occurs in advanced stages of kidney disease.

c. Monitor for skin breakdown, rash, and uremic frost.

d. Provide meticulous skin care and oral hygiene.

e. Avoid the use of soaps.

f. Administer antihistamines and antipruritics as prescribed to relieve itching.

g. Teach the client to keep the nails trimmed to prevent local infection from scratching.

18. Psychosocial problems

a. Listen to the client’s concerns to determine how the client is handling the situation.

b. Allow the client time to mourn the loss of kidney function.

c. With client permission, include the family members in discussions of the client’s concerns.

d. Provide education about treatment options and support their decision.

e. Offer information about support groups.

f. Provide end-of-life care for the client with end-stage kidney disease.

Special Problems in Kidney Failure

■ Activity intolerance and insomnia

■ Anemia

■ Gastrointestinal bleeding

■ Hyperkalemia

■ Hypermagnesemia

■ Hyperphosphatemia

■ Hypertension

■ Hypervolemia

■ Hypocalcemia

■ Hypovolemia

■ Infection

■ Metabolic acidosis

■ Muscle cramps

■ Neurological changes

■ Ocular irritation

■ Potential for injury

■ Pruritus

■ Psychosocial problems 

Key Features of Chronic Kidney Disease

Neurological Manifestations

■ Asterixis

■ Ataxia (alteration in gait)

■ Coma

■ Inability to concentrate or decreased attention span

■ Lethargy and daytime drowsiness

■ Myoclonus

■ Paresthesias

■ Seizures

■ Slurred speech

■ Tremors, twitching, or jerky movements

Cardiovascular Manifestations

■ Cardiac tamponade

■ Cardiomyopathy

■ Heart failure

■ Hypertension

■ Pericardial effusion

■ Pericardial friction rub

■ Peripheral edema

■ Uremic pericarditis

Respiratory Manifestations

■ Crackles

■ Deep sighing, yawning

■ Depressed cough reflex

■ Kussmaul’s respirations

■ Pleural effusion

■ Pulmonary edema

■ Shortness of breath

■ Tachypnea

■ Uremic halitosis

■ Uremic pneumonia

Hematological Manifestations

■ Abnormal bleeding and bruising

■ Anemia

Gastrointestinal Manifestations

■ Anorexia

■ Changes in taste acuity and sensation

■ Constipation

■ Diarrhea

■ Metallic taste in the mouth

■ Nausea

■ Stomatitis

■ Uremic colitis (diarrhea)

■ Uremic fetor

■ Uremic gastritis (possible gastrointestinal bleeding)

■ Vomiting

Urinary Manifestations

■ Diluted, straw-colored appearance

■ Hematuria

■ Oliguria, anuria (later)

■ Polyuria, nocturia (early)

■ Proteinuria

Integumentary Manifestations

■ Decreased skin turgor

■ Dry skin

■ Ecchymosis

■ Pruritus

■ Purpura

■ Soft tissue calcifications

■ Uremic frost (late, premorbid)

■ Yellow-gray pallor

Musculoskeletal Manifestations

■ Bone pain

■ Muscle weakness and cramping

■ Pathological fractures

■ Renal osteodystrophy

Reproductive Manifestations

■ Decreased fertility

■ Decreased libido

■ Impotence

■ Infrequent or absent menses 

Uremic Syndrome

A. Description

1. Accumulation of nitrogenous waste products in the blood caused by the kidneys’ inability to filter out these waste products.

2. Uremic syndrome may occur as a result of AKI or CKD.

B. Assessment

1. Oliguria

2. Presence of protein, red blood cells, and casts in the urine

3. Elevated levels of urea, uric acid, potassium, and magnesium in the urine

4. Hypotension or hypertension

5. Alterations in the level of consciousness

6. Electrolyte imbalances

7. Stomatitis

8. Nausea or vomiting

9. Diarrhea or constipation

C. Interventions

1. Monitor vital signs for hypertension, tachycardia, and an irregular heart rate.

2. Monitor serum electrolyte levels.

3. Monitor intake and output and for oliguria.

4. Provide a limited but high-quality protein diet as prescribed.

5. Provide a limited sodium, nitrogen, potassium, and phosphate diet as prescribed.

6. Assist the client to cope with body image disturbances caused by uremic syndrome.


A. Description

1. Hemodialysis is the process of cleansing the client’s blood.

2. It involves the diffusion of dissolved particles from one fluid compartment into another across a semipermeable membrane; the client’s blood flows through one fluid compartment of a dialysis filter, and the dialysate is in another fluid compartment.

B. Functions of hemodialysis

1. Cleanses the blood of accumulated waste products

2. Removes the by-products of protein metabolism such as urea, creatinine, and uric acid from the blood

3. Removes excess body fluids

4. Maintains or restores the buffer system of the body

5. Corrects electrolyte levels in the body

C. Principles of hemodialysis

1. The semipermeable membrane is made of a thin, porous cellophane.

2. The pore size of the membrane allows small particles to pass through, such as urea, creatinine, uric acid, and water molecules.

3. Proteins, bacteria, and some blood cells are too large to pass through the membrane.

4. The client’s blood flows into the dialyzer; the movement of substances occurs from the blood to the dialysate by the principles of osmosis, diffusion, and ultrafiltration.

5. Diffusion is the movement of particles from an area of higher concentration to one of lower concentration.

6. Osmosis is the movement of fluids across a semipermeable membrane from an area of lower concentration of particles to an area of higher concentration of particles.

7. Ultrafiltration is the movement of fluid across a semipermeable membrane as a result of an artificially created pressure gradient.

D. Dialysate bath

1. A dialysate bath is composed of water and major electrolytes.

2. The dialysate need not be sterile because bacteria and viruses are too large to pass through the pores of the semipermeable membrane; however, the dialysate must meet specific standards, and water is treated to ensure a safe water supply.

E. Interventions

1. Monitor vital signs before, during, and after dialysis; the client’s temperature may elevate because of slight warming of the blood from the dialysis machine (notify the HCP about excessive temperature elevations because this could indicate sepsis; obtain samples for blood culture as prescribed for excessive temperature elevations).

2. Monitor laboratory values before, during, and after dialysis.

3. Assess the client for fluid overload before dialysis and fluid volume deficit following dialysis.

4. Weigh the client before and after dialysis to determine fluid loss.

5. Assess the patency of the blood access device before, during, and after dialysis.

6. Monitor for bleeding; heparin is added to the dialysis bath to prevent clots from forming in the dialyzer or the blood tubing.

7. Monitor for hypovolemia and shock during dialysis, which can occur from blood loss or excess fluid and electrolyte removal.

8. Provide adequate nutrition; the client may eat before or during dialysis.

9. Identify the client’s reactions to the treatment and support coping mechanisms; encourage independence and involvement in care.

Withhold antihypertensives and other medications that can affect the blood pressure or result in hypotension until after hemodialysis treatment. Also withhold medications that could be removed by dialysis, such as water-soluble vitamins, certain antibiotics, and digoxin (Lanoxin).

Access for Hemodialysis

A. Subclavian and femoral catheter

1. Description

a. A subclavian (subclavian vein) or femoral (femoral vein) catheter may be inserted for shortterm or temporary use in AKI.

b. The catheter is used until a fistula or graft matures or develops, which is typically 6 weeks, or may be required when the client’s fistula or graft access has failed because of infection or clotting.

2. Interventions

a. Assess insertion site for hematoma, bleeding, catheter dislodgement, and infection.

b. These catheters should only be used for dialysis treatments.

c. Maintain an occlusive dressing over the catheter insertion site.

