UNIT I NURSING MANAGEMENT OF

PATIENT WITH UROLOGICAL

DISORDERS
Structure
1.0 Objectives
1.1 Introduction
1.2 Related Anatomy and Physiology of the Urinary System
1.3 Problems Related to Micturation
1.3.1 Urinary Incontinence
1.3.2 Urinary Retention
1.4 Infections, Inflammatory Conditions and Trauma
1.4.1 Urethral
1.4.2 Bladder
1.5 Common Renal Disorders
1.5.1 Acute Renal Failure
1.5.2 Chronic Renal Failure
1.5.3 Renal Carcinoma
1.6 Medical Management
1.6.1 Related Pharmacology
1.7 Renal Surgery
1.7.1 Renal Transplantation
1.8 Benign Prostatic Hypertrophy
1.9 Let Us ~ 6 Up
n
1.10 Key Words
1.11 Answers to Check Your Progress
1 .I2 Further Readings

1.0 OBJECTIVES
After completing this unit. you should be able to:
define acute renal failure and identify the categories of acute renal failure:
identify the clinical manifestatio~lsand the major medical therapies for acute
renal failure;
list the clinical manifestation medical and nursing management of patients
with chronic renal failure;
differentiate between acute and chronic renal failure;
identify the benefits and hazards of peritoneal and hemodialysis and describe
the nurse's responsibilities;
describe the nursing care of a patient with acute renal failure;
identify the benefits. risks and complications associated with renal
transplantation;
Urology, Burns, Plastics and list the signs and symptoms of rejection of the graft and discuss the different
Reconstructive Surgery.
Endocrinological, Immunological treatment regimens, if it occurs; and
and Trauma Nursing
describe preoperative and postoperative nursing assessment of the renal
transplant patient.

1 INTRODUCTION
In this unit you will learn about nephrological nursing particularly on various
aspects of acute and chronic renal failure, peritoneal and hemodialysis and renal
transplantation.

Renal failure indicates a state of total or nearly total loss of the kidney's ability to
excrete waste products and to maintain fluid and electrolyte balance. Renal failure
may be acute in onset or may develop slowly and progressively over a course of
several years. When renal failure occurs suddenly. as within a few days,
biochemical changes are often dramatic and the person has little time to adjust to
these changes. Hence, placement in the critical care areas is necessary. When renal
failure occurs as the end result of chronic kidney illness, control of symptoms and
preservation of functional abilities are achievable goals. As renal function
continues to deteriorate, dialysis and transplantation become necessary for
supporting life.

1.2 R E L A T ~ DANATOMY AND PHYSIOLOGY OF

THE URTNARY SYSTEM
The urinary system consists of two kidneys, two uretns, the urinary bladdcr and
the urethra. (Fig. 1.1). The functional unit of the kidney is the nephron (Fig. 1.2).
There are approximately 1 million nephrons. The part of the nephrone involved in
the process of urine formation are the glomerulus and Bowman's capsule, the
proximal convoluted tubule, the loop of Henle, the distal con\oluted tubule and
the collecting tubules. The kidney are segmented into two distinction regions the
cortex and medeulla (Fig. 1.3). Bowman's capsule and the convolut~dtubules are
located within the cortex, whereas the loop of Henle and the collecting tubules are
the medulla. As urine is formed, it drains into the convoluted tubules and flows
into the collecting tubules and finally into the renal pelvis.

Inferior vena cava

Renal vein Abdominal aorta

Ureter

Iliac vein

Urethra
7
Fig. 1.1: Organs and structures of urinary system
 Nursing Management of
Patient with ~rolog'ical
Bowman's Disorders
capsule
Glomerular
filtrate

I '~roximal tubule
w lfi
Distal tubule'

Loop of Henle
Fig. 1.2: Nephron

Cortex

Medulla (pyramid)
Major calyx
Interlobular vein Renal sinus
and artery
Renal artery
Renal column
Renal vein
Fibrous caps~ile Renal pelvts
Minor calyx
Ureter

