NCLEX: Renal and urologic disorders

Nursing diagnoses

When caring for patients with renal or urologic disorders, you’ll find that several nursing diagnoses can be commonly used. These nursing diagnoses appear here, along with appropriate nursing interventions and rationales.

 

Deficient fluid volume

Related to actual loss, Deficient fluid volume can be associated with dialysis, ingestion of large amounts of diuretics, renal failure, or metabolic acidosis.

Expected outcomes
• Patient exhibits normal skin color and temperature.
• Patient produces adequate urine volume.
• Patient’s urine specific gravity remains between 1.005 and 1.030.

Nursing interventions and rationales
• Monitor and record vital signs every 2 hours, or as often as necessary until stable. Then monitor and record vital signs every 4 hours. Tachycardia, dyspnea, or hypotension may indicate deficient fluid volume or electrolyte imbalance.
• Measure intake and output every 1 to 4 hours. Record and report significant changes. Include urine, stools, vomitus, wound drainage, and any other output. Low urine output and high specific gravity indicate hypovolemia.
• Administer fluids, blood or blood products, or plasma expanders to replace fluids and whole blood loss and to promote fluid movement into vascular space. Monitor and record effectiveness and any adverse effects.
• Weigh the patient at the same time daily to give more accurate and consistent data. Weight loss or gain is a good indicator of fluid status.
• Assess skin turgor and oral mucous membranes every 8 hours to check for dehydration. Give meticulous mouth care every 4 hours to avoid dehydrating mucous membranes.

Excess fluid volume

Related to compromised regulatory mechanisms, Excess fluid volume can be associated with acute glomerulonephritis, acute or chronic renal failure, pyelonephritis, or other renal diseases.

Expected outcomes
• Patient’s blood pressure is no higher than 130/80 mm Hg.
• Patient demonstrates no signs of hyperkalemia on electrocardiogram (ECG).
• Patient maintains fluid intake as directed by practitioner.

Nursing interventions and rationales
• Monitor blood pressure, pulse rate, cardiac rhythm, temperature, and breath sounds at least once every 4 hours; record and report changes. Changed parameters may indicate altered fluid or electrolyte status.

• Carefully monitor intake, output, and urine specific gravity at least once every 4 hours. Intake greater than output and elevated specific gravity may indicate fluid retention or overload.
• Monitor BUN, creatinine, electrolyte, and hemoglobin (Hb) levels, as well as hematocrit (HCT). BUN and creatinine levels indicate renal function; electrolyte levels, Hb levels, and HCT reflect fluid status.

Weighing in

• Weigh the patient daily before breakfast, as ordered, to provide consistent readings. Check for signs of fluid retention, such as dependent edema, sacral edema, or ascites.
• Give fluids as ordered. Monitor I.V. flow rate carefully because excess I.V. fluids can worsen the patient’s condition.
• If oral fluids are allowed, help the patient create a schedule for fluid intake. Patient involvement encourages compliance.
• Assess skin turgor to monitor for dehydration.

Urge urinary incontinence

Related to decreased bladder capacity, Urge urinary incontinence may be associated with such conditions as acute bladder infection, bladder obstruction, and interstitial cystitis.

Expected outcomes
• Patient has decreased frequency of incontinence episodes.
• Patient states increased comfort.
• Patient demonstrates skill in managing incontinence.

Nursing interventions and rationales
• Observe voiding pattern and document intake and output to ensure correct fluid replacement therapy and provide information about the patient’s ability to void adequately.
• Provide appropriate care for existing urologic conditions, monitor progress, and report the patient’s responses to treatment. The patient should receive adequate and qualified care as well as understand and participate in care as much as possible.
• Unless contraindicated, maintain fluid intake of 3 qt (3 L)/day to moisten mucous membranes and ensure hydration; limit the patient to 5 oz (150 ml) after supper to reduce the need to void at night.
• Explain the urologic condition to the patient and his family; include instructions on preventive measures and the established bladder schedule.

Common renal and urologic disorders

This section discusses the most common renal and urologic disorders, including their causes, assessment findings, diagnostic tests, treatment, nursing interventions, patient-teaching recommendations, and evaluation criteria.