3. Subclavian vein catheter

a. The catheter is usually filled with heparin and capped to maintain patency between dialysis treatments.

b. The catheter should not be uncapped except for dialysis treatments.

c. The catheter may be left in place for up to 6 weeks if no complications occur.

4. Femoral vein catheter

a. Assess the extremity for circulation, temperature, and pulses.

b. Prevent pulling or disconnecting of the catheter when giving care.

c. Because the groin is not a clean site, meticulous perineal care is required.

d. Use an IV infusion pump or controller with microdrip tubing if a heparin infusion through the catheter to maintain patency is prescribed.

The client with a femoral vein catheter should not sit up more than 45 degrees or lean forward, because the catheter may kink and occlude.

B. External arteriovenous shunt

C. Internal arteriovenous fistula

D. Internal arteriovenous graft




External arteriovenous shunt



1. Description

a. Two Silastic cannulas are surgically inserted into an artery and vein in the forearm or leg to form an external blood path.

b. The cannulas are connected to form a U shape; blood flows from the client’s artery through the shunt into the vein.

c. A tube leading to the membrane compartment of the dialyzer is connected to the arterial cannula.

d. Blood fills the membrane compartment, passes through the dialyzer, and is returned back to the client through a tube connected to the venous cannula.

e. When dialysis is complete, the cannulas are clamped and reattached, reforming the U shape.

2. Advantages

a. The external arteriovenous shunt can be used immediately following its creation.

b. No venipuncture is necessary for dialysis.

3. Disadvantages

a. Disconnection or dislodgment of the external shunt

b. Risk of hemorrhage, infection, or clotting

c. Potential for skin erosion around the catheter site

4. Interventions

a. Avoid getting the shunt wet.

b. Wrap a dressing completely around the shunt and keep it dry and intact.

c. Keep cannula clamps at the client’s bedside or attached to the arteriovenous dressing for use in case of accidental disconnection.

d. Teach the client that the shunt extremity should not be used for monitoring BP, drawing blood, placing IV lines, or administering injections.

e. Fold back the dressing to expose the shunt tubing and assess for signs of hemorrhage, infection, or clotting.

f. Monitor skin integrity around the insertion site.

g. Auscultate for a bruit and palpate for a thrill, although a bruit may not be heard with the shunt.

h. Notify the HCP immediately if signs of clotting, hemorrhage, or infection occur.

5. Signs of clotting

a. Fibrin: White flecks in the tubing

b. Separation of serum and cells

c. Absence of a previously heard bruit; thrill absent on palpation

d. Coolness of the tubing or extremity

e. Tingling sensation at site or in extremity

Internal arteriovenous fistula

1. Description

a. A permanent access of choice for the client with CKD requiring dialysis.

b. The fistula is created surgically by anastomosis of a large artery and large vein in the arm.

c. The flow of arterial blood into the venous system causes the vein to become engorged (matured or developed).

d. Maturity takes about 4 to 6 weeks, depending on the client’s ability to do hand-flexing exercises such as ball squeezing, which help the fistula mature.

e. The fistula is required to be mature before it can be used because the engorged vein is punctured with a large-bore needle for the dialysis procedure.

f. Subclavian or femoral catheters, peritoneal dialysis, or an external arteriovenous shunt can be used for dialysis while the fistula is maturing or developing.

2. Advantages

a. Because the fistula is internal, the risk of clotting and bleeding is low.

b. The fistula can be used indefinitely.

c. The fistula has a decreased incidence of infection because it is internal and is not exposed.

d. Once healing has occurred, no external dressing is required.

e. The fistula allows freedom of movement.

3. Disadvantages

a. The fistula cannot be used immediately after insertion, so planning ahead for an alternative access for dialysis is important.

b. Needle insertions through the skin and tissues to the fistula are required for dialysis.

c. Infiltration of the needles during dialysis can occur and cause hematomas.

d. An aneurysm can form in the fistula.

e. Heart failure can occur from the increased blood flow in the venous system.

Arterial steal syndrome can develop in a client with an internal arteriovenous fistula. In this complication, too much blood is diverted to the vein, and arterial perfusion to the hand is compromised.

E. Interventions for an arteriovenous fistula and arteriovenous graft

1. Teach the client that the extremity should not be used for monitoring blood pressure, drawing blood, placing IV lines, or administering injections.

2. Teach the client with an arteriovenous fistula to perform hand-flexing exercises such as ball squeezing (if prescribed) to promote graft maturity.

3. Note the temperature and capillary refill of the extremity.

4. Palpate pulses below the fistula or graft, and monitor for hand swelling as an indication of ischemia.

5. Monitor for clotting.

a. Complaints of tingling or discomfort in the extremity

b. Inability to palpate a thrill or auscultate a bruit over the fistula or graft

6. Monitor for arterial steal syndrome.

7. Monitor for infection.

8. Monitor lung and heart sounds for signs of heart failure.

9. Notify the HCP immediately if signs of clotting, infection, or arterial steal syndrome occur.

To ensure patency, palpate for a thrill or auscultate for a bruit over the fistula or graft. Notify the HCP if a thrill or bruit is absent.

Internal arteriovenous graft

1. Description

a. The internal graft may be used for chronic dialysis clients who do not have adequate blood vessels for the creation of a fistula.

b. An artificial graft made of Gore-Tex or a bovine (cow) carotid artery is used to create an artificial vein for blood flow.

c. The procedure involves the anastomosis of an artery to a vein, using an artificial graft.

d. The graft can be used 2 weeks after insertion.

e. Complications of the graft include clotting, aneurysms, and infection.

2. Advantages

a. Because the graft is internal, the risk of clotting and bleeding is low.

b. The graft can be used indefinitely.

c. The graft has a decreased incidence of infection.

d. Once healing has occurred, no external dressing is required.

e. The graft allows freedom of movement.

3. Disadvantages

a. The graft cannot be used immediately after insertion.

b. Needle insertions through the skin and tissues to the graft are required for dialysis.

c. Infiltration of the needles during dialysis can occur and cause hematomas.

d. An aneurysm can form in the graft; in addition, grafts clot more frequently than arteriovenous fistulas.

e. Arterial steal syndrome can develop (too much blood is diverted to the vein, and arterial perfusion to the hand is compromised).

f. Heart failure can occur from the increased blood flow in the venous system.

E. Interventions for an arteriovenous fistula and arteriovenous graft

1. Teach the client that the extremity should not be used for monitoring blood pressure, drawing blood, placing IV lines, or administering injections.

2. Teach the client with an arteriovenous fistula to perform hand-flexing exercises such as ball squeezing (if prescribed) to promote graft maturity.

3. Note the temperature and capillary refill of the extremity.

4. Palpate pulses below the fistula or graft, and monitor for hand swelling as an indication of ischemia.

5. Monitor for clotting.

a. Complaints of tingling or discomfort in the extremity

b. Inability to palpate a thrill or auscultate a bruit over the fistula or graft

6. Monitor for arterial steal syndrome.

7. Monitor for infection.

8. Monitor lung and heart sounds for signs of heart failure.

9. Notify the HCP immediately if signs of clotting, infection, or arterial steal syndrome occur.

To ensure patency, palpate for a thrill or auscultate for a bruit over the fistula or graft. Notify the HCP if a thrill or bruit is absent.