Fig. 1.3: Frontal section of kidney

Functions of Kidneys
a Ultra filtration: As the blood through the capillary bed of the glomerulus,
fillration of the plasma occurs. The volume of glomerular filtrate is 125 mll
minute (IS0 Ll24 hours) approximately.
a Reabsorptions: 99 per cent of the glomerular filtrate is reabsorbed by the
kidney tubules.
a Excretions of urine and metabotic wastes: Kidneys excrete 1500 ml of urine
(average) in a day. Alongwith urine kidneys also excrete metabolic wastes
such as urea, creatinine and also drugs.
a Electrolyte balance: Electrolyte balance is achieved mainly in the distal and
collecting tubules of the nephron.
Acid base balance: Acid base balance is maintained potentially through the
reabsorption of bicarbonate in the proximal tubule, Regeneration of
bicarbonates and secreat not Hydrogen ions into the urine.
Urology, Burns. Plastics and Regulation of blood pressure: Kidney regulate blood pressure by regulation
Reconstructive Surgery,
Endocrinological, ln~munological of plasma volume, aldosterone, renin-angiotensin-aldosterone system and
and Trauma Nursipg prostaglandins secretion of ejthropoietin.
Kidney produce e~ythropoietinin response to decreased oxygen delivery: The
erythropoietin stimulate bone marrow to produce RBCs (erythropoiesis).
Regulation of phosphate and calcium: Kidneys control calcium and phosphate
metabolism.

Ureters
The Ureters arise as extensions of the pelvis and empty into the bladder in an
area known as the trigone (Fig. 1.4). The function of the ureters is to propel urine
from the renal pelvis to the bladder.
Umbilical llgament
a------

Mucosa af bladder

Ureteral or~fice Muscularts of bladder

Trigone

Prostate gland- -_7

Urethral crest
Prostatlc urethra Opening of prostate
duct

Fig. 1.4: Interior of urinary bladder and some associated structures. (From Me-Clintic,
J.R., Human Anatomy, St Louis, 1983, The CV Mosby Co.)
Urinary Bladder
Located behind the symphysis pubis in the pelvic regions, serves as a collecting
bag for the urine. The mucous membrane arranged in folds c~illedrugae together
nith the elasticity of the muscular walls, can distend the bladder considerably tn
hold large amounts of urine. The external urinary sphincter is formed by the
encircling skeletal muscle at the base of the bladder. The urethral sphincter
operates under voluntary control.
Cheek Your Progress I
I) Name the functional unit of kidney.

List any four functions of kidney.

...................................................................................................................................
 Nursing Management of
1.3 PROBLEMS RELATED TO MICTURATION Patient with Urokgical
Disorders
I
The problems in micturation leads to different disorders which are as follows:
l

I
a Urinary incontinence
a Urinary retention

1.3.1 Urinary Incontinence

Definition
I It is the involuntary or uncontrolled loss of urine from the bladder. It may be
temporary or permanent.
Incidence
It is common in all age groups but is particularly common in elderly. Age-related
, changes in the urinary tract predispose the older person to incontinence.
Risk Factors
a Age-common in old age.
a Gender-common in women.
More No. of previous deliveries predispose to urinary incontinence.
a Urinary tract infection
Menopause
Genitourinary surgery
a Chronic illness
Various drugs can also lead to incontinence, e.g., anticholinergics, sedatives,
analgesics, diuretics, etc.
Complications
Rashes
a Pressure ulcers
a Skin and urinary tract infections
a Restrictions of activity

w
s
a) Stress incontinence
b) Urge incontinence
C) Overflow incontinence
d) Functional incontinence

e) Mixed forms of urinary incontinence.

Surgical Approaches
Surgical correction may be indicated for stress incontinence. There is wide range
of surgical procedures e.g. vaginal repair, abdominal suspension of bladder,
elevation of bladder neck. A modified artificial sphincter may be used as a self
Urology, Burns, Plusties and regulating pressure mechanism to close the urethra. Application of electronic
Reconstructive Surgery,
Endoerinologkul, Immunological stimulation to the pelvic floor by means of a miniature pulse generator with
and 'Ttauma Nursing electrodes mounted on intra-anal plug.
Management
. Collect thorough history of the problem.
Promote environment that ensures toileting effectively.
Place bad pan or urinal within easy reach.
Leave light on in patient's room.
Help to select clothing that facilitates quick dressing and undressing
Instructing and encouraging patient for pelvic floor exercises.
Bladder training.
Increase fluid intake.

