Regis College NU Renal Disorders – Flashcards

Polycystic kidney disease (PKD) is a genetic disorder characterized by the growth of numerous cysts in the kidneys. When cysts form in the kidneys, they are filled with fluid, destroying the nephrons. PKD cysts can profoundly enlarge the kidneys while replacing much of the normal structure, resulting in reduced kidney function and leading to kidney failure. PKD can also cause cysts in the liver and problems in other organs, such as blood vessels in the brain and heart. The number of cysts as well as the complications they cause help distinguish PKD from the usually harmless "simple" cysts that can form in the kidneys in later years of life.

Signs and symptoms of PKD result from loss of renal function and the increasing size of the kidneys as the cysts grow.Renal damage can result in hematuria, polyuria (large amounts of urine), hypertension, development of renal calculi and associated urinary tract infections, and proteinuria.The growing cysts are noted with reports of abdominal fullness and flank pain (back and lower sides).

Since PKD is a genetic disease, careful evaluation of family history is necessary. Palpation of the abdomen will often re-veal enlarged cystic kidneys. Diagnosis is usually made with ultrasound imaging of the kidney

PKD has no cure and treatment is largely supportive including blood pressure control, pain control, and antibiotics to resolve infections. Once the kidneys fail, renal replacement therapy is indicated. Genetic testing and counseling may be indicated.

Urinary tract infections (UTIs) are caused by pathogenic microorganisms in the urinary tract (the normal urinary tract is sterile above the urethra). UTIs are generally classified as infections involving the upper or lower urinary tract and further classified as uncomplicated or complicated, depending on other patient-related conditions (Chart 45-1). Lower UTIs include bacterial cystitis(inflammation of the urinary bladder), bacterial prostatitis (inflammation of the prostate gland), and bacterial urethritis(inflammationof the urethra). There can be acute or chronic non-bacterial causes of inflammation in any of these areas that can be misdiagnosed as bacterial infections. Upper UTIs are much less common and include acute or chronic pyelonephritis (in-flammation of the renal pelvis), interstitial nephritis (in-flammation of the kidney), and renal abscesses. Upper and lower UTIs are further classified as uncomplicated or complicated, depending on whether the UTI is recurrent and the duration of the infection.

Inability or failure to empty the bladder completely•Obstructed urinary flow caused by:Congenital abnormalities Urethral strictures Contracture of the bladder neck Bladder tumors Calculi (stones) in the ureters or kidneys Compression of the ureters -Decreased natural host defenses or immunosuppression •Instrumentation of the urinary tract (eg, catheterization, cystscopic procedures) •Inflammation or abrasion of the urethral mucosa •Contributing conditions such as:Diabetes mellitus (increased urinary glucose levels create an infection-prone environment in the urinary tract) Pregnancy Neurologic disorders GoutAltered states caused by incomplete emptying of the bladder and urinary stasis

The acute nephritic syndrome is the clinical manifestation of glomerular inflammation. Glomerulonephritisis an inflammation of the glomerular capillaries that can occur in acute and chronic forms.Primary glomerular diseases include postinfectious glomerulonephritis, rapidly progressive glomerulonephritis, mem-brane proliferative glomerulonephritis, and membranous glomerulonephritis. Can be caused by infections of the throat. It may also follow impetigo (infection of the skin) and acute viral infections (upper respiratory tract infections, mumps, varicella zoster virus, Epstein-Barr virus, hepatitis B, and human immunodeficiency virus [HIV] infection). In some patients, antigens outside the body (eg,medications, foreign serum) initiate the process, resulting in antigen-antibody complexes being deposited in the glomeruli. In other patients, the kidney tissue itself serves as the inciting antigen.

The primary presenting features of an acute glomerular inflammation are hematuria, edema, azotemi, an abnormal concentration of nitrogenous wastes in the blood, and proteinuria or excess protein in the urine. The hematuria may be microscopic (identifiable only through microscopic examination) or macroscopic(visible to the eye). The urine may appear cola-colored because of red blood cells (RBCs) and protein plugs or casts;RBC casts indicate glomerular injury. Glomerulonephritis may be mild and the hematuria discovered incidentally through a routine urinalysis, or the disease may be severe,with acute renal failure (ARF) and oliguria.