Complications of Hemodialysis

■ Air embolus

■ Disequilibrium syndrome

■ Electrolyte alterations

■ Encephalopathy

■ Hemorrhage

■ Hepatitis

■ Hypotension

■ Sepsis

■ Shock


Complications of Hemodialysis

Air Embolus


A. Air embolus

1. Description

a. Introduction of air into the circulatory system

b. Results in cardiopulmonary complications

2. Assessment

a. Dyspnea and tachypnea

b. Chest pain

c. Hypotension

d. Reduced oxygen saturation

e. Cyanosis

f. Anxiety

g. Changes in sensorium

3. Interventions

1. Stop the hemodialysis.

2. Turn the client on the left side, with the head down (Trendelenburg’s).

3. Notify the health care provider (HCP).

4. Administer oxygen.

5. Assess vital signs and pulse oximetry.

6. Document the event, actions taken, and the client’s response.

Air embolism occurs when air enters the catheter system and is a complication of hemodialysis. The signs of air embolism include dyspnea, tachypnea, chest pain, hypotension, reduced oxygen saturation, cyanosis, anxiety, and changes in sensorium. Air embolism is a critical situation and if it is suspected, hemodialysis is stopped immediately and the client should be placed in a left side– lying position with the head lower than the feet. This position is used to try to prevent the air from traveling as a bolus to the lungs by trapping it in the right side of the heart. The HCP is notified immediately and oxygen is administered. Vital signs are assessed including pulse oximetry, and other prescribed interventions are done. The event, actions taken, and the client’s response are documented.


Complications of Hemodialysis

Disequilibrium syndrome


1. Description

a. A rapid change in the composition of the extracellular fluid occurs during hemodialysis.

b. Solutes are removed from the blood faster than from the cerebrospinal fluid and brain; fluid is pulled into the brain, causing cerebral edema.

c. Occurs more frequently in a new client during the initial onset of hemodialysis.

2. Assessment

a. Nausea and vomiting

b. Headache

c. Hypertension

d. Restlessness and agitation

e. Muscle cramps

f. Confusion

g. Seizures

3. Interventions

a. Slow or stop the dialysis.

b. Notify the HCP if signs of disequilibrium syndrome occur.

c. Reduce environmental stimuli.

d. Prepare to administer intravenous hypertonic saline solution, albumin, or mannitol if prescribed.

e. Prepare to dialyze the client for a shorter period of time at reduced flow rates to prevent its occurrence.


Complications of Hemodialysis

Dialysis encephalopathy


1. Description: An aluminum toxicity from dialysate water sources containing aluminum; also can occur from ingestion of aluminum-containing antacids (phosphate binders). This is not a common occurrence.

2. Assessment

a. Progressive neurological impairment

b. Mental cloudiness

c. Speech disturbances

d. Dementia

e. Muscle incoordination

f. Bone pain

g. Seizures

3. Interventions

a. Monitor for the signs of dialysis encephalopathy.

b. Notify the HCP if signs of dialysis encephalopathy occur.

c. Administer aluminum-chelating agents as prescribed so that the aluminum is released and dialyzed from the body.

Peritoneal Dialysis

A. Description

1. The peritoneum acts as the dialyzing membrane (semipermeable membrane) to achieve dialysis.

2. Peritoneal dialysis (PD) works on the principles of osmosis, diffusion, and ultrafiltration; PD occurs via the transfer of fluid and solute from the bloodstream through the peritoneum into the dialysate solution.

3. The peritoneal membrane is large and porous, allowing solutes and fluid to move via osmosis from an area of higher concentration in the body to an area of lower concentration in the dialyzing fluid.

4. The peritoneal cavity is rich in capillaries; therefore it provides a ready access to the blood


B. Contraindications to peritoneal dialysis

1. Peritonitis

2. Recent abdominal surgery

3. Abdominal adhesions

4. Other gastrointestinal problems such as diverticulosis

C. Access for peritoneal dialysis

1. A siliconized rubber catheter such as a Tenckhoff catheter is surgically inserted into the client’s peritoneal cavity to allow infusion of dialysis fluid.

2. The preferred insertion site is 3 to 5 cm below the umbilicus; this area is relatively avascular and has less fascial resistance.

3. The catheter is tunneled under the skin, through the fat and muscle tissue to the peritoneum; it is stabilized with inflatable Dacron cuffs in the muscle and under the skin.

4. Over a period of 1 to 2 weeks following insertion, fibroblasts and blood vessels grow around the cuffs, fixing the catheter in place and providing an extra barrier against dialysate leakage and bacterial invasion.

5. If the client is scheduled for transplant surgery, the peritoneal dialysis catheter may either be removed or left in place if the need for dialysis is suspected posttransplantation.


Peritoneal Dialysis

Dialysate solution


1. The solution is sterile.

2. All dialysis solutions are prescribed by the HCP; the solution contains electrolytes and minerals and has a specific osmolarity, specific glucose concentration, and other medication additives as prescribed.

3. The higher the glucose concentration, the greater the hypertonicity and the amount of fluid removed during a peritoneal dialysis exchange.

4. Increasing the glucose concentration increases the concentration of active particles that cause osmosis, increases the rate of ultrafiltration, and increases the amount of fluid removed.

5. If hyperkalemia is not a problem, potassium may be added to each bag of dialysate solution.

6. Heparin is added to the dialysate solution to prevent clotting of the catheter.

7. Prophylactic antibiotics may be added to the dialysate solution to prevent peritonitis.

8. Insulin may be added to the dialysate solution for the client with diabetes mellitus.

Peritoneal dialysis infusion

1. Description

a. One infusion (fill), dwell, and drain is considered one exchange.

b. Fill: 1 to 2 L of dialysate as prescribed is infused by gravity into the peritoneal space, which usually takes 10 to 20 minutes.

c. Dwell time: The amount of time that the dialysate solution remains in the peritoneal cavity is prescribed by the HCP and can last 20 to 30 minutes to 8 or more hours, depending on the type of dialysis used.

d. Drain (outflow): Fluid drains out of body by gravity into the drainage bag.

2. Interventions before treatment

a. Monitor vital signs.

b. Obtain weight.

c. Have the client void, if possible.

d. Assess electrolyte and glucose levels.

3. Interventions during treatment

a. Monitor vital signs.

b. Monitor for respiratory distress, pain, or discomfort.

c. Monitor for signs of pulmonary edema.

d. Monitor for hypotension and hypertension.

e. Monitor for malaise, nausea, vomiting.

f. Assess the catheter site dressing for wetness or bleeding.

g. Monitor dwell time as prescribed by the HCP.

h. Do not allow dwell time to extend beyond the HCP’s prescription because this increases the risk for hyperglycemia.

i. Initiate outflow; turn the client from side to side if the outflow is slow to start.

j. Monitor outflow, which should be a continuous stream after the clamp is opened.

k. Monitor outflow for color and clarity.

l. Monitor intake and output accurately; if outflow is less than inflow, the difference is equal to the amount absorbed or retained by the client during dialysis and should be counted as intake.

m. An outflow greater than inflow should be reported to the HCP as well as the appearance of frank blood or cloudiness in the outflow.

Types of peritoneal dialysis

1. Continuous ambulatory peritoneal dialysis (CAPD)

a. Closely resembles renal function because it is a continuous process

b. Does not require a machine for the procedure

c. Promotes client independence

d. The client performs self-dialysis 24 hours a day, 7 days a week.

e. Four dialysis cycles are usually administered in a 24-hour period, including an overnight 8- hour dwell time.

f. Dialysate, 11⁄2 to 2 L, is instilled into the abdomen four times daily and allowed to dwell as prescribed.

g. After dwell, the bag is placed lower than the insertion site so that fluid drains by gravity flow.

h. After fluid is drained, the bag is changed, new dialysate is instilled into the abdomen, and the process continues.

i. Between exchanges, the catheter is clamped.

2. Automated peritoneal dialysis


Continuous Cycling Peritoneal Dialysis

Dialysis requires a peritoneal cycling machine.

