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RENAL DISORDERS: General Overview

Focused Assessment:
• PMH: DM, HTN, kidney diseases, CV dx, recent strep throat.
• Complaints:
o Fatigue, Pain (Flank, suprapubic, back, abdominal)
o Voiding changes (polyuria, oliguria, frequency, urgency, dysuria, hesitancy)
• GI symptoms (End-Stage Liver Disease)
• Family Hx. (E.g. polycystic kidney)
• Social Hx. (Smoker, drinker, toxic exposures, athletes and take lots of NSAIDs)
• Physical Exam: * Do not do! But it is in text.
o Abdominal inspection, auscultation, o If foley catheter, do inspection.
palpation, and percussion. o Kidney palpation*
o Bladder palpation and percussion. o Palpation of the prostate and inguinal area
o Assessment for edema. (males)*
o Body weight (volume-related weight gain- o Inspection and palpation of the female
VRWG) genitalia*
Gerontologic Considerations:
• GFR decreases following 40 years
• Renal reserve declines
• Multiple medications – toxic metabolites
• Diminished thirst
• Incomplete emptying of bladder
• Urinary incontinence: Detrusor muscle and urinary
sphincter becomes more relaxed.
General Dietary Considerations:
• Heart Healthy foods and preparation (limit ETOH, no
smoking)
• ↓ Salt Intake and ↓ Protein
• As renal function ↓ limit: Potassium, Phosphorus, and fluids become an issue.

RENAL DISORDERS: Renal Diagnostic Evaluation

Diagnostic Procedures: To figure out if it is a urine, structural defect (of kidney, ureter, bladder, urethra),
strictures, stones, or disease of kidney itself (parenchymal [the solid part of kidney] disease, CKD).
• Renal Scan • Urine C&S
• Cystogram • BUN/Creatinine
• Retrograde Pyelogram • KUB X-ray (Kidney, Ureter, Bladder)
• Ultrasound • IVP (Intravenous pyelogram)
• CT • VCG/VCUG (Voiding cystourethrogram): Visualize
• MRI urethra and bladder while pt. urinates.
• Renal Arteriogram • Renal angiogram
• UA • Renal Biopsy
Renal Function Tests:
• BUN/Creatinine Ratio: 10:1 – 20:1; Both found in CMP. ↑ in both values may indicate renal issues.
o Serum Creatinine: 0.6 – 1.2 mg/dL
§ If ↑, kidney less effective in filtering.
§ Creatinine clearance: 24-hour urine collection OR serum levels.
o BUN: 7 – 20 mg/dL
§ CMP, also indicator of renal function
§ If ↑ BUN itself, not necessarily issues. Could be dehydration OR BP low.
• Glomerular filtration rate (GFR): 120 – 130 mL/min corrected for body size (Per 1.73 m2). Provide info on
function and stage of disease. Different in ethnicities.
• Urine osmolality: Concentrating ability
• Microalbuminuria: Damage to glomerular filtration.
• Albumin, glucose, casts, or cloudy urinate indicative of some sort of underlying issue.
Urine Dipstick: May indicate leukocytes, nitrite (bacteria convert nitrate to nitrite), urobilinogen, protein, pH,
blood, specific gravity, ketones, bilirubin, and glucose. Urinate on stick and compare with indication on bottle.
Urinate Analysis, Culture, and Sensitivity (UA, C&S): Culture and sensitivity uses agar plates and culture mediums
to indicate what type of bacteria. MIC (ug/mL) is lowest concentration of antibiotic that inhibits growth of a
particular bacteria.
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RENAL DISORDERS - (GLOMERULAR DISEASES): Acute and Chronic Glomerulonephritis
Pathophysiology:
• Glomerulonephritis: Inflammation of membrane tissue in the kidney that serves as a filter, separating
wastes and extra fluid from the body.
• Glomerulosclerosis: Scarring or hardening of the tiny blood vessels within the kidney.
• Induced inflammatory response; albuminuria; hematuria; reduced GRF; hypoproteinemia; edema.
• Etiology:
o Auto-immune diseases: Lupus, Goodpasture syndrome (Antibody-Antigen complex)
o Hereditary Nephritis: Alport Syndrome
o Infection related Glomerular Disease: Acute post-streptococcal glomerulonephritis (PSGN); HIV;
HBV; Hepatitis C
o Sclerotic Diseases: Diabetic nephropathy; Glomerulosclerosis
o Chronic Kidney Disease
o Other: Membranous glomerulopathy
Risk Factors:
• HTN • Bacterial endocarditis
• DM (Diabetic nephropathy) • Viral infections (HIV, HBV, HCV)
• Cancer • Immune disorders (lupus)
• Strep throat • Vasculitis
• NSAID long-term use
Signs and Symptoms:
• Acute:
o Hematuria • Chronic: Asymptomatic many years.
o Proteinuria o Hematuria
o Oliguria, anuria o Proteinuria
o Azotemia o HTN
o Morning facial edema o Edema (face and extremities).
o HTN o Nocturnal polyuria
o Pulmonary edema (SOB) o Foamy urine (proteinuria).
o Hyperkalemia, metabolic acidosis;
anemia; ↑ serum P/↓ serum Ca.
Complications of Glomerulonephritis:
• Acute Kidney Failure: Loss of function may require emergent dialysis.
• Chronic kidney disease: Gradual loss of function, < 10% = ESRD.
• End-stage renal disease
• HTN: BP driven by kidney.
• Hypertensive encephalopathy.
• Heart Failure, pulmonary edema
• Nephrotic syndrome.
Treatment:
• Reverse Underlying cause.
• Dietary changes (Low protein, Na, K, fluids), Increase carbs.
• Administration of antibiotics (strep)
• Administration of antihypertensives.
• Administration of corticosteroids.
• Dialysis
• Plasmapheresis (autoimmune origin): Treats the etiology, not the disease.
• Kidney transplant.
Nursing Interventions:
• Education
• Monitor VS and I/Os
• Head-to-toe assessment: Cardiac, Pulmonary, Edema?

