CHAPTER 4 Renal-Urinary Disorders
Section One Renal Disorders
Glomerulonephritis
Overview/Pathophysiology
Glomerulonephritis (GN) refers to inflammation of and subsequent damage to the renal glomerular capillaries that lead to leakage of protein and RBCs into the urine. It is not an infection of the glomerulus, but rather is secondary to a systemic infection. GN may be acute or chronic. Most individuals with acute glomerulonephritis (AGN) improve dramatically within weeks and recover completely within 1-2 yr, but renal damage continues to progress for patients with chronic glomerulonephritis (CGN). CGN is one of the most common causes of chronic renal failure (CRF). Most forms of GN are the result of an immunologic response in which immune complexes, formed when antibodies attach to antigens, become entrapped in the glomerulus and produce inflammation (e.g., group A hemolytic streptococcal infection, systemic lupus erythematosus). Other risk factors for GN include metabolic disease, recent use of penicillin or sulfonamide antibiotics, or nephrotoxic drugs. See “Acute Renal Failure,” p. 181, and “Chronic Kidney Disease,” p. 174.
Diagnostic Tests
Plasma complement, antinuclear antibody titer, antistreptolysin O titer, throat and blood cultures, hepatitis B antigen, and immunoelectrophoresis of serum and urine
Nursing Diagnoses and Interventions
Excess fluid volume
related to compromised regulatory mechanisms secondary to decreased renal function
Nursing Interventions
⧫ Assess/monitor for indicators of fluid overload: edema, hypertension, crackles (rales), tachycardia, lethargy, distended neck veins, shortness of breath, and increased CVP. Edema occurs because of lowered serum colloidal osmotic pressure resulting from decreased serum albumin secondary to urinary losses.
⧫ Monitor weight daily. Weigh patient at same time each day; use same scale and have patient wear same amount of clothing. Report unusual or steady gains or losses (e.g., 0.5-1 kg/day).
Nursing Interventions
⧫ Assess patient’s facility with language, and engage an interpreter or provide language-appropriate written materials if necessary.
⧫ Teach patient and significant others to report to health care provider or staff promptly if patient develops signs and symptoms of the following:
• Hypocalcemia: Twitching, numbness and tingling of fingers and circumoral region, and muscle cramps.
• Hyperphosphatemia: May be asymptomatic; report joint or bone pain, rash, or painful or itchy skin lesions.
⧫ Teach patient and significant other to read all labels carefully and avoid foods high in Na+ (BOX 4-1) because many over-the-counter (OTC) preparations are high in Na+ (e.g., mouthwashes, antacids).
Deficient knowledge
related to disease process, treatment plan, and side effects of prescribed medications
Nursing Interventions
⧫ Assess patient’s facility with language, and engage an interpreter or provide language-appropriate written materials if necessary.
⧫ Teach patient and significant other:
• Need for reporting side effects of prescribed medications. Side effects are dependent on dose and duration of therapy and may include decreased resistance to infection, poor wound healing, increasing BP, mental changes, hyperglycemia, capillary fragility, and gastrointestinal (GI) bleeding.
• Need to avoid persons with known infections because corticosteroids and cytotoxic agents suppress the immune system, reduce antibody formation, and thereby increase the risk for infections.
• Need for avoiding the abrupt withdrawal from medication if corticosteroids are taken for 1 wk or longer. Therapy must be withdrawn, with gradual reductions in dosage. Signs and symptoms that can occur with abrupt medication withdrawal include fever, malaise, fatigue, anorexia, orthostatic hypotension, dyspnea, muscle and joint pain, and hypoglycemia. Prevents adrenal insufficiency.
• Potential for cystitis with hematuria, abnormal hair loss. See “Cancer Care,” p. 657, for additional information about cytotoxic agents.
• Potential for development of Cushing’s syndrome as a side effect of prolonged use of corticosteroids. Syndrome is manifested by edema, buffalo hump, hirsutism, moon face, skin striae and thinning, weight gain, peptic ulcer, headache, osteoporosis, aseptic necrosis, nervousness, insomnia, and metabolic acidosis. Notify health care provider or staff promptly if any of these symptoms occur. (See “Cushing’s Disease,” p. 400.) Corticosteroids cause Na+ and water retention and hypokalemia.