Dialysis usually consists of three cycles done at night and one cycle with an 8-hour dwell done in

the morning.

The sterile catheter system is opened only for the on-and-off procedures, which reduces the risk of infection.

The client does not need to do exchanges during the day.


Intermittent Peritoneal Dialysis

Dialysis requires a peritoneal cycling machine.

Dialysis is not a continuous procedure.

Dialysis is performed for 10 to 14 hours, three or four times a week.


Nightly Peritoneal Dialysis

Dialysis requires a cycling machine.

Dialysis is performed 8 to 12 hours each night, with no daytime exchanges or dwells.


a. Automated dialysis requires a peritoneal cycling machine.

b. Automated dialysis can be done as intermittent peritoneal dialysis, continuous cycling peritoneal dialysis, or nightly peritoneal dialysis.

c. The exchanges are automated instead of manual.

Complications of Peritoneal Dialysis

A. Peritonitis

1. Monitor for signs/symptoms of peritonitis: Fever, cloudy outflow, rebound abdominal tenderness, abdominal pain, general malaise, nausea, and vomiting.

2. Cloudy or opaque outflow is an early sign of peritonitis.

3. If peritonitis is suspected, obtain a sample for culture and sensitivity of the outflow to determine the infective organism.

4. Administer antibiotics as prescribed.

5. Avoid infections by maintaining meticulous sterile technique when connecting and disconnecting PD solution bags and when caring for the catheter insertion site.

6. Prevent the catheter insertion site dressing from becoming wet during care of the client or the dialysis procedure; change the dressing if wet or soiled.

7. Follow institutional procedure for connecting and disconnecting PD solution bags, which may include scrubbing the connection sites with an antiseptic solution.

B. Abdominal pain

1. Peritoneal irritation during inflow commonly causes pain during the first few exchanges; the pain usually disappears after 1 to 2 weeks of dialysis treatments.

2. Warm the dialysate before administration, using a special dialysate warmer pad, because the cold temperature of the dialysate can cause discomfort.

C. Abnormal outflow characteristics indicative of complications

1. Bloody outflow after the first few exchanges indicates vascular complications (the outflow should be clear after the initial exchanges).

2. Brown outflow indicates bowel perforation.

3. Urine-colored outflow indicates bladder perforation.

4. Cloudy outflow indicates peritonitis.

D. Insufficient outflow

1. The main cause of insufficient outflow is a full colon; encourage a high-fiber diet, because constipation can cause inflow and outflow problems. Administer stool softeners as prescribed.

2. Insufficient outflow may also be caused by catheter migration out of the peritoneal area; if this occurs, an x-ray will be prescribed to evaluate catheter position.

3. Maintain the drainage bag below the client’s abdomen.

4. Check for kinks in the tubing.

5. Check for fibrin clots in the tubing and milk the tubing to dislodge the clot as prescribed.

6. Change the client’s outflow position by turning the client to a side-lying position or ambulating the client.

E. Leakage around the catheter site

1. Clear fluid that leaks from the catheter exit site will be noted.

2. It takes 1 to 2 weeks following insertion of the catheter before fibroblasts and blood vessels grow into the catheter cuffs, which fix it in place and provide an extra barrier against dialysate leakage and bacterial invasion.

3. Smaller amounts of dialysate need to be used; it may take up to 2 weeks for the client to tolerate a full 2-L exchange without leaking around the catheter site.

Continuous Renal Replacement Therapy

A. Continuous renal replacement therapy (CRRT) provides continuous ultrafiltration of extracellular fluid and clearance of urinary toxins over a period of 8 to 24 hours; used primarily for clients in acute kidney injury (AKI) or critically ill clients with CKD who cannot tolerate hemodialysis.

B. Water, electrolytes, and other solutes are removed as the client’s blood passes through a hemofilter.

C. Because rapid shifts in fluids and electrolytes typically do not occur, hemofiltration is usually better tolerated by critically ill clients.

D. There are five variations of CRRT, some requiring a hemodialysis machine and others that rely on the client’s blood pressure to power the system.

■ Continuous venovenous hemofiltration (CVVH)

■ Continuous arteriovenous hemofiltration (CAVH)

■ Continuous venovenous hemodialysis (CVVHD)

■ Continuous arteriovenous hemodialysis (CAVHD)

■ Slow continuous ultrafiltration (SCUF)

E. If CRRT does not require a hemodialysis machine, the client’s mean arterial blood pressure needs to be maintained above 60 mm Hg and arterial and venous access sites are necessary.

Kidney Transplantation

A. Description

1. A human kidney from a compatible donor is implanted into a recipient.

2. Kidney transplantation is performed for irreversible kidney failure; specific criteria are established for eligibility for a transplant.

3. The recipient must take immunosuppressive medications for life.

B. Living related donors

1. The most desirable source of kidneys for transplantation is living related donors who closely

match the client.

2. Donors are screened for ABO blood group, tissue-specific antigen, human leukocyte antigen suitability, and mixed lymphocyte culture index (histocompatibility); donors are also screened for the presence of any communicable diseases and undergo a complete medical evaluation as well as a nephrology consultation.

3. The donor must be in excellent health, with two properly functioning kidneys.

4. The emotional well-being of the donor is determined.

5. Complete understanding of the donation process and outcome by the donor is necessary.

C. Cadaver donors

1. Cadaver donors must meet the institution’s criteria of brain death.

2. Cadaver donors usually need to be younger than 70 years.

3. Cadaver donors must have normal renal function, although “marginal” donor organs have been used with the consent of the recipient.

4. No malignant disease outside the central nervous system can be present.

5. No generalized infection or communicable disease can be present.

6. No renal trauma can be present.

7. The potential donor must be negative for communicable diseases at the time of donation.

8. Once cerebral death has been established for a potential donor, restoration of intravascular volume, weaning from vasopressors, and establishing diuresis are crucial; management of the donor is determined by organ bank personnel.

9. Continuous ventilation, and normal blood pressure and heart rate, are maintained until the kidneys and other organs are surgically removed.

D. Preoperative interventions

1. Verify histocompatibility tests of donor, which will be done by organ bank personnel.

2. Administer immunosuppressive medications to the recipient for 2 days before the transplantation, as prescribed.

3. Maintain strict aseptic technique for the recipient.

4. Verify that hemodialysis of the recipient was completed 24 hours before transplantation.

5. Ensure that the recipient is free of any infections.

6. Assess renal function studies.

7. Encourage discussion of feelings of the donor and the recipient.

8. Provide psychological support to the live donor or cadaver donor family and the recipient.

E. Postoperative interventions for the recipient

1. Urine output usually begins immediately if the donor was a living donor; it may be delayed for a few days or more with a cadaver kidney.

2. Hemodialysis may be performed until adequate kidney function is established.

3. Monitor vital signs, central venous pressure (CVP), and pulse oximetry for signs of complications.

4. Monitor urine output hourly; immediately report a urine output less than 100 mL/hour.

5. Monitor IV fluids closely; for the first 12 to 24 hours, IV fluid replacement is based on hourly urine output.

6. Administer prescribed diuretics and osmotic agents.

7. Monitor daily weight to evaluate fluid status.

8. Monitor daily laboratory results to evaluate renal function, including hematocrit, BUN, and serum creatinine levels, and monitor urine for blood and specific gravity.

9. Position the client in a semi-Fowler’s position to promote gas exchange, turning from the back to the nonoperative side.

10. Monitor Foley catheter patency; the Foley catheter remains in the bladder for 3 to 5 days to allow for anastomosis healing.