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RENAL DISORDERS - (GLOMERULAR DISEASES): Nephrotic Syndrome
Pathophysiology: Cluster of clinical findings reflecting underlying organ damage.
Risk Factors: Diabetic nephropathy; glomerulonephritis; DM w/ intercapillary glomerulosclerosis; SLE; multiple
myeloma; renal vein thrombosis.
Signs and Symptoms:
• Proteinuria
• Hypoalbuminia
• Hyperlipidemia: Due to loss of albumin à
synthesis of lipoproteins.
• Edema of face and extremities.
Diagnosis:
• UA-proteinuria
• CMP, lipid profile – BUN/creatinine, albumin,
cholesterol
• Renal biopsy
• Renal ultrasound or CT.
Treatment: Treat underlying cause.
• Lifestyle changes to reduce HTN, lipids, and
o Dietary protein: 0.7 – 1.0 g/kg/day
o Na restriction
o Regular exercise
• Medications: Antihypertensives, hyperlipidemia, diuretics.
• Client education and support.

RENAL DISORDERS: Acute Kidney Injury (Acute Renal Failure)

Pathophysiology: Typically, reversible and there is abrupt loss of kidney function and GFR over hours or days.
• Usually caused by event that leads to kidney malfunction such as, dehydration, blood loss from major
surgery or injury, or use of medicines. Results in kidney failure to excrete nitrogenous wastes.
• Without treatment, may progress to ESRD, Uremic syndrome, and death.
• Four Phases: Initiation/Onset à oliguric à diuretic à Recovery.
• Several Causes:
o Prerenal disease: Reduced renal perfusion: Volume
depletion, impaired cardiac efficiency, vasodilation.
o Intrarenal disease:
§ Prolonged renal ischemia: pigment
nephropathy, myoglobinuria, or
hemoglobinuria.
§ Acute tubular necrosis (ATN).
§ Rhabdomyolosis (breakdown of skeletal
muscle).
§ Nephrotoxic agents: NSAIDs; ACE inhibitors;
aminoglycoside antibiotics (gentamicin,
tobramycin)
§ Infections,
o Postrenal disease: After the kidneys, such as
obstructions like calculi, tumors, BPM, strictures, or
blood clots.
o Vascular disease: Acute-vasculitis; Chronic-bilateral renal artery stenosis.
o Interstitial/Tubular disease: Acute-tubular necrosis; Chronic polycystic kidney disease.
o Obstructive uropathy: Bilateral obstruction (tumor, prostatic enlargement)
Signs and Symptoms:
• Prerenal:
o Hypotension, Tachycardia, ↓ cardiac output (CO)
o ↓ urinary output
o Lethargy.
• Intrarenal and Postrenal:
o Oliguria OR anuria o SOB, orthopnea
o Hypertension, tachycardia o N/V
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o generalized edema and weight gain o Lethargy, confusion.
• Both:
o ↑ BUN/Creatinine o ↑ P; ↓ Ca
o ↑ Na (may be hidden due to dilution) o ↓ H/H
o ↑ K+ o ↓ Sp. Gravity.
Medical Management:
• Prerenal: Fluid challenges and diuretics to enhance renal flow.
• Oliguric failure: Low dose dopamine for ↑ perfusion (↑ GFR)
• Regulate electrolytes:
o MEDICATIONS: To shift K+ à cells
§ Kayexalate/sorbitol (polystyrene sulphonate)
§ IV dextrose, Insulin
§ Calcium
o Regulate phosphate levels
