PLANNING, ELIMINATION AND IMPLEMENTATION

Alterations in Elimination  Instrumentation of urinary tract,

cystoscopy, catheterization =  Infectious Complications
urinary tract infection, Complications Infectious of renal
 Elimination refers to the bodily incontinence dysfunction:
process of expelling waste products  Immobilization = kidney stone  Includes: fluid retention, which
from the body by emptying either formation can cause edema in the arms
the bowels or the bladder.  Multiple sclerosis = and legs, hypertension, or fluid
 Some patients feel embarrassed incontinence, neurogenic in the lungs (pulmonary
when they experience alterations in bladder, and other edema)
bowel or bladder habits, resulting to complications  Hyperkalemia, a rapid increase
reluctance of seeking medical help.  Occupational, recreational, or in potassium levels in the blood
 Experiencing an alteration in environmental exposure to that might endanger your life
elimination, either of the bowels or chemicals (plastics, tar, rubber) by affecting how well your
bladder, is a sure sign of an = acute kidney failure heart functions
underlying pathophysiological  Obstetric injury, tumors =  Anemia
process. incontinence  Heart condition
 Parkinson disease =  Bone fracture risk is enhanced
 Planning incontinence and other by weak bones.
 Third part of the nursing process complications  low fertility, erectile problems,
 Planning care for patients with  Pregnancy = proteinuria, or decreased sex desire
altered renal elimination frequent voiding  A central nervous system injury
 Planning on letting the patient  Radiation therapy to pelvis = may result in personality
and family understand the cystitis, fibrosis of ureter, or changes, difficulties focusing,
condition. fistula in urinary tract or convulsions.
 Plan is aimed at identifying the  Recent pelvic surgery =  Reduced immunological
cause, addressing abnormal inadvertent trauma to ureters or response, which increases
signs and symptoms, alleviating bladder your susceptibility to infection
complications like infections,  Sickle cell disease, multiple  An inflammation of the sac-like
fluid and electrolyte imbalance, myeloma = chronic kidney membrane that surrounds your
and blood component disease heart is called pericarditis.
complications.  Spinal cord injury = neurogenic  Problems in pregnancy that put
 Planning on how to achieve bladder, urinary tract infection, both the mother and the fetus
normal renal elimination incontinence at danger
patterns  Strep throat, impetigo, nephrotic  irreversible renal damage that
 Planning on how to educate or syndrome = chronic kidney eventually necessitates dialysis
health teach patient and family. disease or a kidney transplant in order
 Planning on lifestyle changes  Systemic lupus erythematosus to survive
like diet and voiding schedule. = nephritis, chronic kidney
disease Nursing Care Plan:
 Identifying Risk Factors
Risk Factors: - Identifying conditions that are SHORT TERM: After 10 hours of nursing
 Advanced age = incomplete present and health history (past, intervention the client will be able to:
emptying of bladder, leading to present)  Early recognition of infection to
urinary tract infection and - Prioritizing in identifying the allow for prompt treatment.
urosepsis cause will identify the direction  Patient will demonstrate a
 Benign prostatic hyperplasia = for further evaluation and meticulous hand washing
obstruction to urine flow, leading treatment options. technique.
to frequency, oliguria, anuria - Knowing the risks you and your  Alleviate or reduce the
 Diabetes = chronic kidney family may face can help you problems related with the
disease, neurogenic bladder find ways to avoid health infection.
 Gout, hyperparathyroidism, problems. It can also keep you
Crohn’s disease, ileostomy = from fretting over unlikely LONG TERM: After 5 days of nursing
kidney stone formation threats. Knowing the risks and intervention the client will be able to:
 Hypertension = renal benefits of a medical treatment  Client will remain free of
insufficiency, chronic kidney can help you and your doctor infection, as evidenced by
failure make informed decisions. normal vital signs and absence

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 PLANNING, ELIMINATION AND IMPLEMENTATION
of signs and symptoms of the kidneys are responsible for Hypovolemia SHORT TERM: After 9
infection. keeping the body's hours of nursing intervention the client
 Client will maintain or restore homeostasis in check. will be able to:
defenses.  The best treatment for a  Client will verbalize understanding
ADDITIONAL: uremic crisis is careful of causative factors and purpose of
1. Don’t smoke management of fluid balance, therapeutic interventions.
2. Follow instructions on over the which entails thoughtful  Client will demonstrate behaviors to
counter medications assessment of hydration, a monitor and correct deficit, as
3. Maintain a healthy weight fluid treatment plan tailored to appropriate.
4. Don’t smoke the individual patient, repeated  The patient will express a decrease
 Manage your medication and frequent reassessments of in his or her degree of anxiousness.
condition with your doctors’ fluid and electrolyte balance,
Hypovolemia LONG TERM: After 3 days
help and appropriate changes in the
of nursing intervention the client will be
 Fluid Balance treatment plan in response to
able to:
 Fluid balance is the monitoring the patient's rapidly changing
 The patient will demonstrate
of fluid intake and outflow, as clinical situation.
suitable coping strategies
well as their mutual balance.  Metabolic acidosis frequently
 The patient will maintain appropriate
Hypervolemia and hypovolemia results in disorders of sodium,
cardiac output as shown by strong
 Hypervolemia refers to the chloride, potassium, calcium,
peripheral pulses, systolic blood
excessive retention of water and phosphorus, some of
pressure within 20 mm Hg of
and sodium in the extracellular which can be fatal.
baseline, heart rate 60 to 100 beats
fluid (ECF) in almost the same  Nutritional assistance and
per minute with a steady rhythm,
quantities as they do in the metabolic acidosis treatment
urine output 30 ml/hr or higher and
ECF ordinarily. This results in are frequently required.
normal state of consciousness.
an isotonic volume expansion
 The patient will retain optimum
of the ECF. On the other hand, Nursing Care Plan:
tissue perfusion to vital organs as
hypovolemia is the exact Hypervolemia SHORT TERM: After 8
indicated by continuous and steady
opposite. hours of nursing intervention the client
peripheral pulses, vital signs within
The importance of Fluid Balance will be able to:
the patient’s accepted value,
 To prevent dehydration and other  Client will verbalize
balanced input and output, absence
unwelcome consequences in order understanding of individual
of inflammation, normal ABG levels,
to promote a patient's recovery. dietary and fluid restrictions.
and lack of chest discomfort.
 One of the most important  Client will verbalize
components of health is fluid understanding of individual
ADDITIONAL:
balance, which also contributes to dietary and fluid restrictions.
1. Maintenance of fluid volume at a
the body's ability to maintain its  Patient describes symptoms
functional level.
overall level of energy. that indicate the need to
2. Display of normal laboratory values.
 Fluid balance influences the body's consult with health care
3. Demonstration appropriate changes
capacity to fight infections and provider.
in lifestyle and behaviors including
preserve general health.
Hypervolemia LONG TERM: After 3 days eating patterns and food
 The proper fluid balance can help
of nursing intervention the client will be quantity/quality.
prevent common issues like
able to: 4. Reestablishment and maintenance
weariness and headaches.