11. Note that urine is pink and bloody initially but gradually returns to normal within several days to weeks.

12. Notify the HCP if gross hematuria and clots are noted in the urine.

13. Monitor the three-way bladder irrigation, if present, for clots; irrigate only if a HCP’s prescription is present.

14. Remove the Foley catheter as soon as possible to prevent infection.

15. Maintain aseptic technique and monitor for infection; infection is the primary cause of death in the first year posttransplantation.

16. Maintain strict aseptic technique with wound care.

17. Monitor for bowel sounds and for the passage of flatus; initiate a specific diet and oral fluids as prescribed when flatus and bowel sounds return (usually, fluids, sodium, and potassium are restricted if the client is oliguric).

18. Maintain good oral hygiene, monitoring for stomatitis and bacterial and fungal infections.

19. Encourage coughing and deep-breathing exercises.

20. Administer medications as prescribed, which may include antifungal medications, antibiotics, immunosuppressive agents, and corticosteroids.

21. The client is usually ambulated after 24 hours.

22. Assess for organ rejection by monitoring of laboratory values closely.

23. Promote live donor and recipient relationship.

24. Monitor both the donor and recipient for depression.

25. Provide the recipient with instructions following the kidney transplantation

26. Assist the recipient to cope with the body image disturbances that occur from long-term use of immunosuppressants.

27. Advise the recipient of available support groups.

F. Graft rejection

1. Assessment

2. Hyperacute rejection

a. Hyperacute rejection occurs at the time of anastomosis of the organ.

b. Interventions: Removal of rejected kidney

3. Acute rejection

a. Most common type; occurs most frequently within 6 weeks postoperatively, but can occur any time posttransplantation.

b. Interventions: Potentially reversible with increased immunosuppression and if treated early; high doses of corticosteroids, or monoclonal antibodies may be prescribed if corticosteroids are ineffective.

4. Chronic rejection

a. Occurs slowly months to years after transplant and mimics CKD.

b. Interventions: Immunosuppressive medications and retransplantation if necessary.

Except for identical twin donors and recipients, the major postoperative complication following renal transplant is graft rejection.

Client Instructions Following Kidney Transplantation

Avoid prolonged periods of sitting.

Monitor intake and output.

Recognize the signs and symptoms of infection and rejection.

Use medications as prescribed, and maintain immunosuppressive therapy for life.

Avoid contact sports.

Avoid exposure to persons with infections.

Know the signs and symptoms that require the need to contact the health care provider.

Ensure follow-up care. 

Clinical Signs of Renal Transplant (Graft) Rejection

■ Temperature higher than 100 ° F (37.7 ° C)

■ Pain or tenderness over the grafted kidney

■ 2- to 3-lb weight gain in 24 hours

■ Edema

■ Hypertension

■ Malaise

■ Elevated blood urea nitrogen and serum creatinine levels

■ Decreased creatinine clearance

■ Elevated white blood cell count

■ Rejection indicated by ultrasound or biopsy 

Causes of Cystitis

■ Allergens or irritants, such as soaps, sprays, bubble bath, perfumed sanitary napkins

■ Bladder distention

■ Calculus

■ Hormonal changes, influencing alterations in vaginal flora

■ Indwelling urinary catheters

■ Invasive urinary tract procedures

■ Loss of bactericidal properties of prostatic secretions in the male

■ Microorganisms

■ Poor-fitting vaginal diaphragms

■ Sexual intercourse

■ Synthetic underwear and pantyhose

■ Urinary stasis

■ Use of spermicides

■ Wet bathing suits 

Cystitis (Urinary Tract Infection)

A. Description

1. Cystitis (urinary tract infection, UTI) is an inflammation of the bladder from an infection, obstruction of the urethra, or other irritants

2. The most common causative organisms are Escherichia coli and Enterobacter, Pseudomonas, and Serratia species.

3. Cystitis is more common in women because women have a shorter urethra than men and the urethra in the woman is located close to the rectum.

4. Sexually active and pregnant women are most vulnerable to cystitis.

B. Assessment

1. Frequency and urgency

2. Burning on urination

3. Voiding in small amounts

4. Inability to void

5. Incomplete emptying of the bladder

6. Lower abdominal discomfort or back discomfort

7. Cloudy, dark, foul-smelling urine

8. Hematuria

9. Bladder spasms

10. Malaise, chills, fever

11. Nausea and vomiting

12. WBC count greater than 100,000 cells/mm3 on urinalysis

13. An elevated specific gravity and pH may be noted on urinalysis.

Altered mentation is a sign of a urinary tract infection in older adults; frequency and urgency may not be specific symptoms of UTI because of urinary elimination changes that occur with aging.

C. Interventions

1. Before administering prescribed antibiotics, obtain a urine specimen for culture and sensitivity, if prescribed, to identify bacterial growth.

2. Encourage the client to increase fluids up to 3000 mL/day, especially if the client is taking a sulfonamide; sulfonamides can form crystals in concentrated urine.

3. Administer prescribed medications, which may include analgesics, antiseptics, antispasmodics, antibiotics, and antimicrobials.

4. Maintain an acid urine pH (5.5); instruct the client about foods to consume to maintain acidic urine.

5. Provide heat to the abdomen or sitz baths for complaints of discomfort.

6. Note that if the client is prescribed an aminoglycoside, sulfonamide, or nitrofurantoin (Macrodantin), the actions of these medications are decreased by acidic urine.

7. Use sterile technique when inserting a urinary catheter.

8. Maintain closed urinary drainage systems for the client with an indwelling catheter and avoid elevating the urinary drainage bag above the level of the bladder.

9. Provide meticulous perineal care for the client with an indwelling catheter.

10. Discourage caffeine products such as coffee, tea, and cola.

11. Client education

a. Avoid alcohol.

b. Take medications as prescribed.

c. Take antibiotics on schedule and complete the entire course of medications as prescribed, which may be 10 to 14 days.

d. Repeat the urine culture following treatment.

e. Prevent recurrence of cystitis

Use good perineal care, wiping front to back.

Avoid bubble baths, tub baths, and vaginal deodorants or sprays.

Void every 2 to 3 hours.

Wear cotton pants and avoid wearing tight clothes or pantyhose with slacks.

Avoid sitting in a wet bathing suit for prolonged periods of time.

If pregnant, void every 2 hours.

If menopausal, use estrogen vaginal creams to restore pH.

Use water-soluble lubricants for intercourse, especially after menopause.

Void and drink a glass of water after intercourse.

Client Instructions for Prevention of Cystitis

Use good perineal care, wiping front to back.

Avoid bubble baths, tub baths, and vaginal deodorants or sprays.

Void every 2 to 3 hours.

Wear cotton pants and avoid wearing tight clothes or pantyhose with slacks.

Avoid sitting in a wet bathing suit for prolonged periods of time.

If pregnant, void every 2 hours.

If menopausal, use estrogen vaginal creams to restore pH.

Use water-soluble lubricants for intercourse, especially after menopause.

Void and drink a glass of water after intercourse.


A. Description

1. Urosepsis is a gram-negative bacteremia originating in the urinary tract.

2. The most common causative organism is Escherichia coli.

3. In a client who is immunocompromised, the most common cause is infection from an indwelling urinary catheter or an untreated UTI.

4. The major problem is the ability of this bacterium to develop resistant strains.

5. Urosepsis can lead to septic shock if not treated aggressively.

B. Assessment: Fever is the most common and earliest manifestation.

C. Interventions

1. Obtain a urine specimen for urine culture and sensitivity before administering antibiotics.

2. Administer antibiotics intravenously as prescribed, usually until the client has been afebrile for 3 to 5 days.

3. Administer oral antibiotics as prescribed after the 3- to 5-day afebrile period.


A. Description

1. Inflammation of the urethra commonly associated with a sexually transmitted infection; may occur with cystitis.

2. In men, urethritis most often is caused by gonorrhea or chlamydial infection.

3. In women, urethritis most often is caused by feminine hygiene sprays, perfumed toilet paper or sanitary napkins, spermicidal jelly, UTI, or changes in the vaginal mucosal lining.