• Normalize acid-base balance.
Nursing Management:
• Monitor: I/O; F&E (↑ K+); Other labs. • Mouth care
• Reduce metabolic demands • Daily weights
• Maintain nutrition • Assess for signs of heart failure.
• Maintain ALL IV access and infusions, medication • Skin integrity problems.
administration. • Malaise? Getting better?
• Safety measures • Answer questions and support given.

RENAL DISORDERS: Chronic Kidney Disease (Chronic Renal Failure)

Pathophysiology: CKD is progressive and irreversible deterioration; occurs over months to years.
• Usually caused by LONG-TERM disease, such as HTN or DM, that slowly damages kidneys and reduces function over
time.
• Uremia develops due to inability of kidney to filter products of protein breakdown.
• 75% of function loss and 90% - 95% considered chronic
Risk Factors:
• #1 DM
• #2 HTN
• Heart disease
• Family hx.
• Ethnic origin: African-American, Native American, or
Asian.
• > 60 years old.
• Chronic glomerulonephritis, pyelonephritis, urinary
tract obstruction, PKD, vascular and autoimmune
disorders, infections, medications, toxic agents.
Signs and Symptoms:
• Neurologic: LOC changes, confusion, seizures,
agitation, neuropathies, RLS.
• CV: HTN (RAAS), heart failure, pulmonary edema,
pericarditis, MI
• Pulmonary: Crackles, Kussmaul respirations, pleuritic
pain.
• GI: N/V, anorexia, Uremic fetor (Ammonia odor to
breath), constipation or diarrhea.
• GU: Proteinuria, Amenorrhea
• Derm: Severe pruritus, Uremic frost (urea crystals)
• Uremia: S/S: HA, seizures, coma, dry skin, rapid pulse,
elevated BP, scant urine, labored breathing.
• METABOLIC ACIDOSIS is hallmark sign of CKD.
Management:
• Lower stages:
o Eat healthy diet, exercise, no smoking, o Keep BP at healthy level.
minimal ETOH o Blood glucose control.
§ Protein, Na, K+, Ca, P, restrictions o Regular lab monitoring.
dependent on stage and o Medication administration
comorbidities.
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• Later stages: Lifestyle changes, Medications, Renal replacement therapy (dialysis), Kidney transplant.
Nursing Management:
• Frequent monitoring: I/O, CV function, respiratory o MEDICATIONS: Erythropoietin (-alfa); Iron;
status, F&Es, nutrition, mental status, emotional active vit. D; Phosphorus binders; B-
well-being, skin care, bleeding problems. complex & folic acid; BP meds, insulin, or
• Care of shunt or catheter oral, statins. Leukopoietic growth factors
• Education to client and family (-stim)
• Ensure proper medication regimen:
End-Stage Renal Disease: Slow, insidious process.
• Final stage is ESRD
• Increasing incidence.
• Diabetic nephropathy and HTN leading causes in U.S.
• Manifestations: Nausea, apathy, weakness, fatigue, confusion.
CKD Concerns:
• Hyperkalemia
• HTN
• Anemia
• Hypocalcemia, hyperphosphatemia, Abnormal vit. D lead to bone and vascular dx.
• Fluid overload – Cardiac impairment
• Insulin resistance.