 Client will demonstrate stable fluid of normal pattern and GI
 Many individuals don't understand
volume as evidenced by stable vital functioning.
how crucial fluid equilibrium is until
signs, balanced intake and output, 5. Diet
they start having issues.
stable weight, and absence of signs 6. Fluid intake
 Lack of the proper fluid balance can
of edema. 7. Medications
cause the body to begin losing
 Patient has clear lung sounds as
water weight, which can result in  Electrolyte Imbalance
manifested by absence of
weight gain and a weaker immune  When taking into account the
pulmonary crackles.
system. results on electrolytes in
 Patient is normovolemic as
patients with altered renal
evidenced by urine output greater
elimination, the importance of
Prevention: than or equal to 30 mL/hr
the kidneys in maintaining the
 Imbalance in fluid, electrolyte,
balance of fluid and electrolytes
and acid-base balance result
in the blood becomes obvious.
from renal dysfunction since
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PLANNING, ELIMINATION AND IMPLEMENTATION
A variety of symptoms can excrete as much sodium as a health care professional who
result from altered levels of usual, thus causing treats people with kidney
electrolytes such potassium, hypernatremia, which is problems or related conditions.
sodium, magnesium, associated with symptoms Iron
phosphorus, and calcium. such as: If you don’t have enough iron in your
 Disorientation body, your health care professional may
Nursing Care Plan: (Plan and goals for
 Muscular twitching prescribe iron supplements, either as a
electrolyte imbalances)
 Hypertension pill or intravenous (IV) infusion. If you’re
 Identify electrolytes that are
 Weakness on dialysis, you may be given an IV iron
affected in altered renal
 Hypermagnesemia supplement during your dialysis
elimination
(magnesium imbalance) treatment. Iron supplements help your
 Identify the normal ranges of
Likewise, renal failure can also body make healthy red blood cells.
these electrolytes
commonly cause an increase
 Identify electrolytes imbalances
in the levels of magnesium in Vitamins
related to altered renal
the blood, due to insufficient Your health care professional may ask
elimination
excretion of the electrolytes. you to take vitamin supplements such as
 Maintaining fluid volume at a
Hypermagnesemia is vitamin B12 or folate—both needed to
functional level
associated with symptoms make healthy blood cells—if your body
 Patient exhibits normal
such as: doesn’t have enough of these vitamins.
laboratory values
 Hypotension
 Demonstrates appropriate
 Reduced heart rate Medicines
changes in lifestyle and
 Cardiac arrest  Your health care professional
behaviors
 Hypocalcemia – (phosphorus may prescribe an
 re-establishing and maintaining
and calcium imbalance) erythropoiesis-stimulating
normal pattern
There is a reciprocal agent (ESA) to treat your
 Hyperkalemia (potassium anemia. ESAs send a signal to
relationship between
Imbalance) your bone marrow to make
phosphorus and calcium, and
The kidneys are primarily more red blood cells.
the levels of both of these
responsible for the excretion of  If you’re on hemodialysis, you
electrolytes can be affected by
potassium from the body and may receive IV or
kidney failure.
alter the extent of potassium subcutaneous ESAs during
It can lead to retention of
excretion according to the your dialysis treatments.
phosphorus and a reduction in
current concentration in the  If you are on peritoneal dialysis
the levels of calcium in the
blood. or do not receive dialysis, your
blood.
An individual with acute kidney health care professional may
Hypocalcemia is associated
failure may not be able to give ESAs as shots and may
with symptoms such as:
excrete as much potassium as teach you how to give yourself
 Muscle spasms
usual, which has the potential these shots at home.
 Seizures
cause hyperkalemia.  Your health care professional
 Arrhythmias
Hyperkalemia is associated may prescribe iron
 Demineralization of bones
with symptoms such as: supplements to help ESAs
 Cardiac failure
 Abdominal cramping work better or to reduce the
 Preventing Anemia
 Fatigue amount of ESAs you need.
Health care professionals first
 Muscle weakness  ESAs may ease your
treat any underlying conditions
 Paralysis symptoms and help you avoid
that may be causing the
 Cardiac arrest blood transfusions NIH external
anemia, such as an iron or
 Hypernatremia (sodium link, but the treatment is not
vitamin deficiency.
Imbalance) right for everyone with CKD
If your anemia is mild and you
The concentration of sodium is and anemia.
have few symptoms, you may
essential for maintaining fluid  Talk with your health care
not need treatment at first.
and acid-base balance and for professional about the risks
Treatments for anemia may
neuromuscular function. and benefits of ESAs and if the
ease your symptoms and
Healthy kidneys alter the medicine is right for you.
improve your quality of life
excretion of sodium in the urine
Your health care professional
to prevent hypernatremia. Blood transfusions
may refer you to a
An individual with altered renal  In some cases, health care
hematologist or a nephrologist,
elimination may not be able to professionals may use blood
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PLANNING, ELIMINATION AND IMPLEMENTATION
transfusions to treat severe Management: -Erythropoietin supplements for anemia
anemia in CKD. -Vitamin D supplements to address
 A blood transfusion can quickly - Work at managing blood sugar levels if weakening bones
increase the number of red you have diabetes. -Phosphate binders to prevent
blood cells in your body and - Follow your doctor’s advice for lowering calcification in the blood vessels
temporarily relieve the blood pressure if you have hypertension. -Following a lower protein diet so your
symptoms of anemia. - Maintain a healthy, balanced diet. kidneys don’t have to work as hard
 Health care professionals may - Don’t use tobacco.
limit or avoid blood - Engage in physical activity for 30 Stage 4
transfusions because they can minutes a day, at least 5 days a week.
sometimes lead to other health - Try to maintain an appropriate weight - GFR= 15-29 mL/min/1.73 m2 \
problems, including the body for your body. - Severe decrease in GFR
may develop antibodies over -Symptoms: Neausea and vomiting,
time that damage or destroy muscle twitches or cramps, shortness of
the donor blood cells and may Stage 2 breath. Complication may include
delay or reduce the possibility anemia, bone disease and high blood
of a future kidney transplant - GFR= 60-89 mL/min/1.73 m2 pressure.
iron NIH external link from - Mild decrease in GFR
transfused red blood cells can - Symptoms: Fatigue, Itching, Loss of Management:
build up in the body and appetite, Sleep problems and weakness.
damage organs, called iron -Work very closely with doctors. In
overload or hemochromatosis. addition to the same treatment as earlier
Management: stages, start discussions about dialysis
Chronic Kidney Disease and kidney transplant should your
-Develop a relationship with a kidney kidneys fail.
-It is an umbrella term that describes specialist. There’s no cure for CKD, but
kidney damage or a decrease in the early treatment can slow or stop Stage 5
glomerular filtration rate (GFR) which progression.
lasts for 3 or more months. Untreated -GFR= <15 mL mL/min/1.73 m2
CKD can result in end-stage kidney -Address the underlying cause. If you -End-Stage kidney disease or Chronic
disease (ESKD). Risk factors includes have diabetes, high blood pressure, or Kidney Disease
diabetes, hypertension, cardiovascular heart disease, follow your doctor’s -Symptoms: Neausea and vomiting,
disease and obesity instructions for managing these muscle twitches or cramps, shortness of
conditions. breath. Complication may include
Pathophysiology anemia, bone disease and high blood
-Maintain a good diet, get regular pressure.