1.3.2 Urinary Retention

Definition
Urinary retention refers to the inability to urinate despite the patient's urge or
desire to do so. Chronic retention will often lead to overflow incontinence (due
pressure of retained urine in the bladder) or residual urine. Residual urine refers
urine that remains in the bladder after voiding.
Risk Factors
Post-operative patient with perheal or anal regions that resulted in reflex
spasm of the sphincters.
Acutely ill patients
Elderly patients
Bed ridden patients.
Causes
Anxiety
Prostatic enlargement
Urethral pathology (infection, tumour, calculus).
Trauma
Neurogenic bladder dysfunction
Some drugs like anticholinergics, antispasmodics, antidepressants,
antihypertenives, etc.
Complications
Infection due to overdistention of bladder
Cornpromised blood supply to the bladder wall.
Proliferation of bacteria
Impaired renal function e.g. due to obstruction of urinary &act.
 Nursing Interventions Nursing Management of
Patient with Urological
Disorders
e Encourage voiding by providing privacy.
e Assist patient to bathroom or commode in order to provide a more natural
setting for voiding, or allowing the male patient to stand beside the bed
while using urinal.
e Provide warmth to relax sphincters e.g. by sitz bath, warm compresses to
perineum, showers, etc.
a Give patient hot tea or drink.
r Provide psychological reassurance and support.
a Catheterization, if required can be done.

1.4 INFECTIONS, INFLAMMATORY

CONDITIONS AND TRAUMA
Infections, Inflanatory conditions and trauma may lead to different disorder which
are discussed and explained below:

1.4.1 Urethral
Urethritis
Urethritis refers to the inflammation of urethra. The distal position of urethra is
frequently colonized with bacteria following colonization of vaginal introitus. A
defect of the mucosa of the urethra, vagina or external genitalia may allow
organisms to adhere and colonize at periurethral sites and to invade the bladder.

Clinical Manifestations
Signs and symptoms of Urinary Tract Infection (UTI) cover a broad range.
Frequently, the patient is asymptomatic and is found to have bacteria in the urine
(bacteriuria) while undergoing a routine physical examination. It may include
I
frequent pain and burning on urination, sometimes accompanied. by spasms in the
region of bladder and suprapubic area. Haematuria and back pain may also be
present.
1
Acute urethritis due to sexually. transmitted organisms (e.g. chlamydia trachomatis,
Neisseria gonorrhoea and herpes simplex) or acute vaginitis infections (caused by
Trichomonas or Candida) may be responsible for symptoms similar to those of
UTI. requiring evaluation to distinguish between them. These are dysuria,
haematuria, fever chills, nausea, vomiting, piuritus, edema, weight loss and
shortness of breath, etc.
!
Management
The ideal treatment of urethral infections is antibacterial therapy that eradicates
bacteria from the urinary tract with minimal effects on focal and vaginal flora,
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thereby minimizing the incidence of vaginal yeast infections. Common drugs used
are anti-emetics, antibiotics, etc. depending on the symptoms present in-patient.
I

A caruncle is a small red extremely vascular polyp like growth situated just within
and protruding from the external urethral meatus of women. It may be acutely
Urology, Burns, Plastics and sensitive, causing increased frequency of urination, which is painhl and local
Reconstructive Surgery,
EndocrlnologlcaI, Immunological burning pain may be exaggerated by exertion, local excision of caruncle will
and Trauma Nurslng remove the symptoms.

1.4.2 Bladder
Cystitis
Definition I
Cystitis is an inflammation of the urinary bladder that is most often caused by an
ascending infection from the urethra.
Causes
Urethrovesical reflux
Focal contamination
Use of catheter or cystoscope
Use of Diaphragm-spermicide contraception.
Manifestations
Increased frequency of urination
Pain on urination
Nocturia
Pain or spasm in region of bladder and suprapubic area.
Pyuria
Management
Antibiotics and urinary antiseptics may be administered. Course of drugs may
vary from 3-4 days to 7-10 days. Longer medication courses are indicated for
men, pregnant women and women with pyelonephritis and with other types
of complicated urinary tract infections (UTIs). Although treatment of UTI for
3 days is usually adequate in women, recurrence of infection occurs in about
20 per cent of women treated for uncomplicated UTI. Recurrent infections in
men are usually due to persistence of same organism.
Increase fluid intake. However, avoid irritating fluids like coffee, tea, cola,
etc.
m Frequent voiding (every 2-3 hours) is encouraged to empty the bladder
completely, because this can significantly lower urine bacterial counts, reduce
urinary stasis and prevent re-infection.

COMMON RENAL DISORDERS

Renal disorders are the very common amongst the elderly population which
ultimately may Gand to end shape rend disease which are given below.