Acute poststreptococcal glomerulonephritis

Acute poststreptococcal glomerulonephritis is a bilateral inflammation of the glomeruli, commonly following a streptococcal infection. It’s most common in boys ages 3 to 10 but can occur at any age. Up to 95% of children and up to 70% of adults fully recover; the rest may progress to chronic renal failure within months.

What causes it
Causes of the disorder include:
• streptococcal infection of the respiratory tract
• impetigo
• immunoglobulin (Ig) A nephropathy (Berger’s disease)
• lipoid nephrosis.

Pathophysiology
Acute poststreptococcal glomerulonephritis results from entrapment and collection of antigen-antibody complexes in the glomer ular capillary membranes after infection with group A hemolytic streptococci. The antigens stimulate the formation of antibodies. Circulating antigen-antibody complexes become lodged in the glomerular capillaries.

Complex process

Glomerular injury occurs when complexes initiate the release of immunologic substances that break down cells and increase membrane permeability. The severity of glomerular damage and renal insufficiency depends on the size, number, location, duration of exposure, and type of antigen-antibody complexes.

What to look for
Typically, this disorder begins 1 to 3 weeks after untreated pharyngitis. The most common symptoms are:
• mild to moderate edema
• azotemia
• hematuria (smoke- or coffee-colored urine)

• oliguria (less than 400 ml/day)
• fatigue
• mild to severe hypertension
• sodium or water retention.

What tests tell you
• Blood studies reveal elevated electrolyte, BUN, and creatinine levels.
• Urine studies reveal RBCs, WBCs, mixed cell casts, and protein.
• Elevated antistreptolysin-O titers (in 80% of patients), elevated streptozyme and anti-DNase B titers, and low serum complement levels verify recent streptococcal infection.
• A throat culture may also show group A beta-hemolytic streptococci.
• KUB X-rays show bilateral kidney enlargement.

How it’s treated
The goals of treatment are the relief of symptoms and the prevention of complications. Vigorous supportive care includes bed rest, fluid and dietary sodium restrictions, and correction of electrolyte imbalances (possibly with dialysis, although this is rarely necessary). Therapy may include diuretics such as furosemide (Lasix) to reduce extracellular fluid overload and an antihypertensive such as hydralazine. The use of antibiotics to prevent secondary infection or transmission to others is controversial.

What to do
• Promote bed rest during the acute phase. Allow the patient to resume normal activities gradually as symptoms subside; the disorder usually resolves within 2 weeks.
• Monitor vital signs, electrolyte values, intake and output, and daily weight.
• Assess renal function daily through serum creatinine and BUN levels, and urine creatinine clearance.
• Watch for and immediately report signs of acute renal failure (such as oliguria, azotemia, and acidosis).

Keep the calories coming

• Consult the dietitian to provide a diet high in calories and low in protein, sodium, potassium, and fluids.
• Evaluate the patient. After successful treatment, the patient has normal serum creatinine and BUN levels and a normal urine creatinine clearance and is free from complications. He’s prepared to follow a diet high in calories and low in protein and obtain the necessary follow-up examination.

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Acute pyelonephritis

One of the most common renal diseases, acute pyelonephritis is a sudden bacterial inflammation. It primarily affects the interstitial area, the renal pelvis and, less commonly, the renal tubules. With treatment and continued follow-up care, the prognosis is good. Extensive permanent damage is rare.

What causes it
Causes of chronic pyelonephritis include:
• infection
• hematogenous or lymphatic spread.

Factoring in risk

Risk factors include:
• diagnostic and therapeutic use of instruments, as in catheterization, cystoscopy, or urologic surgery
• inability to empty the bladder

• urinary stasis
• urinary obstruction
• sexual activity (in women)
• use of diaphragms and condoms with spermicidal gel
• pregnancy
• diabetes
• other renal diseases.

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Pathophysiology
Typically, the infection spreads from the bladder to the ureters, then to the kidneys. Bacteria refluxed to intrarenal tissues may create colonies of infection within 24 to 48 hours.

What to look for
Signs and symptoms of pyelonephritis include:
• urinary urgency and frequency
• burning during urination
• dysuria, nocturia, and hematuria
• cloudy urine with an ammonia or fish odor
• temperature of 102º F (38.9º C) or higher
• shaking chills
• flank pain
• anorexia
• general fatigue.