-In the early signs of CKD, there can be exercise, and manage your weight.
significant damage to the kidneys without
signs or symptoms. The pathophysiology Stage 3 Management:
of CKD is thought to be caused by
prolonged acute inflammation that is not - GFR= 30-59 mL/min/1.73 m2 -Hemodialysis
organ specific and thus has subtle - Moderate Decrease in GFR
systemic manifestations. - Symptoms: Backpain, Fatigue, Loss of Albumin-Creatinine Ration (ACR): This
Appetite, persistent itching, sleep test shows if protein is leaking into the
STAGES OF CKD: problems, peripheral edema, frequqnt urine (proteinuria), which is a sign of
urination, and weakness. kidney damage. ACR levels are staged
Stage 1 as follows:
Management:
- GFR is more than 90 mL/min/1.73 m2  A1- lower than 3mg/mmol, a normal to
- Kidney damage with normal or -High blood pressure medications such mild increase
increased GFR as angiotensin-converting enzyme (ACE)  A2- 3–30mg/mmol, a moderate increase
- Symptoms: Typically, there are no inhibitors or angiotensin II receptor  A3- higher than 30mg/mmol, a severe
symptoms when kidneys function at 90 blockers increase
percent or better -Diuretics and a low salt diet to relieve
. fluid retention
-Cholesterol-lowering medications
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 PLANNING, ELIMINATION AND IMPLEMENTATION
Assessment and Diagnostic findings- Epstein-Barr virus, hepatitis B and HIV
The GFR is the amount of plasma filtered virus,
through the glomeruli per unit of time. Assessment and Diagnostic findings  In some patient, antigens outside the
Creatinine clearance are able to clear in body initiate the process, resulting in
a 24-hour period. Normal values differ in  Symptoms are rare early in the disease, antigen-antibody complexes being
men and women. even though the urine usually contains deposited in the glomeruli.
proteins and occasional casts. Renal
Key takeways: insufficiency and associated signs and Clinical manifestations:
symptoms occur late t in the diseases
 There are 5 stages of chronic kidney  Hematuria
disease. Stages are determined with Medical management:  Edema
blood and urine tests and the degree of  Azotemia
kidney damage.  Aggressive hypertensive therapy.  Proteinuria
 While it’s a progressive disease, not  ACE inhibitor alone or in combination  BUN and serum creatinine levels may
everyone will go on to develop kidney with other hypertensive medications. increase as urine output decreases.
failure.  In more severe form, patient my
 Symptoms of early stage kidney disease Primary Glomerular Disease experience headache, malaise and flank
are mild and can be easily overlooked. pain.
That’s why it’s important to have regular  Diseases that destroy glomerulus of the  Older patients may experience
checkups if you have diabetes or high kidney are the third most common cause circulatory overload with dyspnea,
blood pressure, the leading causes of of stage 5 CKD. In these disorders, the engorged neck veins, cardiomegaly and
kidney disease. glomerular capillaries are primarily pulmonary edema.
 Early diagnosis and management of involved. Antigen-antibody complexes  Atypical symptoms include confusion,
coexisting conditions can help slow or form in the blood and become trapped in somnolence and seizures which are
prevent progression. the glomerular capillaries (the filtering often confused with the symptoms of a
portion of the kidneys), inducing an primary neurologic disorder.
Nephrosclerosis inflammatory response. Ig G- the major
immunoglobulin can be found in the Diagnostics:
 This is the hardening of the renal blood-- can be detected in the glomerular
arteries. capillary walls.  Urine tests. A urinalysis can reveal
 Most often due to prolonged abnormalities in your urine, such as large
hypertension and diabetes. Acute Nephritic Syndrome amounts of protein. You might be asked
 Major cause of CKD and ESKD to collect urine samples over 24 hours.
secondary to many disorders.  It is a type of kidney disease with  Blood tests. A blood test can show low
glomerular inflammation. levels of the protein albumin and often
Pathophysiology Glomerulonephritis is the inflammation of decreased levels of blood protein overall
the glomerular capillaries that can occur  Kidney biopsy. Your doctor might
 There are 2 forms of nephrosclerosis: in acute and chronic forms. recommend removing a small sample of
Malignant and Benign. Malignant ia often kidney tissue for testing.
associated with significant hypertension Pathophysiology
(diastolic BP higher than 130 mmHg). Complications:
 It usually occurs in young adults and  Primary Glomerular diseases include
twice as often in men compared to postinfections glomerulonephritis, rapidly  Hypertensive encephalopathy
women. progressive glomerulonephritis,  Heart failure
 Damage is caused by decreased blood membrane proliferative  Pulmonary Edema
flow to the kidney resulting in patchy glomerulonephritis and Membranous
necrosis of the renal parenchyma. glomerulonephritis. Medical Management:
Overtime, fibrosis occurs and glomeruli  Postinfections are caused by group A
are destroyed. beta-hemolytic streptococcal infection of
 It consist primarily of treating symptoms,
 Benign nephrosclerosis refers to renal the throat that precedes the onset of
attempting to preserve kidney function
damage resulting from essential glomerulonephritis by 2-3 weeks,
and treating complications.
hypertension, usually defined as a  It may also follow impetigo and acute
 This includes corticosteroids, managing
diastolic blood pressure in excess of 90 viral infections (upper respiratory tract
hypertensions and controlling proteinuria.
mm Hg. infections, mumps, varicella zoster virus,

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 PLANNING, ELIMINATION AND IMPLEMENTATION
 Penicillin or other antibiotics may be rest periods and encourage the child to • Peripheral neuropathy with diminished
prescribed if residual streptococcal rest when fatigued; plan quiet, age- deep tendon reflexes and neurosensory
infection is suspected. appropriate activities that interest the changes occur late in the disease.
 Dietary protein is restricted when renal child.
insufficiency and nitrogen retention  Preventing infection. Protect the child Assessment and Diagnostic Findings
(elevated BUN) develop. from anyone with an infection: staff, • Urinalysis reveal a fixed specific gravity
 Sodium is restricted when the patient has family, visitors, and other of about 1.010, variable proteinuria, and
hypertension, edema and heart failure. children; handwashing and strict medical urinary casts. As kidney disease
asepsis are essential; and observe for progresses, the GFR falls below
Assessment: any early signs of infection. 50mL/min.
 Chest x-ray may show cardiac
 Edema. Observe for edema when KIDNEY DISEASE enlargement and pulmonary edema.
performing physical examination of the • The electrocardiogram may be normal or
child with nephrotic syndrome. -Kidney disease occurs when the may indicate left ventricular hypertrophy
 Weigh and measure. Weigh the child and kidneys can't eliminate wastes or associated with hypertension and signs
record the abdominal measurements to regulate the body. Impaired renal of electrolyte disturbances.
serve as a baseline. excretion causes compounds typically • Computed tomography (CT) and
 Vital signs. Obtain vital signs, including removed in urine to accumulate in bodily magnetic resonance imaging (MRI)
blood pressure. fluids, altering endocrine, metabolic, scans show a decreased in the size of
 Pitting edema. Note any swelling about fluid, electrolyte, and acid–base balance. renal cortex.
the eyes or the ankles and other Kidney disease is a systemic disease
dependent parts. that leads to other kidney and urinary Medical Management
 Skin. Inspect the skin for pallor, irritation, tract ailments. Each year, renal disease • Weight is monitored daily, and diuretic
or breakdown; examine the scrotal area mortality rise (USRDS, 2015). medications are prescribed to treat fluid
of the male child for swelling, redness, overload.
and irritation. CHRONIC GLOMERULONEPHRITIS • Proteins of high biologic value (dairy
• Glomerulonephritis is inflammation of the products, eggs, meats) are provided to
Nursing Responsibilities: tiny filters in the kidneys (glomeruli). promote good nutritional status.