Some degree of edema and hypertension is present inmost patients. Marked proteinuria due to the increased permeability of the glomerular membrane may also occur,with associated pitting edema, hypoalbuminemia, hyperlipidemia, and fatty casts in the urine. Blood urea nitrogen (BUN) and serum creatinine levels may increase as urine output decreases. In addition, anemia may be present. In the more severe form of the disease, patients also com-plain of headache, malaise, and flank pain. Elderly patients may experience circulatory overload with dyspnea, en-gorged neck veins, cardiomegaly, and pulmonary edema. Atypical symptoms include confusion, somnolence, and seizures, which are often confused with the symptoms of aprimary neurologic disorder.

Complications of acute glomerulonephritis include hypertensive encephalopathy, heart failure, and pulmonary edema. Hypertensive encephalopathy is a medical emergency, and therapy is directed toward reducing the blood pressure without impairing renal function. This can occur in acute nephritic syndrome or preeclampsia with chronic hypertension of greater than 140/90 mm Hg.

Management consists primarily of treating symptoms, attempting to preserve kidney function, and treating complications promptly. Treatment may include corticosteroids,managing hypertension, and controlling proteinuria. Pharmacologic therapy depends on the cause of acute glomerulonephritis. If residual streptococcal infectionis suspected, penicillin is the agent of choice; however,other antibiotic agents may be prescribed. Dietary protein is restricted when renal insufficiency and nitrogen retention(elevated BUN) develop. Sodium is restricted when the patient has hypertension, edema, and heart failure.

In a hospital setting, carbohydrates are given liberally to provide energy and reduce the catabolism of protein. I&O are carefully measured and recorded. Fluids are given based on the patient's fluid losses and daily body weight. Insensible fluid loss through the lungs (300 mL) and skin (600 mL) is considered when estimating fluid loss (see Chapter 14). If treatment is effective, diuresis will begin, resulting in decreased edema and blood pressure. Proteinuria and microscopic hematuria may persist for many months; in fact, 20%of patients have some degree of persistent proteinuria or de-creased GFR 1 year after presentation

Patient education is directed toward symptom management and monitoring for complications. Fluid and diet restrictions must be reviewed with the patient to avoid worsening of edema and hypertension. The patient is instructed verbally and in writing to notify the physician if symptoms of renal failure occur (eg, fatigue, nausea, vomiting, diminishing urine output) or at the first sign of any infection.

The importance of follow-up evaluations of blood pressure, urinalysis for protein, and BUN and serum creatinine levels to determine if the disease has progressed is stressed to the patient. A referral for home care may be indicated; a visit from a home care nurse provides an opportunity for careful assessment of the patient's progress and detection of early signs and symptoms of renal insufficiency. If corticosteroids, immunosuppressant agents, or antibiotic medications are prescribed, the home care nurse or nurse in the out patientsetting uses the opportunity to review the dosage, desired actions, and adverse effects of medications and the precautions to be taken

Chronic Glomerulonephritis is similar to Acute GN with exacerbated symptoms. Management of symptoms guides the treatment. In Chronic GN however, dialysis is usually performed. Dialysis is initiated early in the course of the disease tokeep the patient in optimal physical condition, preventfluid and electrolyte imbalances, and minimize the risk ofcomplications of renal failure.

Whether the patient is hospitalized or cared for in the home,the nurse observes the patient for common fluid and electrolyte disturbances in renal disease. Changes in fluid and electrolyte status and in cardiac and neurologic status are reported promptly to the physician.Anxiety levels are often extremely high for both the patient and family. Throughout the course of the disease and treatment, the nurse gives emotional support by providing opportunities for the patient and family to verbalize their concerns,have their questions answered, and explore their options.