What tests tell you
• Urinalysis reveals pyuria and, possibly, a few RBCs; low specific gravity and osmolality; slightly alkaline pH; and, possibly, proteinuria, glycosuria, and ketonuria.
• Urine culture reveals more than 100,000 organisms/μl of urine.
• KUB radiography may reveal calculi, tumors, or cysts in the kidneys and the urinary tract.
• Excretory urography may show asymmetrical kidneys.

How it’s treated
Treatment centers on antibiotic therapy appropriate to the specific infecting organism, after identification by urine culture and sensitivity studies.

A broader approach

When the infecting organism can’t be identified, therapy usually consists of a broad-spectrum antibiotic. If the patient is pregnant, antibiotics must be prescribed cautiously. Analgesics are also appropriate. Signs and symptoms may disappear after several days of antibiotic therapy. Although urine usually becomes sterile within 48 to 72 hours, the course of such therapy is 10 to 14 days. Follow-up treatment includes reculturing urine 1 week after drug therapy stops, then periodically for the next year to detect residual or recurring infection. Most patients with uncomplicated infections respond well to therapy and don’t suffer reinfection. Infection from obstruction or vesicoureteral reflux may not respond as well to antibiotics. The patient may then need surgery to relieve the obstruction or correct the anomaly. Patients at high risk for recurring UTIs and kidney infections, such as those using an indwelling urinary catheter for a prolonged period and those on maintenance antibiotic therapy, require long-term follow-up care.

What to do
• Administer antipyretics for fever.
• Encourage increased fluid intake to achieve a urine output of more than 2,000 ml (2 qt)/day. Don’t encourage intake of more than 2 to 3 qt (2 to 3 L) because this may decrease the effectiveness of antibiotics.
• Evaluate the patient. The recovering patient has a normal temperature, has no urinary discomfort or flank pain, forces fluids, and takes antibiotics as prescribed.

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Acute renal failure

Acute renal failure (ARF) is the sudden interruption of kidney function from obstruction, reduced circulation, or renal parenchymatous disease. It’s usually reversible with treatment. Otherwise, it can progress to end-stage renal disease, uremic syndrome, or death.

What causes it
ARF may be classified as prerenal, intrarenal, or postrenal. Each type has separate causes. (See Causes of ARF.)

Pathophysiology
Prerenal failure results from conditions that damage blood flow to the kidneys (hypoperfusion). When renal blood flow is interrupted, so is oxygen delivery. The ensuing hypoxemia and ischemia can rapidly and irreversibly damage the kidney. The tubules are most susceptible to the effects of hypoxemia. Intrarenal failure results from damage to the filtering structures of the kidneys. Causes of intrarenal failure are classified as nephrotoxic, inflammatory, or ischemic. When the damage is caused by nephrotoxicity or inflammation, the delicate layer under the epithelium (the basement membrane) becomes irreparably damaged, typically leading to chronic renal failure. Severe or prolonged lack of blood flow by ischemia may lead to renal damage (ischemic parenchymal injury) and excess nitrogen in the blood (intrinsic renal azotemia). Postrenal failure is a consequence of bilateral obstruction of urine outflow. The cause may be in the bladder, ureters, or urethra.

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What to look for
Signs and symptoms of acute renal failure include:
• oliguria (usually the earliest sign)
• anorexia
• nausea and vomiting
• diarrhea or constipation
• stomatitis
• GI bleeding
• hematemesis
• dry mucous membranes
• uremic breath
• hypotension.

What tests tell you
• Blood studies reveal elevated BUN, creatinine, and potassium levels as well as low pH, bicarbonate levels, Hb levels, and HCT.
• Urine specimens show casts, cellular debris, decreased specific gravity and, in glomerular diseases, proteinuria and urine osmolality close to serum osmolality. Urine sodium level is less than 20 mEq/L if oliguria results from decreased perfusion; greater than 40 mEq/L if it results from an intrinsic problem.
• A creatinine clearance test measures the GFR and is used to estimate the number of remaining functioning nephrons.

Picturing the problem

• Other studies include ultrasonography of the kidneys, renal scan, CT scan, retrograde pyelography, MRI, and plain films of the abdomen, kidneys, ureters, and bladder.