• Chronic glomerulonephritis may be due • Dialysis is initiated early in the course of
 Monitoring fluid intake and to repeated episodes of acute nephritic the disease to keep the patient in optimal
output. Accurately monitor and document syndrome, hypertensive nephrosclerosis, physical condition, prevent fluid and
intake and output; weigh the child at the hyperlipidemia, chronic tubulointerstitial electrolyte imbalances.
same time every day, on the same scale injury, or hemodynamically mediated
in the same clothing; measure the child’s glomerular sclerosis. NEPHROTIC SYNDROME
abdomen daily at the level of the Clinical Manifestations • Is a type of kidney disease characterized
umbilicus. • The condition may be discovered when by increased glomerular permeability and
 Improving nutritional intake. Offer a hypertension or elevated BUN and is manifested by massive proteinuria.
visually appealing and nutritious diet; serum creatinine levels are detected. • Clinical findings include a marked
consult the child and the family to learn • Loss of weight and strength, increasing increase in protein (particularly albumin)
which foods are appealing to the child; irritability, and an increased need to in the urine (proteinuria), a decreased
serving six small meals my help increase urinate at night (nocturia). albumin in the blood (hypoalbuminemia),
the child’s total intake better. • Headaches, dizziness and digestive diffuse edema, high serum cholesterol,
 Promoting skin integrity. Inspect all skin disturbance are also common. and low-density lipoproteins
surfaces regularly for breakdown; turn • The patient appears poorly nourished, (hyperlipidemia).
and position the child every 2 hours; with a yellow-fray pigmentation of the Clinical Manifestations
protect skin surfaces from pressure by skin and periorbital and peripheral • Soft and pitting edema occurs around the
means of pillows and padding; protect (dependent) edema. eyes (periorbital), in dependent areas
overlapping skin surfaces from rubbing • Retinal findings include haemorrhage, (sacrum, ankles, and hands), and in the
by careful placement of cotton gauze; exudate, narrowed tortuous arterioles, abdomen (ascites).
bathe the child regularly; a sheer dusting and papilledema. • Patient may also exhibit irritability,
of cornstarch may be soothing to the • Anemia causes pale mucous headache, and malaise.
skin. membranes.
 Promoting energy conservation. Bed rest • Cardiomegaly, a gallop rhythm, Assessment and Diagnostic Findings
distended neck veins and other signs • Proteinuria (predominantly albumin)
is common during the edema stage of
and symptoms of heart attack may be exceeding 3.5 g/day is the hallmark of
the condition; balance the activity with
present. the diagnosis of nephrotic syndrome.
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 PLANNING, ELIMINATION AND IMPLEMENTATION
• The urine may also contain increased and creatinine levels, oliguria, and other
white blood cells (WBCs) as well as Medical Management symptoms may be reversed.
granular and epithelial casts. • PKD has no cure, and treatment is
-Some forms of renal stones may raise
• A needle biopsy of the kidney may be largely supportive and includes blood
performed for histologic examination of pressure control, pain control, and the risk of AKI.
renal tissue to confirm the diagnosis. antibiotic agents to resolve infections. -Some hereditary stone diseases,
• Renal replacement therapy is indicated
primary struvite stones, and infection-
Medical Management once the kidney fail.
• Treatment is focus on addressing the • Genetic linkage studies and counselling related urolithiasis associated with
underlying disease state causing may be indicated, particularly when anatomic and functional urinary tract
proteinuria, slowing progression of CKD, screening family members for potential
anomalies and spinal cord injury can
and relieving symptoms. Typical kidney donation
treatment includes diuretic agents for cause recurrent obstruction and crystal-
edema, ACE inhibitors to reduce specific damage to tubular epithelial cells
ACUTE KIDNEY INJURY
proteinuria, and lipid-lowering agents for and interstitial renal cells.
hyperlipidemia. -Acute kidney injury (AKI) causes rapid
loss of kidney function.
POLYCYSTIC KIDNEY DISEASE -Treatment aims to temporarily replace
• Is a genetic disorder characterized by the renal function to limit potentially lethal
growth of numerous fluid-filled cysts in consequences and diminish kidney
the kidneys, which destroy the nephrons. damage sources to minimize long-term
• Cysts develop primarily within your renal function loss.
kidneys, causing your kidneys to enlarge -AKI affects inpatients and outpatients.
and lose function over time. Cysts are AKI is diagnosed when serum creatinine
noncancerous round sacs containing rises by 50% or more above baseline
fluid. The cysts vary in size, and they can (normal is 1 mg/dL).
grow very large. -Normal urine volume may fluctuate. \
• Autosomal dominant PKD is the most  Nonoliguria (>800 mL/day),
common inherited form. Symptoms  Oliguria (0.5 mL/kg/hr),
usually develop between 30 and 40  Anuria (50 mL/day) are possible
years of age, but they can begin earlier, modifications
even in childhood.
• Autosomal recessive PKD is a rare Pathophysiology
inherited form. Symptoms of autosomal - Although AKI and oliguria's etiology
recessive PKD begin in the earliest isn't always known, there is often a
months of life or in utero. specific reason.
Clinical Manifestations
• Signs and symptoms of PKD result from - If discovered and addressed quickly,
loss of renal function and the increasing some of the factors may be reversible.
size of the kidneys as the cysts grow. -The following conditions diminish renal
• Kidney damage can result in hematuria,
blood flow and compromise kidney
polyuria (excessive urine production),
hypertension, development of renal function:
calculi and associated UTIs, and 1. Hypovolemia
proteinuria.
2. Hypotension
• The growing cysts are noted with reports
of abdominal fullness and flank pain 3. Reduced cardiac output
(back and lower sides). 4. Heart failure
5. Kidney or urinary tract obstruction by
Assessment and Diagnostic Findings
• Careful evaluation of family history is tumor, blood clot, or kidney stone, and
necessary. bilateral renal artery or vein obstruction.
• Palpation of the abdomen will often
reveal enlarged cystic kidneys.
• Ultrasound imaging of the kidneys is the -If these disorders are addressed before
preferred technique for diagnosis. kidney damage occurs, elevated BUN

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 PLANNING, ELIMINATION AND IMPLEMENTATION
Classifications of Acute Kidney Injury  A progressive increase in urine output  BUN rises steadily with protein
Acute kidney injury has replaced indicates that glomerular filtration is
acute renal failure because it better recovering.
characterizes this disease in patients  Laboratory values steadily decline.
who encounter mild abnormalities in Normal or high urine output may mask
renal function. AKI is classified by impaired renal function.
severity and result. RIFLE is a 5-point  Due to uremic symptoms, specialist
catabolism, renal perfusion, and protein
system: Risk, Injury, Failure, Loss, and medical and nursing care is still needed.
ESKD  During this period, the patient must be intake.
monitored for dehydration; if dehydrated,  Serum creatinine levels are important for
-Kidney Injuries Prerenal, intrarenal, and uremic symptoms may worsen.
evaluating renal function and disease
postrenal AKI are the main types
-Recovery: development.
(obstruction to urine flow).
 Renal healing can take 3 to 12 months.
-Prerenal AKI: caused by decreased  Patients at risk for hyperkalemia have a
 Laboratory values normalize. Permanent
blood flow that leads to hypoperfusion of declining GFR, oliguria, and anuria.
1% to 3% GFR decline is clinically
the kidney and renal artery stenosis,
insignificant.  Protein catabolism releases cellular
resulting in a drop in GFR.
 Some people with reduced renal function
-Intrarenal AKI is caused by glomeruli or potassium, causing severe hyperkalemia.
and nitrogen retention excrete normal
tubule injury.  Hyperkalemia can cause dysrhythmias
amounts of urine (1 to 2 L/day).
 ATN, or renal tubule damage, is the most
 Nonoliguric kidney injury occurs following and cardiac arrest.
prevalent kind of intrinsic AKI.
exposure to nephrotoxic chemicals,  Normal tissue catabolism, food, GI blood,
 ATN causes intratubular blockage,
burns, trauma, and halogenated
tubular back leak (abnormal filtrate or blood transfusion are potassium
anesthetics.
reabsorption and reduced urine flow),
sources (e.g., IV infusions, potassium
vasoconstriction, and glomerular
Clinical Manifestations penicillin, and extracellular shift in
permeability alterations.