B. Assessment

1. Pain or burning on urination

2. Frequency and urgency

3. Nocturia

4. Difficulty voiding

5. Males may have clear to mucopurulent discharge from the penis.

6. Females may have lower abdominal discomfort.

C. Interventions

1. Encourage fluid intake.

2. Prepare the client for testing to determine whether a sexually transmitted infection (STI) is present.

3. Administer antibiotics as prescribed.

4. Instruct the client in the administration of sitz or tub baths.

5. If stricture occurs, prepare the client for dilation of the urethra and instillation of an antiseptic solution.

6. Instruct the female client to avoid the use of perfumed toilet paper or sanitary napkins and feminine hygiene sprays.

7. Instruct the client to avoid intercourse until the symptoms subside or treatment of the STI is complete.

8. Instruct the client about STIs if this is the cause.

a. Prevent STIs by the use of latex condoms or abstinence.

b. All sexual partners during the 30 days before diagnosis with chlamydial infection should be notified, examined, and treated if indicated.

c. Chlamydial infection often coexists with gonorrhea; diagnostic testing is done for both STIs.

d. Treatment for STIs includes antibiotics as prescribed to treat the causative organism.

e. The most serious complication of chlamydial infection is sterility.

f. Follow-up culture may be requested in 4 to 7 days to evaluate the effectiveness of medications.


A. Description: An inflammation of the ureter commonly associated with bacterial or viral infections and pyelonephritis

B. Assessment

1. Dysuria

2. Frequent urination

3. Clear to mucopurulent penile discharge in males

C. Interventions

1. Treatment includes identifying and treating the underlying cause and providing symptomatic relief.

2. Metronidazole (Flagyl) or clotrimazole (Mycelex) may be prescribed for treating Trichomonas infection.

3. Nystatin (Mycostatin) or fluconazole (Diflucan) may be prescribed for treating yeast infections.

4. Doxycycline (Vibramycin) or azithromycin (Zithromax) may be prescribed for treating chlamydial infections.


A. Description

1. An inflammation of the renal pelvis and the parenchyma, commonly caused by bacterial invasion

2. Acute pyelonephritis often occurs after bacterial contamination of the urethra or following an invasive procedure of the urinary tract.

3. Chronic pyelonephritis most commonly occurs following chronic urinary flow obstruction with reflux.

4. Escherichia coli is the most common causative bacterial organism.

B. Acute pyelonephritis

1. Acute pyelonephritis occurs as a new infection or recurs as a relapse of a previous infection.

2. It can progress to bacteremia or chronic pyelonephritis.

3. Assessment

a. Fever and chills

b. Tachycardia and tachypnea

c. Nausea

d. Flank pain on the affected side

e. Costovertebral angle tenderness

f. Headache

g. Dysuria

h. Frequency and urgency

i. Cloudy, bloody, or foul-smelling urine

j. Increased white blood cells in the urine

Chronic pyelonephritis

1. A slow, progressive disease usually associated with recurrent acute attacks

2. Causes contraction of the kidney and dysfunctioning of the nephrons, which are replaced by scar tissue

3. Causes the ureter to become fibrotic and narrowed by strictures

4. Can lead to acute kidney injury or chronic kidney disease

5. Assessment

a. Frequently diagnosed incidentally when a client is being evaluated for hypertension

b. Inability to conserve sodium

c. Poor urine-concentrating ability

d. Pyuria

e. Azotemia

f. Proteinuria

D. Interventions

1. Monitor vital signs, especially for elevated temperature.

2. Encourage fluid intake up to 3000 mL/day to reduce fever and prevent dehydration.

3. Monitor intake and output (ensure that output is a minimum of 1500 mL/24 hour).

4. Monitor weight.

5. Encourage adequate rest.

6. Instruct the client in a high-calorie, low-protein diet.

7. Provide warm, moist compresses to the flank area to help relieve pain.

8. Encourage the client to take warm baths for pain relief.

9. Administer analgesics, antipyretics, antibiotics, urinary antiseptics, and antiemetics as prescribed.

10. Monitor for signs of acute kidney injury or chronic kidney disease

11. Encourage follow-up urine culture

Polycystic Kidney Disease

A. Description

1. Cyst formation and hypertrophy of the kidneys, which leads to cystic rupture, infection, formation of scar tissue, and damaged nephrons

2. There is no specific treatment to arrest the progress of the destructive cysts.

3. The ultimate result of this disease is chronic kidney disease.

B. Types

1. Infantile polycystic disease: An inherited autosomal recessive trait that results in the death of the infant within a few months after birth

2. Adult polycystic disease: An autosomal dominant trait that manifests between 30 and 40 years of age and results in end-stage kidney disease

C. Assessment

1. Often asymptomatic until the age of 30 to 40 years

2. Flank, lumbar, or abdominal pain that worsens with activity and is relieved when lying down

3. Fever and chills

4. Recurrent urinary tract infections

5. Hematuria, proteinuria, pyuria

6. Calculi

7. Hypertension

8. Palpable abdominal masses and enlarged kidneys

9. Increased abdominal girth

D. Interventions

1. Monitor for gross hematuria, which indicates cyst rupture.

2. Increase sodium and water intake because sodium loss rather than retention occurs.

3. Provide bed rest if ruptured cysts and bleeding occur.

4. Prepare the client for percutaneous cyst puncture for relief of obstruction or for draining an abscess.

5. Administer antihypertensives as prescribed.

6. Prevent and/or treat urinary tract infections.

7. Prepare the client for dialysis or renal transplantation.

8. Encourage the client to seek genetic counseling.

9. Provide psychological support to the client and family.

10. Provide psychosocial support and genetic counseling for family members who may want to donate a kidney.


A. Description

1. Distention of the renal pelvis and calices caused by an obstruction of normal urine flow

2. The urine becomes trapped proximal to the obstruction.

3. The causes include calculus, tumors, scar tissue, ureter obstructions, and hypertrophy of the prostate.


B. Assessment

1. Hypertension

2. Headache

3. Colicky or dull flank pain that radiates to the groin

C. Interventions

1. Monitor vital signs frequently.

2. Monitor for fluid and electrolyte imbalances, including dehydration after the obstruction is relieved.

3. Monitor for diuresis, which can lead to fluid depletion.

4. Monitor weight daily.

5. Monitor urine for specific gravity and albumin and glucose levels.

6. Administer fluid replacement as prescribed.

7. Prepare the client for insertion of a nephrostomy tube or a surgical procedure to relieve the obstruction if prescribed.

Renal Calculi

A. Description

1. Calculi are stones that can form anywhere in the urinary tract; however, the most frequent site is the kidneys.

2. Problems resulting from calculi are pain, obstruction, tissue trauma, secondary hemorrhage, and infection.

3. The stone can be located through radiography of the kidneys, ureters, and bladder; intravenous pyelography; CT scanning; and renal ultrasonography.

4. A stone analysis will be done after passage to determine the type of stone and assist in determining treatment.

5. Urolithiasis refers to the formation of urinary calculi; these form in the ureters.

6. Nephrolithiasis refers to the formation of kidney calculi; these form in the renal parenchyma.

7. When a calculus occludes the ureter and blocks the flow of urine, the ureter dilates, producing hydroureter 

8. If the obstruction is not removed, urinary stasis results in infection, impairment of renal function on the side of the blockage, hydronephrosis, and irreversible kidney damage.