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RENAL REPLACEMENT THERAPY: General Overview
Chronic Renal Failure:
• Medical treatment
• IV glucose and insulin (Lower K+)
• Sodium bicarb, Ca, Vit. D, phosphate binders
• Fluid restriction, diuretics
• Iron supplements, blood erythropoietin
• High carbs, low protein
• Dialysis after all methods fail.
Renal Replacement Therapy (RRT):
• Replaces nonendocrine kidney function in pts
w/ renal failure.
• Home, outpatient, inpatient.
• Short-term or long-term (chronic)
• Multidisciplinary team approach
Dialysis:
• MANY CRF eventually require dialysis
• Diffuse harmful waste out of body.
• Control BP
• Keep safe level of chemicals in body.
• 2 Types:
o Hemodialysis (HD)
§ Intermittent
§ Continuous
• Continuous venovenous hemofiltration: Does not require arterial access.
• Continuous venovenous hemofiltration w/ dialysis: Like CVVH but also has
dialysate to create a concentration gradient.
o Peritoneal dialysis (PD)

RENAL REPLACEMENT THERAPY: Peritoneal Dialysis

Peritoneal Dialysis: Done if some function of kidney remaining. Not done if extensive abdominal scarring, or if
inflammatory disorders of the GI.
• Semipermeable membrane
• Catheter inserted through abdominal wall into peritoneal cavity
• Cost less
• Fewer restrictions (diet, lifestyle)
• Can be done at home
• Risk of peritonitis
• 3 phases: inflow, dwell, and outflow.
Automated Peritoneal Dialysis:
• Done at home at night.
• Maybe 6-7 times/week.
Continuous ambulatory peritoneal dialysis (CAPD):
• Done as outpatient.
• 1.5 – 2 L dialysate; Usually 4x/daily
Continuous Cyclic Peritoneal Dialysis

RENAL REPLACEMENT THERAPY: Hemodialysis-Intermittent (IHD) & Continuous Renal Replacement

Therapy (CRRT)

IHD: Done 3 – 4 times a week. Takes 2 – 4 hours. Dialysis RN.

CRRT: ICU care, CCRN monitors process, 24 hrs/day x several days.