 These processes reduce GFR, cause -Failing renal regulatory mechanisms response to metabolic acidosis).
azotemia, and cause fluid and electrolyte affects almost every body system. The  Progressive metabolic acidosis arises in
imbalances. patient may look sick and lethargic.
 ATN causes CKD, diabetes, heart failure, kidney illness because individuals can't
Dehydration dries skin and mucous
hypertension, and cirrhosis. membranes. Drowsiness, headache, excrete daily metabolic acid-type
muscular twitching, and seizures are compounds.
-Postrenal AKI is caused by renal calculi,
CNS symptoms.
strictures, blood clots, benign prostatic  Normal kidney buffering fails.
hypertrophy, malignancies, and  Serum CO2 and pH levels drop.
Assessment and Diagnostic Findings
pregnancy. GFR drops as tubule
 The AKI patient's urine, kidney shape,  Blood phosphate levels may rise; low
pressure rises.
and lab results are evaluated. calcium levels may be a compensatory
 AKI causes scanty to normal urine flow,
strategy for elevated blood phosphate
-AKI phases Initial AKI, oliguria, diuresis, hematuria, and low-specific gravity urine
levels.
and recovery. (compared with a normal value of 1.010
-The starting period lasts until oliguria
to 1.025).
occurs.
-During oliguria:  Inability to concentrate urine is a
 kidney-excreted chemicals in the blood symptom of tubular injury
rise (urea, creatinine, uric acid, organic
 Prerenal azotemia patients had low urine
acids, and the intracellular cations
[potassium and magnesium]). sodium (less than 20 mEq/L) and normal
 400 mL of urine in 24 hours or 0.5 sediment.
mL/kg/hr is needed to remove typical  Intrarenal azotemia is characterized by
metabolic waste.
 In this phase, uremic symptoms and high urine sodium levels, urinary casts,
hyperkalemia emerge. and cellular debris.

-During Diuresis:  Ultrasound is essential for evaluating

kidney disease patients. Sonograms, CT,
and MRI may show anatomic alterations.
8
 PLANNING, ELIMINATION AND IMPLEMENTATION
 Anemia is frequent in AKI due to o Suppression of thirst, enforced bed pressure, and patient status are
diminished erythropoietin production, rest, lack of drinking water, and used to maintain fluid balance.
uremic GI lesions, shortened RBC disorientation all contribute to an  -Fluid replacement is based on
lifespan, and GI blood loss. elderly patient's failure to ingest parenteral and oral intake and
appropriate fluids, leading to production of urine, gastric
Prevention
dehydration and further weakening drainage, feces, wound drainage,
-Exposure to nephrotoxic agents or
renal function. and perspiration.
environmental contaminants is carefully
o Community-dwelling older persons  -Fluid management also considers
documented.
insensible fluid produced by
commonly have AKI.
-Most drugs' metabolic by-products are metabolism and lost through the
o All drugs must be monitored for side skin and lungs.
eliminated by the kidneys, making them
effects that could cause kidney  -Dyspnea, tachycardia, and swollen
vulnerable to side effects.
neck veins indicate fluid overload.
injury through decreased circulation
-Patients receiving nephrotoxic drugs  -Auscultated lungs for moist
or nephrotoxicity. crackles.
should have their renal function
o Outpatient procedures requiring  -Fluid overload can cause
evaluated frequently.
pulmonary edema, thus it's
-Before and during therapy, kidney fasting or bowel preparation may
important to avoid it.
function must be checked cause dehydration and require close  -Examining the presacral and
-Long-term painkiller use can develop monitoring. pretibial areas daily detects
widespread edema.
renal insufficiency. Medical Management  -To induce diuresis, doctors may
-Analgesics, especially NSAIDs, can  -AKI treatment aims to restore administer mannitol (Osmitrol),
cause interstitial nephritis and papillary furosemide (Lasix), or ethacrynic
chemical balance and prevent
acid (Edecrin).
necrosis. problems until renal tissue and  -IV fluids or blood transfusions can
-NSAID-induced kidney damage is more function may be repaired. restore renal blood flow in prerenal
likely in patients with heart failure or AKI patients.
 -Eliminate the underlying cause,
 -Hypovolemic hypoproteinemic AKI
cirrhosis with ascites. maintain fluid balance, limit fluid may be treated with an albumin
-Age, kidney illness, and several excesses, and provide renal infusion.
nephrotoxic drugs increase kidney  -Hyperkalemia, metabolic acidosis,
replacement therapy as needed.
pericarditis, and pulmonary edema
damage risk. Hospital-acquired AKI is  -Optimizing renal perfusion treats can be prevented by dialysis.
often caused by CIN. prerenal azotemia, while reducing  -Dialysis corrects metabolic
-High-risk patients had creatinine levels blockage treats postrenal failure. imbalances, liberalizes fluid, protein,
above 2 mg/dL. Limiting contrast agents and sodium intake, and reduces
 -Intrarenal azotemia is treated by
bleeding.
and nephrotoxic drugs reduces CIN risk removing causative substances,  -Hemodialysis (a procedure that
(Rank, 2013). managing prerenal and postrenal circulates the patient's blood
-Rehydration with saline is regarded the through an artificial kidney [dialyzer]
failure, and avoiding risk factors.
to remove waste products and
most effective way to prevent CIN.  -Immediately treat shock and excess fluid),.
Gerontologic Considerations infection.  -PD a procedure that uses the
o Half of hospitalized AKI patients are patient's peritoneal membrane as
 -Myoglobinuria (rhabdomyolysis) is
the semipermeable membrane to
over 60. treated in patients with crush exchange fluid and solutes), or a
o Dehydration, intrarenal nephrotoxic injuries, compartment syndrome, or variety of continuous renal
substances (e.g., medicines, replacement therapies (CRRTs)
heat-induced sickness.
(methods used to replace normal
contrast agents), and significant  -Daily body weight, serial kidney function by circulating the
surgery complications induce AKI in measurements of central venous patient's blood through an artificial
older persons pressure, serum and urine kidney [dialyzer]).

concentrations, fluid losses, blood

9
PLANNING, ELIMINATION AND IMPLEMENTATION
Pharmacologic Therapy  Antibiotics (particularly  Blood chemistry tests evaluate salt,
 Hyperkalemia is the most dangerous aminoglycosides), digoxin (Lanoxin), potassium, and water replacement
fluid and electrolyte alteration in phenytoin (Dilantin), ACE inhibitors, needs and over- or underhydration.
kidney patients. and magnesium-containing medicines  After the diuretic phase, the patient is
 The patient is evaluated for often require adjustments. given a high-protein, high-calorie diet
hyperkalemia by serial serum  Diuretics are used to control fluid and urged to gradually resume
electrolyte levels (potassium > 5 volume, but they don't promote AKI activity.
mEq/L), ECG alterations (tall, tented, recovery.
Nursing Management
or peaked T waves), and clinical  Patients with severe acidosis must
AKI patients need careful nursing
status changes. have their arterial blood gases and
care. The nurse monitors problems, treats
 Hyperkalemia causes agitation, serum bicarbonate levels (CO2)
fluid and electrolyte imbalances, assesses
stomach cramps, and diarrhea, monitored. They may need sodium
patient progress and response to
paresthesia, and muscle weakness. bicarbonate therapy or dialysis.
treatment, and gives physical and
 Slurred speech, trouble breathing,  If respiratory issues arise, ventilation
emotional support. The nurse informs
paresthesia, and paralysis are must be used.
family members about the patient's illness,
symptoms of muscle weakness. As  Phosphate-binding drugs (calcium or
explains treatments, and offers emotional
potassium rises, heart and muscle lanthanum carbonate) assist avoid a
support. Although AKI is dangerous, the
function diminish, causing a medical continuous rise in serum phosphate
nurse continues to treat the original
emergency. Oral cation exchange levels by limiting intestinal absorption.
disease (e.g., burns, shock, trauma,
resins (sodium polystyrene sulfonate
Nutritional Therapy obstruction of the urinary tract).