Nursing Interventions
⧫ Assess for signs of infection if patient is immunocompromised from prescribed corticosteroids or cytoxic agents. Signs of infection include increased body temperature; adventitious breath sounds; and increased, thickened, or colored airway secretions. Older adults and individuals who are uremic tend to have subnormal temperatures; therefore even slight fevers can be significant. Corticosteroids and other immune suppressive agents may mask signs and symptoms of infection.
⧫ Encourage frequent deep breathing or coughing or provide suctioning at frequent intervals if respiratory secretions are noted, to prevent atelectasis. (See “Atelectasis,” p. 57.)
⧫ Use meticulous sterile technique when performing invasive procedures or manipulating urinary catheters, peripheral IV lines, or central venous catheters to prevent the introduction of microorganisms.
Patient-Family Teaching and Discharge Planning
Include verbal and written information:
⧫ Medications, including drug names, purpose, dosage, schedule, precautions, and potential side effects. Also discuss drug/drug, herb/drug, and food/drug interactions.
⧫ Diet: include fact sheet listing foods that should be avoided or limited. Inform patient that diet and fluid restrictions may be altered as renal function changes. Provide sample menus with examples of how dietary restrictions may be incorporated into daily meals.
⧫ Indicators that require medical attention: irregular pulse, fever, unusual shortness of breath or edema, sudden change in urine output, or unusual weakness.
⧫ Necessity for continued medical evaluation; confirm date and time of next health care provider appointment, if known.
⧫ Necessity of avoiding infections and seeking treatment promptly if they occur. Teach signs and symptoms of URI, otitis media, urinary tract infection (UTI), and impetigo. (See “Urinary Tract Infection (Cystitis),” p. 197.)
⧫ Phone numbers to call if questions or concerns arise about therapy or this condition after discharge. Additional general information can be obtained by accessing the following:
Pyelonephritis
Diagnostic Tests
BUN/serum creatinine
Unless an anatomic or preexisting renal disease is present, renal function should remain normal.
Nursing Diagnoses and Interventions
Acute pain
related to tissue inflammation secondary to infection
Nursing Interventions
⧫ Monitor for presence of CVA pain and tenderness, abdominal pain, and dysuria, all of which are indicators of pyelonephritis.
⧫ Administer prescribed analgesics as needed and document their effectiveness using the pain scale. Encourage patient to request medication before discomfort becomes severe. Notify health care provider about unrelieved or increasing flank pain.
Nursing Interventions
⧫ Assess/monitor for signs of infection: temperature of 38° C (100.4° F); flank, CVA, low back, buttock, scrotal, or labial pain; foul-smelling or cloudy urine; malaise; headache; and frequency and urgency of urination. Establishes baseline for later comparisons to determine effectiveness of interventions.
⧫ Monitor BP, pulse, and for indications of peripheral vasoconstriction at least q4h. Hypotension and tachycardia can indicate sepsis, which can lead to septic shock.
⧫ Monitor for indications of pulmonary infection. If secretions are noted, encourage frequent deep breathing or coughing or provide suctioning at frequent intervals. CVA pain decreases patient’s desire to cough and thereby increases the risk for atelectasis. (See “Atelectasis,” p. 57).
⧫ Administer prescribed antibiotics as scheduled to maintain effective antibiotic serum levels to assure eradication of infectious organism.
⧫ Avoid use of urinary catheters unless mandatory. Urinary catheterization is a significant source of pathogen introduction into the urinary system. Intermittent catheterization carries less risk of UTI than does indwelling catheterization.
⧫ Use sterile technique when inserting or irrigating urinary catheters or obtaining specimens. Maintain unobstructed flow; always keep urinary collection container below level of patient’s bladder to prevent reflux of urine; tape catheter to thigh or abdomen in male patients to decrease meatal irritation; and provide perineal care daily to prevent infection or reinfection.