B. Causes

1. Family history of stone formation

2. Diet high in calcium, vitamin D, protein, oxalate, purines, or alkali

3. Obstruction and urinary stasis

4. Dehydration

5. Use of diuretics, which can cause volume depletion

6. Urinary tract infections and prolonged urinary catheterization

7. Immobilization

8. Hypercalcemia and hyperparathyroidism

9. Elevated uric acid level, such as in gout

C. Assessment

1. Renal colic, which originates in the lumbar region and radiates around the side and down to the testicles in men and to the bladder in women

2. Ureteral colic, which radiates toward the genitalia and thighs

3. Sharp, severe pain of sudden onset

4. Dull, aching pain in the kidney

5. Nausea and vomiting, pallor, and diaphoresis during acute pain

6. Urinary frequency, with alternating retention

7. Signs of a urinary tract infection

8. Low-grade fever

9. High numbers of red blood cells, white blood cells, and bacteria noted in the urinalysis report

10. Gross hematuria

D. Interventions

1. Monitor vital signs, especially the temperature, for signs of infection.

2. Monitor intake and output.

3. Assess for fever, chills, and infection.

4. Monitor for nausea, vomiting, and diarrhea.

5. Encourage fluid intake up to 3000 mL/day, unless contraindicated, to facilitate the passage of the stone and prevent infection; monitor for obstruction.

6. Administer fluids intravenously as prescribed if unable to take fluids orally or in adequate amounts to increase the flow of urine and facilitate passage of the stone.

7. Provide warm baths and heat to the flank area (massage therapy should be avoided).

8. Administer analgesics at regularly scheduled intervals as prescribed to relieve pain.

9. Assess the client’s response to pain medication.

10. Assist the client in performing relaxation techniques to assist in relieving pain.

11. Encourage client ambulation, if stable, to promote the passage of the stone.

12. Turn and reposition the immobilized client to promote passage of the stone.

13. Instruct the client in the diet restrictions specific to the stone composition if prescribed

14. Prepare the client for surgical procedures if prescribed.

Nutritional Therapy for Calculi

Note: Depending on the type of calculi, the diet is modified to decrease foods that are high in the substance that is the cause of the calculi.


■ High: Sardines, herring, mussels, liver, kidney, goose, venison, meat soups, sweetbreads

■ Moderate: Chicken, salmon, crab, veal, mutton, bacon, pork, beef, ham


■ High: Milk, cheese, ice cream, yogurt, sauces containing milk; all beans (except green beans), lentils; fish with fine bones (e.g., sardines, kippers, herring, salmon); dried fruits, nuts; Ovaltine, chocolate, cocoa


■ High: Dark roughage, spinach, rhubarb, asparagus, cabbage, tomatoes, beets, nuts, celery, parsley, runner beans; chocolate, cocoa, instant coffee, Ovaltine, tea; Worcestershire sauce


*Uric acid is a waste product from purine in food.

Treatment Options for Renal Calculi

A. Cystoscopy

1. Cystoscopy may be done for stones in the bladder or lower ureter.

2. No incision is made.

3. One or two ureteral catheters are inserted past the stone; the stone may be manipulated and dislodged by the procedure and the catheters may guide the stones mechanically downward as they are removed.

4. The catheters are left in place for 24 hours to drain the urine trapped proximal to the stone and to dilate the ureter.

5. A continuous chemical irrigation may be prescribed to dissolve the stone.

B. Extracorporeal shock wave lithotripsy (ESWL)

1. A noninvasive mechanical procedure for breaking up stones located in the kidney or upper ureter so that they can pass spontaneously or be removed by other methods

2. No incision is made and no drains are placed; a stent may be placed to facilitate passing stone fragments.

3. Fluoroscopy is used to visualize the stone and ultrasonic waves are delivered to the area of the stone to disintegrate it.

4. The stones are passed in the urine within a few days.

5. Preprocedure: Maintain the client on NPO status for 8 hours before the procedure.

6. Postprocedure

a. Monitor vital signs, especially for hypotension and tachycardia, which could indicate bleeding or hematoma formation.

b. Monitor intake and output.

c. Monitor for bleeding.

d. Monitor for pain and signs of urinary obstruction.

e. Instruct the client that if a ureteral stent is placed to help the stone pass, it is usually removed

in 1 to 2 weeks.

f. Instruct the client to increase fluid intake to flush out the stone fragments.

g. Inform the client that ambulation is important.

C. Percutaneous lithotripsy

1. Performed for stones in the bladder, ureter, or kidney

2. An invasive procedure in which a guide is inserted under fluoroscopy near the area of the stone; an ultrasonic wave is aimed at the stone to break it into fragments.

3. Percutaneous lithotripsy may be performed via cystoscopy or nephroscopy.

4. No incision is required for cystoscopy; a small flank incision is needed for nephroscopy.

5. The client might have an indwelling bladder catheter.

6. A nephrostomy tube may be placed to administer chemical irrigations to break up the stone; the nephrostomy tube may remain in place for 1 to 5 days.

7. Encourage the client to drink 3000 to 4000 mL of fluid/day as prescribed following the procedure.

8. Monitor for and instruct the client to monitor for complications of infection, hemorrhage, and extravasation of fluid into the retroperitoneal cavity.

D. Ureterolithotomy

1. An open surgical procedure performed if lithotripsy is not effective for removal of a stone in the ureter

2. An incision is made through the lower abdomen or flank and then into the ureter to remove the stone.

3. The client may have a Penrose drain, ureteral stent catheter, and/or indwelling bladder catheter.

E. Pyelolithotomy and nephrolithotomy

1. Pyelolithotomy is an incision into the renal pelvis to remove a stone; a large flank incision is required and the client may have a Penrose drain and indwelling bladder catheter.

2. Nephrolithotomy is an incision into the kidney made to remove a stone; a large flank incision is required, and the client may have a nephrostomy tube and an indwelling bladder catheter.

F. Partial or total nephrectomy

1. Performed for extensive kidney damage, renal infection, severe obstruction from stones or tumors, and prevention of stone recurrence

2. Postoperative interventions

a. The plan of care depends on the incision location and the type of drainage tubes present.

b. Monitor the incision, particularly if a Penrose drain is in place, because it will drain large amounts of urine.

c. Protect the skin from urinary drainage, changing dressings frequently if necessary.

d. Place an ostomy pouch over the Penrose drain to protect the skin if urinary drainage is excessive.

e. Monitor the nephrostomy tube, which may be attached to a drainage bag, for a continuous flow of urine.

f. Do not irrigate the nephrostomy or bladder catheters unless specifically prescribed.

g. Monitor the indwelling bladder catheter for drainage.

h. Encourage fluid intake to ensure a urine output of 2500 to 3000 mL/day or more.

i. Measure intake and output accurately.

j. If a stone was removed, determine its composition from laboratory analysis.

Kidney Tumors

A. Description

1. Kidney tumors may be benign or malignant, bilateral or unilateral.

2. Common sites of metastasis of malignant tumors include bone, lungs, liver, spleen, and the other kidney.

3. The exact cause of renal carcinoma is unknown.

B. Assessment

1. Dull flank pain

2. Palpable renal mass

3. Painless gross hematuria

C. Radical nephrectomy

1. Description

a. Surgical removal of the entire kidney, adjacent adrenal gland, and renal artery and vein

b. Radiation therapy and possibly chemotherapy may follow radical nephrectomy.

c. Before surgery, radiation may be used to embolize (occlude) the arteries supplying the kidney to reduce bleeding during nephrectomy.