[Kayexalate]) can lower high
 AKI produces nutritional imbalances
potassium levels.
(nausea and vomiting reduce dietary
 Kayexalate exchanges sodium for
intake), decreased glucose usage
potassium in the gut.
and protein synthesis, and
 Sorbitol and Kayexalate might cause
accelerated tissue catabolism.
diarrhea (it induces water loss in the
 If the nitrogen balance is negative,
GI tract). If a Kayexalate retention
the patient loses 0.2 to 0.5 kg daily
enema is given (the colon is the main
(i.e., caloric intake falls below caloric Monitoring Fluid and Electrolyte Balance
potassium exchange site), a balloon
requirements).  Because AKI can induce
rectal catheter may be utilized to aid
 Fluid retention should be suspected if dangerous fluid and electrolyte
retention.
a patient gains or maintains weight or imbalances, the nurse checks
 To promote potassium elimination,
develops hypertension. the patient's serum electrolyte
the patient should hold Kayexalate for
 Nutritional assistance depends on the levels and physical indications
30 to 60 minutes (preferably 6 to 10
origin of AKI, the catabolic response, throughout the condition.
hours).
renal replacement therapy,  IV solutions must be selected
 As a prophylactic against fecal
comorbidities, and nutritional status. based on fluid and electrolyte
impaction, a cleansing enema may be
 Individualized protein replacement condition.
recommended afterward.
helps reduce uremic symptoms. High-  Cardiac and musculoskeletal
 IV dextrose 50%, insulin, and calcium
carbohydrate diets meet caloric function are examined for
replacement may be given if the
needs because they save protein for hyperkalemia.
patient is hemodynamically unstable
growth and healing.  The nurse monitors fluid status
(low blood pressure, mental status
 Bananas, citrus fruits and drinks, and by observing fluid intake (IV
changes, dysrhythmia).
coffee are banned. drugs should be administered in
 Temporary potassium transfer into
 The oliguric phase of AKI lasts 10 to the smallest volume possible),
intracellular space requires
14 days, followed by the diuretic urine output, edema, jugular vein
emergency dialysis.
phase, when urine output increases, distention, heart and breath
 AKI patients must reduce their drug
signifying recovery. sounds, and breathing trouble.
dosages because many are removed
through the kidneys.
10
PLANNING, ELIMINATION AND IMPLEMENTATION
 Weights and I&O data must be nurse to repeat herself. The family should  Coarse, thinning hair
accurate. Indicators of poor fluid be encouraged and helped to touch and  Dry, flaky skin
talk to the patient during these operations.  Ecchymosis
and electrolyte status are
In Intensive care, many of the nurse’s  Gray-bronze skin color
reported immediately to the duties are technical; however, the patient  Pruritus
primary provider. and family’s psychological needs must be  Purpura
met. Continued examination of AKI
 Hemodialysis, PD, or CRRT can  Thin, brittle nails
complications and precipitants is vital.
treat severe fluid and electrolyte Cardiovascular
imbalances. END-STAGE KIDNEY DISEASE OR  Engorged neck veins
CHRONIC KIDNEY DISEASE  Hyperkalemia
Reducing Metabolic Rate  Hyperlipidemia
When a patient has sustained enough
Nurse lowers patient's metabolic  Hypertension
kidney damage to require renal
rate. In the acute stage, bed rest may be  Pericardial effusion
replacement therapy on a permanent  Pericardial friction rub
recommended to minimize exertion and
basis, the patient has moved into the fifth  Pericardial tamponade
metabolic rate. Fever and infection, which  Pericarditis
or final stage of CKD, also referred to as
increase metabolism and catabolism, are  Periorbital edema
ESKD.
treated quickly.  Pitting edema (feet, hands,
sacrum)
Clinical Manifestations
Promoting Pulmonary Function Pulmonary/Respiratory
The severity of these signs and symptoms
 Crackles
To prevent atelectasis and depends in part on the degree of renal  Depressed cough reflex
respiratory tract infection, pulmonary impairment, other underlying conditions,  Kussmaul-type respirations
function is monitored and the patient is and the patient's age.  Pleuritic pain
encouraged to turn, cough, and take deep  Shortness of breath
 Cardiovascula
breaths. Lethargy and drowsiness may  Tachypnea
 r disease is the predominant cause of  Thick, tenacious sputum
impede the patient from moving and
death in patients with ESKD.  Uremic pneumonitis
turning.
 Peripheral neuropathy, a disorder of Gastrointestinal
the peripheral nervous system, is  Ammonia odor to breath (uremic
Preventing Infection fetor)
present in some patients.
Asepsis is necessary with invasive  Anorexia, nausea and vomiting
- Patients complain of severe
lines and catheters to reduce infection and  Bleeding from gastrointestinal
pain and discomfort. tract
metabolism. An indwelling urinary catheter
- Restless leg syndrome and  Constipation or diarrhea
is avoided due to the high risk of UTI, but  Hiccups
burning feet can occur in the
may be needed to adequately monitor fluid  Metallic taste
early stage of uremic peripheral
I&O.  Mouth ulcerations and bleeding
neuropathy.
Hematologic
Note: it is generally thought that
Providing Skin Care  Anemia
the accumulation of uremic
 Thrombocytopenia
Due to edema, the skin may be dry
waste products is the probable
or prone to disintegration. Toxins in the Reproductive
cause.
 Amenorrhea
patient's tissues may cause skin
 Decreased libido
excoriation and itching. Cool baths, regular Be alert for the following signs and
 Infertility
turning, clean, well-moisturized skin, and symptoms:
 Testicular atrophy
clipped fingernails can prevent skin Neurologic
Musculoskeletal
deterioration.  Asterixis
 Bone fractures
 Behavior changes
 Burning of soles of feet  Bone pain
Providing Psychosocial Support  Confusion  Foot drop
AKI requires hemodialysis, PD, or  Disorientation  Loos of muscle strength
CRRT. Length of treatment depends on  Inability to concentrate  Muscle cramps
cause and extent of kidney impairment.  Restlessness of legs  Renal osteodystrophy
Patient and family require help,  Seizures
explanation and support. Primary provider  Tremors
explains treatment to patient and family.  Weakness and fatigue Assessment and Diagnostic Findings
High anxiety and panic may require the Integumentary
11
PLANNING, ELIMINATION AND IMPLEMENTATION
A. Glomerular Filtration Rate  However, in kidney disease, the body  If seizures occur, the onset of the
 As the GFR decreases (due to does not respond normally to the seizure is recorded along with the
nonfunctioning glomeruli). the increased secretion of parathormone; type, duration, and general effect on
creatinine clearance decreases, as a result, calcium leaves the bone, the patient.
whereas the serum creatinine and often producing bone changes and  The primary provider is notified
BUN levels increase. bone disease as well as calcification immediately. IV diazepam (Valium) or
 Serum creatinine is a more sensitive of major blood vessels in the body. phenytoin is usually given to control
indicator of renal function than BUN. seizures.