Nursing Management: Daily weights, I&Os, Post-op fluid restriction, Post-op restriction, monitor for bleeding
(coag), Hypothermia prevention, Lab review (CMP/CBC), Medications (ask if not noted).
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RENAL REPLACEMENT THERAPY: Hemodialysis
Hemodialysis: Typically done for someone done with CRF or ESRD.
• Vascular access:
o Temporary: Subclavian or femoral
o Permanent: Shunt
o Care post insertion
• Can be done rapidly.
• Takes about 4 hours
• Done 3x a week.
Types of Access:
• Temporary site: HD subclavian or femoral.
o Non-tunneled catheter: “Quinten” catheters
o Tunneled cuffed “Permacath”
• Permanent: shunt, in arm.
• AV fistula: Allow at least 14 days to heal, and mature although 4 – 6 weeks preferable.
o Surgeon constructs by combining an artery and a vein.
o 3 – 6 months to mature; Encourage squeezing ball to increase size of veins while healing.
o NURSING INTERVENTIONS:
§ No BP on same arm.
§ Protect arm from injury
§ Control obvious hemorrhage: Bleeding is arterial, maintain direct pressure.
§ No IV on same arm as fistula.
§ Listen to fistula for BRUIT and palpate THRILL.
• AV graft: Created when patient vessels not suitable for creation of fistula. Ideally created 2 – 6 months
before need for renal replacement therapy.
o Man-made tube inserted by surgeon to connect artery and vein.
o 2 – 6 weeks to mature. Like AV fistula, encourage ball squeeze, monitor for clotting, palpate
pulses, and hand swelling indicates ischemia.
Access Problems:
• AV Graft thrombosis
• AV fistula or graft bleeding
• AV graft infection.
• Steal phenomenon: Also called subclavian steal syndrome (SSS) or subclavian steal steno-occlusive
disease. Graft stenosis and backs up. Arterial steal syndrome, too much blood diverted to vein à
compromised arterial perfusion.
Nursing Considerations:
• Make sure dressing remains intact.
• Do not push or pull on catheter.
• Always transport patient and bags/catheters as one piece.
• Never injection anything into catheter.
Dialysis Related Problems:
• Lightheaded: usually give fluids, but asses first.
• Hypotension
• Dysrhythmias
• Air embolus: Stop hemodialysis à left-side, w/ head down à Call HCP and rapid response à oxygen,
assess VS à document.
• Disequilibrium Syndrome (cerebral edema):
o Restlessness, confusion, tremor, seizure.
o Altered LOC.

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URINARY TRACT DISORDERS: Urinary Incontinence
Pathophysiology: Loss of bladder control. Affects both men and women.
• Types:
o Stress: Coughing, sneezing, laughing.
o Urge (overactive): Infection, DM
o Overflow: Detrusor overactivity
o Reflex: neuro impairment
o Functional: Illness or disability
Risk Factors:
• Female • Neurological diseases: Parkinson’s, MS
• Vaginal childbirth • Infective process
• Advancing age • Urinary obstruction
• Prostate surgery • Menopause
• Pelvic surgery • Smoking
• DM • Obesity
• CNS damage/injury • Family Hx.
Diagnostic Procedures: For Urinary incontinence/Urinary retention
• As always, get H&P: Bladder diary?
• UA, urine C&S
• Ultrasonic Bladder scan: bedside
• Urodynamic testing:
o Postvoid residual urine
o Cystometrography
o Uroflowmetry
Medical Management:
• MEDICATIONS:
o Inhibit detrusor muscle, increase bladder capacity. Are either anticholinergics, antispasmodics or
both. (-terodine, -fenacin).
§ Oxybutynin (Ditropan XL)
§ Tolterodine (Detrol)
§ Festerodine (Toviaz)
§ Darifenacin (Enablex)
§ Solifenacin (Vesicare)
§ Trospium (Sancutra)
o Estrogen therapy
• Behavioral Therapy:
o Bladder training
o Scheduled toileting
o Fluid and diet management
• Surgery:
o Bladder neck suspension
o Prostatectomy
Nursing Management:
• Evaluating:
o Keep voiding diary
o Identify wetting episodes
o Assess willingness to participate in social activities.
• Teaching:
o Home environment
o Voiding diary
o Therapies: Kegels, medications.
Gerontologic Considerations: Transient episodes of incontinence is abrupt in onset. Question onset of s/s and
changes in other organ systems. Onset provoked by acute UTI, infection, constipation, stool impaction, change
in chronic disease pattern (such as DM, HTN).

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URINARY TRACT DISORDERS: Urinary Retention
Pathophysiology: Inability to empty bladder.
• Obstructive and non-obstructive cause:
o Males: BPH, urethral stenosis o Neurologic diseases: Stroke, DM, MS
o Females: Cystocele, rectocele o Trauma: CNS, previous urinary
o Surgery (anesthesia) catheter use.
o Medications: antihistamines, tricyclic o Infection, stricture, stones, cancer,
antidepressants, antispasmodic renal stones.
agents, alpha-adrenergic agents,
beta-adrenergic blockers, estrogens.
Diagnostic Procedures:
• Portable bladder scan (post-void residual urine measurement)
• Cystoscopy
• Prostate-specific-antigen (PSA)
Management:
• Treatment depends on cause:
o Self-catheterization
o Medications: Bethanechol.
o Behavioral: Running water, sitz bath, relaxation techniques,
o Surgery
o Stimulation techniques: Medtronic bladder control therapy.
• Complications:
o Hydronephrosis, renal calculi
o Renal failure
o UTI à pyelonephritis à sepsis