⧫ Send urine samples to the laboratory immediately after they are obtained, or refrigerate. Urine left at room temperature has greater potential for bacterial growth, turbidity, and alkalinity. Urine for culture should not be refrigerated. Decreases risk for distorted test results.
Nursing Interventions
⧫ Assess patient’s facility with language; engage an interpreter or provide language-appropriate written materials.
⧫ Teach patient/significant other:
• Indicators of kidney infection and the importance of reporting them promptly to health care provider or staff to facilitate early treatment.
• Importance of emptying bladder at least q3-4h and once during the night to help prevent UTI caused by residual urine, which can ascend into renal pelvis.
• Necessity of maintaining fluid intake of at least 2-3 L/day and drinking fruit juices (cranberry, plum, prune) that leave an acid ash in the urine. Helps prevent pathogens from adhering to urinary bladder wall and ascending to the kidneys.
Patient-Family Teaching and Discharge Planning
Include verbal and written information about:
⧫ Medications, including drug names, purpose, dosage, schedule, precautions, and potential side effects. Also discuss drug/drug, herb/drug, and food/drug interactions.
⧫ Necessity of reporting the following to their health care provider: chills; fever; hematuria; flank, CVA, suprapubic, low back, buttock, scrotal, or labial pain; cloudy and foul-smelling urine; increased frequency, urgency; dysuria; and increasing or recurring incontinence.
Hydronephrosis
Collaborative Management
Management of hydronephrosis focuses on the cause and duration of the urinary tract obstruction. Major causes of obstruction in the pelvis and ureter are calculi (see “Ureteral Calculi,” p. 199) and neoplasms. Major causes of obstruction in the bladder and urethra are neoplasms, and neurogenic bladder (see “Neurogenic Bladder,” p. 217), and benign prostatic hypertrophy (BPH) (see “Benign Prostatic Hypertrophy,” p. 627).
Nursing Diagnoses and Interventions
Risk for infection
Nursing Interventions
⧫ Assess and monitor for indicators of infection, such as fever, pain, purulent drainage, and tachycardia. Document changes in color, odor, or clarity of urine to establish a baseline for later comparison.
⧫ Do not change, clamp, or irrigate nephrostomy tube unless specifically prescribed by health care provider. Because the renal pelvis is small and holds little volume, never instill more than 5 mL at one time into the tube unless a larger amount has been specifically prescribed by health care provider.
⧫ Avoid kinks in the tubing and keep urine collection container and tubing in a dependent position to prevent reflux of tube contents into the renal pelvis.
Desired outcome
⧫ Report gross hematuria (urine that is bright red, possibly with clots). Transient hematuria can be expected for 24-48 hr after tube insertion.
⧫ Notify health care provider of leakage around catheter, which can occur with blockage, or sudden decrease in urine output. Signals a dislodged or blocked catheter.
⧫ Report sudden onset of or increase in pain. Can indicate perforation of a body organ by the catheter.
⧫ Keep tube securely taped to patient’s flank with elastic tape. If tube accidentally becomes dislodged, cover site with a sterile dressing; notify health care provider immediately. Helps prevent tube from becoming dislodged.
⧫ Before removing nephrostomy tube, check with health care provider. Provider may request that nephrostomy tube be clamped for several hours at a time to evaluate patient tolerance. While the tube is clamped, monitor patient for indications of ureteral obstruction: flank pain, diminished urinary output, and fever. Signals excessive pressure within kidney.
Patient-Family Teaching and Discharge Planning
Include verbal and written information about:
⧫ Medications, including drug names, purpose, dosage, schedule, precautions, and potential side effects. Also discuss drug/drug, herb/drug, and food/drug interactions.
⧫ Care of nephrostomy catheter, if catheter is in place upon discharge, and procedure to follow if the catheter becomes dislodged.
⧫ Frequency of and procedure for dressing changes. Patient or significant others should demonstrate safe dressing-change technique before hospital discharge or receive a referral for home health follow-up.
⧫ Need for continued medical follow-up; confirm date and time of next health care provider appointment, if known.
Renal Artery Stenosis