Complications
 The BUN is affected not only by  The side rails of the bed should be
 Anemia raised and padded to protect the
kidney disease but also by protein
 Bone disease and metastatic and patient.
intake in the diet, catabolism (tissue
vascular calcifications
and RBC breakdown), paren teral d. Erythropoietin
 Hyperkalemia
nutrition, and medications such as  Anemia associated with ESKD is
 Pericarditis, pericardial effusion, and
corticosteroids. treated with erythrocyte stimulating
pericardial tamponade
B. Sodium and Water Retention agents (recombinant human
erythropoietin).
 The kidney cannot concentrate or Medical Management
 Epoetin alfa is administered IV or
dilute the urine normally in ESKD.
subcutaneously three times a week in
 Appropriate responses by the kidney
Pharmacologic Therapy ESKD.
to changes in the daily intake of water
- It may take 2 to 6 weeks for
and electrolytes, therefore, do not a. Calcium and Phosphorus Binders
the hematocrit to increase;
occur.  Hyperphosphatemia and
therefore, the medication is
 Some patients retain sodium and hypocalcemia are treated with
not indicated for patients
water, increasing the risk for edema, medications that bind dietary
who need immediate
heart failure, and hypertension. phosphorus in the GI tract.
correction of severe
 Hypertension may also result from  Binders such as calcium carbonate
anemia.
activation of the renin-angiotensin (Os-Cal) or calcium acetate (PhosLo)
 Adverse effects seen with
aldosterone axis and the concomitant are prescribed, but there is a risk of
erythropoietin therapy include:
increased aldosterone secretion. hypercalcemia.
 Hypertension (especially during
 Other patients have a tendency to  If calcium is high or the calcium-
early stages of treatment),
lose sodium and run the risk of phosphorus product exceeds 55
 Increased clotting of vascular
developing hypotension and mg/dL, a polymeric phosphate binder
access sites
hypovolemia. such as sevelamer hydrochloride
(Renagel) may be prescribed. This  Seizures, and;
 Vomiting and diarrhea may cause
medication binds dietary phosphorus  depletion of body iron stores
sodium and water deple tion, which
worsens the uremic state. in the intestinal tract; one to four  Management involves:
tablets are given with food to be  Adjustment of heparin to prevent
C. Acidosis effective. clotting of the lines during
 Metabolic acidosis occurs in ESKD hemodialysis treatments.
because the kidneys are unable to b. Antihypertensive and Cardiovascular  Frequent monitoring of hemoglobin
excrete increased loads of acid. Agents and hematocrit,
 Decreased acid secretion results from  Hypertension is managed by  And, periodic assessment of serum
the inability of the kidney tubules to intravascular volume control and a iron and transferrin levels. Because
excrete ammonia (NH3-) and to variety of antihypertensive agents. adequate stores of iron are
reabsorb sodium bicarbon ate  Heart failure and pulmonary edema necessary for an adequate response
(HCO3-). There is also decreased may also require treatment with fluid to epoetin alfa, supplementary iron
excretion of phos phates and other restriction, low-sodium diets, diuretic may be prescribed.
organic acids. agents, inotropic agents such as  In addition, blood pressure and
digoxin or dobutamine (Dobutrex), serum potassium level are
D. Calcium and Phosphorus Imbalance and dialysis.
 Serum calcium and phosphate levels monitored to detect hypertension
 The metabolic acidosis of ESKD and increasing serum potassium
have a reciprocal relationship in the usually produces no symptoms and
body: As one increases, the other levels, which may occur with therapy
requires no treat ment; however, and the increasing RBC mass.
decreases. sodium bicarbonate supplements or
 With a decrease in filtration through  The occurrence of hypertension
dialysis may be needed to correct the
the glomerulus of the kidney, there is requires initiation or adjustment of
acidosis, if it causes symptoms.
an increase in the serum phosphate the patient's antihyper tensive
level and a reciprocal or c. Anticonvulsant Agents therapy. Hypertension that cannot
corresponding decrease in the serum  Neurologic abnormalities may occur, be controlled is a contraindication to
calcium level. so the patient must be observed for recombinant erythropoietin therapy.
 The decreased serum calcium level early evidence of slight twitching,
causes increased secretion of headache, delirium, or seizure
Nutritional Therapy
parathormone from the parathyroid activity.
 Dietary intervention includes
glands. careful regulation of protein intake,
12
PLANNING, ELIMINATION AND IMPLEMENTATION
fluid intake to balance fluid losses, Signs and symptoms of  Contain free Hgb that is
sodium intake to balance sodium hyperkalemia (muscle liposome-encapsulated or
losses, and some restriction of weakness, diarrhea, abdominal modified.
potassium. cramps)  Can be stored >1 year
 Adequate caloric intake and Signs and symptoms of access  No blood substitutes have yet to
vitamin supplementation must be problems (clotted fistula or graft, prove to increase survival and
ensured. infection) some have adverse effects
 Protein is restricted because urea, (hypotension)
These signs and symptoms of decreasing
uric acid, and organic acids-the
renal function, in addition to increasing Non-hemorrhagic Hypovolemia
breakdown products of dietary and
BUN and serum creatinine levels, may  Isotonic Solution
tissue proteins-accumulate rapidly
indicate a need to alter the dialysis  Typically given for Iv
in the blood when there is impaired
prescription. The dialysis nurses also repletion during shock and
renal clearance.
provide ongoing education and support at hypovolemia
 Hyperkalemia is usually prevented
each treatment visit.  Pts w/ dehydration and
by ensuring adequate dialysis
treatments with potassium removal IMPLEMENTATION adequate circulatory
and careful monitoring of diet, volume have a free water
medications, and fluids for their Fluid Resuscitation deficit
potassium content.  Hypotonic solutions (5%
Fluid Resuscitation is the rapid dextrose in H2O; 0.45%
Dialysis delivery of fluids to patients who saline) are used.
The patient with increasing symptoms of have acutely impaired
kidney disease is referred to a dialysis and ROUTE AND RATE OF FLUID
hemodynamics.
transplantation center early in the course ADMINISTRATION
Resuscitation fluids are given
of progressive kidney disease. Dialysis is universally to patients in
usually initiated when the patient cannot A. Peripheral IV catheters
hypovolemic shock and lesser
maintain a reasonable lifestyle with - Standard; large (14-16
forms of dehydration, severe
conservative treatment. gauge)
sepsis and septic shock.
B. With an Infusion pump
Patients are given fluid
Nursing Management - 1L crystalloid in 10-15
resuscitation if the MAP <60-65
mins and 1 unit of RBC
mmHg or CVP <8 mmHg
 Nursing care is directed toward: in 20 mins.
Medical Management: C. For pts with exsanguination
 Assessing fluid status and identifying
- CVP catheter; large (8.5
potential sources of imbalance,
Hemorrhage French) more rapid
implementing a dietary program to
1. Crystalloid solutions (IV); infusion
ensure proper nutritional intake within
typically Isotonic (0.9% saline or D. For patients in Shock
the limits of the treatment regimen,
Ringer’s lactate) - Adults are given 1L of
and promoting positive feelings by
 Ringer’s Lactate preferred for crystalloid solution
encouraging increased self-care and
hemorrhagic shock (20mL/kg in children)
greater independence.