How it’s treated
The major goals for ARF are to reestablish effective renal function, if possible, and to maintain the constancy of the internal environment despite transient renal failure. Supportive measures include a diet high in calories and low in protein, sodium, and potassium, with supplemental vitamins and restricted fluids. Meticulous electrolyte monitoring is essential to detect hyperkalemia.
If hyperkalemia occurs, acute therapy may include dialysis, sodium bicarbonate, and hypertonic glucose and insulin infusions, all administered I.V. Sodium polystyrene sulfonate (Kayexalate) can be administered by mouth or by enema to remove potassium from the body. If these measures fail to control uremic symptoms, the patient may require hemodialysis or peritoneal dialysis.

What to do
• Measure and record intake and output, including all body fluids, such as wound drainage, nasogastric output, and diarrhea. Weigh the patient daily.
• Assess HCT and Hb level and replace blood components as ordered. Don’t use whole blood if the patient is prone to heart failure and can’t tolerate extra fluid volume.
• Monitor vital signs.
• Watch for and report any signs or symptoms of pericarditis (such as pleuritic chest pain, tachycardia, and pericardial friction rub), inadequate renal perfusion (such as hypotension), or acidosis.
• Maintain the patient’s nutritional status. Provide a high-calorie, low-protein, low-sodium, and low-potassium diet, with vitamin supplements. Give the anorectic patient small, frequent meals.

Days with malaise

• Maintain electrolyte balance. Strictly monitor potassium levels. Watch for symptoms of hyperkalemia (such as malaise, anorexia, paresthesia, and muscle weakness) and ECG changes (including tall, peaked T waves; widening QRS segment; and disappearing P waves) and report them immediately. Don’t administer medications that contain potassium.
• Assist with peritoneal dialysis or hemodialysis as needed.
• Evaluate the patient. After successful treatment, the patient has no weight gain, has stable vital signs, exhibits no complications or signs of infection, talks openly about his illness, and has normal blood values. The patient is prepared to follow his diet and any necessary medical regimen at home.

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Chronic glomerulonephritis

Chronic glomerulonephritis, a slowly progressive, noninfectious disease, is characterized by inflammation of the renal glomeruli. It remains subclinical until the progressive phase begins. By the time it produces symptoms, it’s usually irreversible. It results in eventual renal failure.

What causes it
• Membranoproliferative glomerulonephritis
• Membranous glomerulopathy
• Focal glomerulosclerosis
• Poststreptococcal glomerulonephritis

Blame the system

Systemic causes include:
• lupus erythematosus
• Goodpasture’s syndrome
• hemolytic uremic syndrome.

Pathophysiology
The inflammation of the glomeruli that occurs with this condition results in sclerosis, scarring, and eventual renal failure.

What to look for
This disease usually develops insidiously and without producing symptoms, commonly over many years. At any time, however, it may suddenly become progressive. The initial stage includes:
• nephrotic syndrome
• hypertension
• proteinuria
• hematuria.
Late-stage findings include azotemia, nausea, vomiting, pruritus, dyspnea, malaise, fatigability, mild to severe anemia, and severe hypertension, which may cause cardiac hypertrophy, leading to heart failure.

What tests tell you
• Urinalysis reveals proteinuria, hematuria, cylindruria, and RBC casts.
• Blood tests reveal rising BUN and serum creatinine levels, indicating advanced renal insufficiency.
• X-ray or ultrasound examinations show small kidneys.

How it’s treated
Treatment is essentially nonspecific and symptomatic. The goals are to control hypertension with antihypertensives and a sodium-restricted diet, correct fluid and electrolyte imbalances through restrictions and replacement, reduce edema with diuretics such as furosemide, and prevent heart failure. Treatment may also include antibiotics (for symptomatic UTIs), dialysis, or transplantation.

What to do
• Provide supportive patient care, focusing on continual observation and sound patient teaching.
• Monitor vital signs, intake and output, and daily weight to evaluate fluid retention. Observe for signs of fluid, electrolyte, and acid base imbalances.
• Consult the dietitian to plan low-sodium, high-calorie meals with adequate protein.
• Administer medications as ordered, and provide good oral hygiene and skin care (because of pruritus and edema).
• Evaluate the patient. After successful treatment, the patient has normal vital signs and hasn’t gained weight after complying with his diet and medication regimen. He shows no signs of complications, is prepared to follow dietary and medical regimens at home, openly expresses his feelings about his illness, and exhibits good understanding of necessary procedures.

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