•Gender: Affects men more than women•Tobacco use•Occupational exposure to industrial chemicals, such aspetroleum products, heavy metals, and asbestos•Obesity•Unopposed estrogen therapy•Polycystic kidney disease These tumors may metastasize early to thelungs, bone, liver, brain, and contralateral kidney. Onequarter of patients have metastatic disease at the time of di-agnosis. A

Many renal tumors produce no symptoms and are discovered on a routine physical examination as a palpable abdominal mass. The classic signs and symptoms, which occur in only 10% of patients, include hematuria, pain, and amass in the flank. 1.) The usual sign that first calls attention to the tumor is painless hematuria, which may be either intermittent and microscopic or continuous and gross. 2.)There may be a dull pain in the back (Flank Pain) from the pressure produced by compression of the ureter, ex-tension of the tumor into the perirenal area, or hemorrhage into the kidney tissue.

The diagnosis of a renal tumor may require intravenous(IV) urography, cystoscopic examination, nephrotomograms, renal angiograms, ultrasonography, or a CT scan.These tests may be exhausting for patients already debilitated by the systemic effects of a tumor as well as for elderly patients and those who are anxious about the diagnosis and outcome. The nurse assists the patient to prepare physically and psychologically for these procedures and monitors care-fully for signs and symptoms of dehydration and exhaustion.

A radical nephrectomy is the preferred treatment if the tumor can be removed. This includes removal of the kidney(and tumor), adrenal gland, surrounding perinephric fat and Gerota's fascia, and lymph nodes. Laparoscopic nephrectomy can be performed for removal of the kidney with as mall tumor. Radiation therapy, hormonal ther-apy, or chemotherapy may be used along with surgery. For patients with bilat-eral tumors or cancer of a functional single kidney,nephron-sparing surgery (partial nephrectomy) may be considered.

The Patient usually has catheters and drains in place to maintain a patent urinary tract, to remove drainage, and to permit accurate measurement of urine output. Because of the location of the surgical incision, the patient's position during surgery, and the nature of the surgical procedure,pain and muscle soreness are common. Pharmacologic management often includes immunosuppressant agents;therefore, patients are monitored for infection. The patient requires frequent analgesia during the post-operative period and assistance with turning, coughing, useof incentive spirometry, and deep breathing to prevent at-electasis and other pulmonary complications. The patientand family require assistance and support to cope with thediagnosis and uncertain prognosis. Monitor for complications: Hemorrhage and shock, adrenal insufficiency, abdominal distention and paralytic ileus, Infection and DVT. Monitor remaining Kidney function.

The nurse teaches the patient to inspect and care for the incision and perform other general postoperative care including activity and lifting restrictions, driving, and pain management. Instructions are provided about when to notify the physician about problems (eg, fever, breathing difficulty, wound drainage, blood in the urine, pain or swelling of the legs). The nurse encourages the patient to eat a healthy diet and to drink adequate liquids to avoid constipation and to maintain an adequate urine volume. E

The patient who has had surgery for renal carcinoma should have a yearly physical examination and chest x-ray, because late metastases are not uncommon

Acute renal failure (ARF) is a rapid loss of renal function due to damage to the kidneys. Depending on the duration and severity of ARF, a wide range of potentially life-threatening metabolic complications can occur, including metabolic acidosis as well as fluid and electrolyte imbalances. Treatment is aimed at replacing renal function temporarily to minimize potentially lethal complications and reduce potential causes of increased renal injury with the goal of minimizing long-term loss of renal function.

Some of the factors may be reversible if identi-fied and treated promptly, before kidney function is im-paired. This is true of the following conditions that re-duce blood flow to the kidney and impair kidney function:(1) hypovolemia; (2) hypotension; (3) reduced cardiacoutput and heart failure; (4) obstruction of the kidney orlower urinary tract by tumor, blood clot, or kidney stone;and (5) bilateral obstruction of the renal arteries or veins.If these conditions are treated and corrected before thekidneys are permanently damaged, the increased BUNand creatinine levels, oliguria, and other signs may be re-versed.Although renal stones are not a common cause of ARF,some types may increase the risk for ARF

The major categories of ARF are (1) prerenal (hypoperfusion of kidney) is the result of impaired blood flow that leads to hypoperfusion of the kidney and a decrease in the GFR, (2) intrarenal (actual damage to kidney tissue) is the result of actual parenchymal damage to the glomeruli or kidney tubules, and (3) postrenal (obstruction to urine flow).