 0.9% saline is effective for Acute E. For patients in IV volume
 It is extremely important to provide
Brain Injury. depletion w/o shock
explanations and information to the
2. Colloid Solutions (Albumin, - Receive rate at
patient and family concerning ESKD,
dextran, hydroxyethyl starch) 500mL/hr
treatment options, and potential
 No major advantage to
complications. FLUID IV RESUSCIATAION SURGICAL
Crystalloid solutions
 A great deal of emotional support is MANAGEMENT
 Hydroxyethyl starch increases
needed by the patient and family
the risk of renal injury
because of the numerous changes I. Minimally/moderately invasive
 Dextran & Hydroxyethyl starch
experienced. surgery
can adversely affect coagulation
 Specific interventions, along with - Administer 1-2L of a
when >1.5L is given.
rationale and evaluation criteria, are balanced electrolyte
presented in more detail in the plan of Blood solution for procedures
nursing care for the patient with  1-2 units of type O Rh-negative that will not incur
ESKD. blood significant fluid shift or
 In addition, the patient and family  Patients receiving >6 units may blood loss
need to know what problems to report require replacement of clotting - Typically administered
to the primary provider. These include factors with an infusion of frozen during surgery for 30
the following: plasma. mins up to 2 hrs
Worsening signs and symptoms - Addresses the mild
of kidney disease (nau sea, Blood Substitutes dehydration in an
vomiting, change in usual urine  Can be Hgb-based or ambulatory pts caused
output [if any). ammonia odor perfluorocarbons by preoperative fasting
on breath) w/ less risk for PONV;

13
PLANNING, ELIMINATION AND IMPLEMENTATION
Postoperative Nausea of dialysis solution—water w/ salt and comes into contact w/ capillaries
and Vomiting. other additives—flows. perfusing the peritoneum and
II. Major invasive surgery - The bag is then detached after it is viscera.
-Restive (zero-balance) strategy empty, and the catheter is covered w/  Solutes diffuse from the blood in
 With the expected blood loss of a cap so that the pts can resume the capillaries into the dialysate
<500mL, this strategy is typically usual activities. The dialysis solution and are discarded.
employed to minimize fluid collects toxins and excess fluid from  A transmembrane pressure
administration the body while it is within the gradient applied-osmotically-and
 This approach ONLY replaces stomach. results in ultrafiltration of fluid
the fluid that is lost during the from the capillary tubes into the
surgery dialysate; that fluid too is then
Goals of PD:
 Potential disadvantage: discarded.
 Removes toxic substances and
Hypovolemia may not be
metabolic wastes.
clinically appreciated.
 Reverse the symptoms of
 Hypotension may also occur
uremia
which makes it difficult to
determine the etiology
 A modified approach of this
version was developed in 2014
called “restrictive deferred
hydration”
- Conducted a
randomized trial in 166
pts undergoing radical
cystectomy employing a
restrictive approach  Peritoneal membrane is located
 Reestablish normal fluid and
- Resulted to fewer in the abdomen w/ a rich supply
electrolyte imbalance
complication and a of blood—acts as the semi
 Maintain a positive nitrogen
lower median duration permeable barrier for the
balance
of hospital stay. exchange of waste products to
 Prolong life
III. Goal-directed Fluid Therapy occur within.
 Have the maximum level of
 Typically employed in pts w/  A fluid called dialysate is
quality of life
anticipated bld loss of >500mL inserted in the peritoneal and by
and fluid shifts to achieve a pre- Anatomy and Physiology of the diffusion and active transport the
specified goal Peritoneum waste products are filtered from
 Ensures that intravascular - Refers to the lining of the the blood.
volume status is optimal before abdominal cavity.  Once the session is over the
adding vasopressor therapy to - Consists of 2 layers: Parietal and fluid is drained from the cavity.
achieve optimal BP Visceral layers.
 Disadvantages includes - The parietal, is the anterior wall
requiring invasive monitoring of and undersurface of the
dynamic hemodynamic diaphragm.
parameters - The visceral, covers the
abdominal organs.
ENDPOINT AND MONITORING OF
FLUID RESUSCITATION Transport Processes in PD
 Optimize tissue perfusion - Diffusion is the movement of
solute from an area of higher to
lover concentration.
Complications of IV fluid Resuscitation
- It is created by having a
o Pulmonary edema
concentration gradient on either Catheters
o ARDS
side of a semipermeable Catheters for long term use are
o Hemodilution membrane. usually made of silicone and are radio-
PERITONEAL DIALYSIS - Osmosiis, the movement of h20 opaque to permit visualization of x-ray.
- Is a tx for pts w/ severe CKD that form high lower solute to higher
filters the blood inside the body using solute concentration. These catheters have 3 sections:
the lining of the abdomen or the i. An intraperitoneal section w/
peritoneum The Peritoneal Cavity as a Dialysis numerous openings and an open
- Few weeks before PD, a surgeon System top to let dialysate flow freely.
inserts a soft tube or catheter into the  The same processes are utilized ii. A subcutaneous section that
abdomen passes from the peritoneal
in a peritoneal dialysis except
- During the tx, a catheter is inserted membrane and tunnels through
that dialysate is introduced into
into the abdomen through w/c a bag the peritoneal cavity where it
14
PLANNING, ELIMINATION AND IMPLEMENTATION

Entire exchange time

o 1-4 H ( depending on prescribed
dwell time)

Dextrose Solutions
o Dextrose solutions of 1.5%,
2.3% and a 4.25% are available
in several volumes. From 500
muscle and subcutaneous fat to mL to 3,000 mL, allowing the
the skin dialysate selection to fit the
iii. An external section for patient’s tolerance, size and
connection to the dialysate physiologic need.
section.
TYPES OF PERITONEAL DIALYSIS
Continuous Ambulatory Peritoneal Dialysis
(CAPD)
PRE-INSERTION PREPARATION o Carried out during daytime,
Determine the catheter site. manually by pts or by caregivers
Site: o Dialysis fluid is infused to the
o Midline, 3 cm below the peritoneal cavity
umbilicus o Dwell time for between 3-10 hrs
o On a line, halfway between the o Most suitable for pts whose
umbilicus and anterior superior membrane transport solutes at a
iliac spine slow to average rate.
o Left lateral side is preferred as it
avoids caecum Automated Peritoneal Dialysis
o Is performed through a cycler
PROCEDURE machine.
Patient Preparations o During the night when the pt is
o Explain the procedure & obtain asleep
informed consent.
o Baseline vital signs, wt, serum Continuous cycling peritoneal dialysis
electrolyte levels are recorded. o Pt carries PD solution in the
o Assess pts anxiety about the abdominal cavity through the
procedure. day but performs no exchanges
o Broad spectrum antibiotics o At bedtime, patient hooks up to
prophylactically. the cycler, which drains and
refills the abdomen with solution
Equipment Preparation three or,more times in the
o Assemble the equipment needed course of the night.
o Check physician’s order for the
Intermittent Peritoneal Dialysis (PD)
concentration of dialysate and
o This is offered to pts in a
medications to be added
temporary basis when their bp is
o Heparin: to prevent clotting
low or in a children with acute
o KCl: to prevent hypokalemia
renal failure to tide over a crisis.
o Antibiotics: For peritonitis
o Performed for a short period of
o Insulin: for diabetic patients
12-24 hrs. 2-3 times weekly.
Warm the dialysate solution to body o Common routine hourly
temperature: exchange consts of 10 minutes
o To prevent pt discomfort and infusion. 30 mins dwell time and
abdominal pain a 20-minutes drain time
o To dilate the vessel of Nocturnal Intermittent PD
peritoneum o Pt drains out fully at the end of
o Dry heating should be done the cycling period, so the
o Too cold solution causes pain, abdomen is dry all day.
cramping and reduce clearance o Clearances are lower on NIPD.
Drainage Fluid
o Colorless or straw-colored
o Should not be cloudy
o Bloody drainage may be seen in
the first few exchanges

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