2. Postoperative interventions

a. Monitor vital signs for signs of bleeding (hypotension and tachycardia).

b. Monitor for abdominal distention, decreases in urinary output, and alterations in level of consciousness as signs of bleeding; check the bed linens under the client for bleeding.

c. Monitor for signs of adrenal insufficiency, which include a large urinary output followed by hypotension and subsequent oliguria.

d. Administer fluids and packed red blood cells intravenously as prescribed.

e. Monitor intake and output and daily weight.

f. Monitor for a urinary output of 30 to 50 mL/hour to ensure adequate renal function.

g. Monitor urine specific gravity.

h. Maintain the client in a semi-Fowler’s position.

i. Monitor for signs of respiratory complications related to surgery; encourage coughing and deep-breathing exercises.

j. Monitor for passing of flatus and bowel sounds (lack of flatus and bowel sounds can be indicative of paralytic ileus).

k. Apply antiembolism stockings as prescribed.

l. If a nephrostomy tube is in place, do not irrigate (unless specifically prescribed) or manipulate the tube.

m. Administer pain medications as prescribed.


A. Description

1. Acute or chronic inflammation of the epididymis that occurs as a result of a UTI, STI, prostatitis, or long-term use of a bladder catheter

2. The infective organism travels upward through the urethra and ejaculatory duct and along the vas deferens to the epididymis.

B. Assessment

1. Scrotal pain

2. Groin pain

3. Swelling in the scrotum and groin

4. Pus and bacteria in the urine

5. Fever and chills

6. Abscess development

C. Interventions

1. Encourage fluid intake.

2. Encourage bed rest with the scrotum elevated to prevent traction on the spermatic cord, facilitate drainage, and relieve pain.

3. Instruct the client in the intermittent application of cold compresses to the scrotum.

4. Instruct the client in the use of tub or sitz baths.

5. Instruct the client in the administration of antibiotics for self and sexual partner if the cause is chlamydial or gonorrheal infection.

6. Instruct the client to avoid lifting, straining, and sexual contact until the infection subsides.

7. Instruct the client to limit the force of the stream because organisms can be forced into the vas deferens and epididymis from strain or pressure during voiding.

8. Teach the client that condom use can help prevent urethritis and epididymitis.

9. Teach the client measures to prevent UTI or STI recurrence.


A. Description

1. Inflammation of the prostate gland commonly caused by an infectious agent; may be acute or chronic.

2. The bacterial type occurs as a result of the organism reaching the prostate via the urethra, bladder, bloodstream, or lymphatic channels.

3. The abacterial type usually occurs following a viral illness or a decrease in sexual activity.

B. Assessment

1. Bacterial prostatitis

a. Client becomes acutely ill.

b. Fever and chills

c. Frequency and urgency of urination; dysuria

d. Perineal and low back pain

e. Urethral discharge

f. Prostate is tender, indurated, and warm to the touch.

g. Urethral discharge on palpation of prostate

h. White blood cells are found in prostatic secretions.

i. Urine culture is usually positive for gram-negative bacteria, especially after prostate massage.

2. Abacterial prostatitis (most common form of chronic prostatitis)

a. Backache

b. Dysuria

c. Perineal pain

d. Frequency

e. Hematuria

f. Irregularly enlarged, firm, and tender prostate

C. Interventions

1. Encourage adequate fluid intake.

2. Instruct the client in the use of tub or sitz baths to promote comfort.

3. Administer antibiotics, analgesics, antispasmodics, and stool softeners as prescribed.

4. Inform the client of activities to drain the prostate, such as intercourse, masturbation, and prostatic massage.

5. Instruct the client to avoid spicy foods, coffee, alcohol, prolonged automobile rides, and sexual intercourse during an acute inflammation.

Benign Prostatic Hypertrophy (Hyperplasia)

A. Description

1. Benign prostatic hypertrophy (benign prostatic hyperplasia; BPH) is a slow enlargement of the prostate gland, with hypertrophy and hyperplasia of normal tissue.

2. Enlargement compresses the urethra, resulting in partial or complete obstruction.

3. Usually occurs in men older than 50 years

B. Assessment

1. Diminished size and force of urinary stream (early sign of BPH)

2. Urinary urgency and frequency

3. Nocturia

4. Inability to start (hesitancy) or continue a urinary stream

5. Feelings of incomplete bladder emptying

6. Postvoid dribbling from overflow incontinence (later sign)

7. Urinary retention and bladder distention

8. Hematuria

9. Urinary stasis

10. Dysuria and bladder pain

11. UTIs

C. Interventions

1. Encourage fluid intake of up to 2000 to 3000 mL/day unless contraindicated.

2. Prepare for urinary catheterization to drain the bladder and prevent distention.

3. Avoid administering medications that cause urinary retention, such as anticholinergics, antihistamines, decongestants, and antidepressants.

4. Administer medications as prescribed to shrink the prostate gland and improve urine flow.

5. Administer medications as prescribed to relax prostatic smooth muscle and improve urine flow.

6. Instruct the client to decrease intake of caffeine and artificial sweeteners and limit spicy or acidic foods.

7. Instruct the client to follow a timed voiding schedule.

8. Prepare the client for surgery or invasive procedures as prescribed

Laser Prostatectomy: Ablation of the enlarged prostate, using laser instead of radiofrequency waves

Perineal Prostatectomy: Removal of prostatic tissue (may be performed for prostatic cancer) low in the pelvic region through an incision between the scrotum and rectum; impotence and incontinence usually result.

Retropubic Prostatectomy: Removal of hypertrophied prostatic tissue high in the pelvic region through a low abdominal incision; the bladder is not incised.

Suprapubic Prostatectomy: Removal of prostatic tissue mass through a low midline incision; an incision is made into the bladder and urethral mucosa to the anterior aspect of the prostate.

Transurethral Electrovaporization of the Prostate: Placement of a special metal instrument that emits a high-frequency electrical current that cuts and vaporizes excess tissue and seals the remaining tissue to prevent bleeding; this is especially useful for men on anticoagulants and those at risk for complications.

Transurethral Incision of the Prostate (TUIP): Removal of prostatic tissue through an incision

made in the bladder neck

Transurethral Microwave Thermotherapy: Application of heat to destroy the hypertrophied


Transurethral Needle Ablation of the Prostate (TUNA): Placement of interstitial radiofrequency

needles through the urethra and into the lateral lobes of the prostate, causing heat-induced coagulation necrosis of the prostate for treating benign prostatic hypertrophy (BPH)

Transurethral Resection of the Prostate (TURP): Removal of benign prostatic tissue surrounding the urethra with use of a resectoscope introduced through the urethra; there is little risk of impotence and it is most commonly used for BPH

Urethral Stents: Application of stents or coils in the urethra where it is narrowed by the prostate


Bladder Trauma

A. Description

1. Occurs following a blunt or penetrating injury to the lower abdomen

2. Blunt trauma causes compression of the abdominal wall and bladder.

3. Penetrating wounds occur as a result of a stabbing, gunshot wound, or other objects piercing the abdominal wall.

4. A fractured pelvis that causes bone fragments to puncture the bladder is a common cause of bladder trauma.

B. Assessment

1. Anuria

2. Hematuria

3. Pain below the level of the umbilicus; can radiate to the shoulders

4. Nausea and vomiting

C. Interventions

1. Monitor vital signs.

2. Monitor for hematuria, bleeding, and signs of shock.

3. Promote bed rest.

4. Monitor pain level.

5. If blood is seen at the meatus, avoid urinary catheterization until a retrograde ureterogram canbe obtained.

6. Prepare the client for insertion of a suprapubic catheter to aid in urinary drainage if prescribed.

7. Prepare the client for surgical repair of the laceration if indicated.




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