URINARY TRACT DISORDERS: Urinary Tract Infections (UTIs)

Pathophysiology: Unfortunately, happens more often in acute-care setting.
• Prominently female.
• Incidence increase w/ aging.
• Catheter-associated Urinary Tract Infection (CAUTI)
• Cystitis most common (bladder)
Diagnostic Procedures:
• UA, C&S
Management:
• Antibiotics:
o Uncomplicated UTI: single dose, short-course 3 – 4 days, or 7 – 10 days.
§ Fluoroquinolones (-floxacin): Administer w/ full glass of water. Risk for liver/renal toxic.
§ Nitrofurantoin: Do not use in renal insufficiency, ineffective at GFR < 50 mL/min. May
cause peripheral neuropathy.
• Comfort:
o Antispasmodics
o Phenazopyridine: Urinary analgesic. Urine turn dark orange.

URINARY TRACT DISORDERS: Cystitis

Signs and Symptoms: May be asymptomatic.
• Frequency, urgency, dysuria, incontinence
• Hematuria, pyuria (cloudy), dark,
• Pain (lower back, suprapubic)
• Fever, chills, oliguria, foul-smelling urine.
• If left untreated à Urosepsis (first sign, fever), pyelonephritis
• ELDERLY: Sudden behavior change, incontinence, confusion.
Management: Administer meds to treat (infection, pain, fever). Monitor VS for s/s infection. Assess hydration,
encourage ↑ fluid intake. Comfort measures (heating pad, sitz, bath etc.) Educate about hygiene and
prevention.

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URINARY TRACT DISORDERS: Pyelonephritis
Pathophysiology: Renal pelvis affected. Kidney infection from untreated UTI. Beings in urethra or bladder and
travels up one or both kidneys.
Risk Factors:
• Recent UTI
• Pregnancy
• Urinary tract obstruction
• Vesicoureteral reflux (VUR)
• Diabetes and/or immunodeficient
• Urinary retention
Signs and Symptoms:
• Acute:
o Rapid onset
o Chills, fever
o Malaise, vomiting
o Dysuria, frequency, urgency.
o Tachycardia and tachypnea
o Flank pain, CVA (costovertebral angle) tenderness
o Headache
o Cloudy, bloody, foul-smelling urine
o Increased WBC’s in urine
• Chronic:
o Fibrosis
o Scarring
o Renal failure.
o Proteinuria, azotemia
• Cystitis
Nursing Care for UTI/Pyelonephritis:
• Monitor for worsening infection/progression: Tachycardia, fever/chills, ↑ BP
• Assess for urinary retention
• Assess hydration status and encourage fluid intake.
• Provide comfort measures: Heating pad.
• Provide education regarding hygiene and prevention of future infections
• Administer medications:
o Infection
o Fever
o Pain

URINARY TRACT DISORDERS: Renal Calculi

Pathophysiology: Form anywhere in urinary tract, most frequent in
kidneys. Urolithiasis is in ureters, can lead to hydroureter. Nephrolithiasis
is in kidney, form in renal parenchyma.
Risk Factors:
• Family hx.
• High calcium, vit d, protein, oxalate, purine, or alkali intake.
• Obstruction and urinary stasis
• Dehydration
• Diuretic use.
• UTIs and prolonged urinary catheterization
• Immobilization
• Hypercalcemia and hyperparathyroidism
• Elevated uric acid level, such as gout.
Treatment: Cystoscopy, Extracorporeal shock wave lithotripsy,
Percutaneous lithotripsy, Ureterolithotomy, pyelolithotomy and
nephrolithotomy, Partial or total nephrectomy.

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