1.5.1 Acute Renal Failure

Acute renal failure (ARF) is defined as a rapid deteriorating condition of renal
functions, resulting in the accumulation of nitrogenous waste in the body. It is a
reversible condition.
 k Incidence and Risk Nursing Managem. of
Patient with Umwgicnl
Dirders
f It is estimated that more than 10,000 adults have acute renal failure each year.
Unfortunately, the mortality rate is high, often as high as 60 per cent. Persons at

It risk are those with atherosclerosis that obstructs renal artery blood flow, those
who are dehydrated, those with other ludney diseases or those taking nephrotoxic
drugs.

r Stages in Renal Failure

Renal failure can be described in four stages, depending on the degree of loss as
manifested by the glomeruler fitration rate (GFR).

i) Renal impairment is the first stage of damage. The GFR is 40 to 50 per

cent of normal, but the client may have no other clinical or biochemical
evidence of loss of ludney function.

I I
ii) Renal insufficiency: The GFR is 20 to 40 per cent of normal and functional
loss also appears as azotemia, with abnormally high serum levels of
nitrogenous wastes such as urea, uric acid and creatinine, anaemia may also
occur.
iii) Renal failure: There is only 10 per cent GFR remaining. Fluid and
electrolyte imbalances appear as kidney function rapidly diminishes.

iv) Uraemia represents the end stages of kidney failure or end stage renal
disease (ESRD). High levels of nitrogenous wastes accumulate in the blood
and there are a multitude of clinical manifestations. Ultimately the uric acid
and other wastes precipitate on the skin, producing uraemic frost; coma and
death follow.
L
Causes of Acute Renal Failure
The causes of acute renal failure can be categorized into pre-renal, renal and post-
renal. Pre-renal causes interfere with renal perfusion. Conditions that contribute to
decreased renal blood flow include volume depletion such as vomiting, diarrhoea,
haemorrhage, excessive use of diuretics, bums, renal salt-wasting conditions and
glycosuria, vasodilating drugs, hepato-renal syndrome and severe nephrotic

I syndrome.
Renal causes refer to parenchymal changes from disease or nephrotoxic

I
substances. Acute tubular necrosis, glomerulonephritis, haemolytic-uraemic
syndrome, thrombosis, vasculitis, scleroderma,'trauma, atherosclerosis, tumour
invasion and cortical necrosis.
Post-renal causes occur because of obstruction in the urinary tract anywhere fiom
the tubules to the urethral meatus. Common causes of obstruction include prostatic
hypertrophy, calculi, invading tumours, surgical accidents and retroperitoneal
fibrosis.

t Pathophysiology of Acute Renal Failure

Changes in structure and function of the kidney are related to the underlying
cause of the renal failure. There is damage to the nephron, there is loss of
filtering action, diminished reabsorption and loss of ability to produce rennin,
erythropoietin and other substances. As the nephrons are destroyed. others adapt
and compensate by filtering more blood, but eventuaily become overwhelmed or
diseased.
There is decreased tubular reabsorption of sodium in the proximal tubule with
increased reabsorption in the distal tubule. The increased sodium concentration in
~rulng?,Barn++.plestics and the distal tubule stiinulates production of rennin. causing vasoconstriction and
Recc~nslruetPveSul'pT,
Fnilocrincrb@h.*' immunolopical
further reducing rend blood flow. Iiypertension soon follows.
2nd Tr%uma&.:ts:%g
Signs and Symptoms
The most common overall sign of acute failure is alteration in the expected urine
output. The signs and symptoms are due to retention of fluids, electrolytes and
waste materials.
Oliguria (urine output below 400 ml/day) or anuria (urine output below 100 mV
day) may be present. The specific gravity of urine is low. Oedema occurs. When
fluid overload is excessive, signs of congestive heart failure, hypertension and
pulnionary oedema may occur.

Retention of electrolytes and waste materials from cellular metabolism produces

signs and symptoms of uraemia. Serum potassium, BUN (blood urea nitrogen) and .

serum creatinine values rise sharply. As urinary excretion of the acid end products-
of nletabolism decreases, acidosis develops and Kussmaul respiration occurs.
Symptolns attributable to retained wastes and altered electrolyte balance include
nausea, drowsiness, fatigue and shortiless of breath with fluid overloading; signs
include vomiting, confusion, convulsions, coma, gastrointestinal bleeding and
asterixis.

Additional problems include pericarditis and infection. Fluid accumulate in the

pericardial sac and pulsus paradoxus is likely to be present.
Course
The onset covers the period from the precipitating event to the development of
oliguria. In the oliguric anuric phase the urine output falls to below 400 ml per
day. The duration of this is from one day to 8 wccks. The longer the persistence,
the poorer the prognosis. A gradual or abrupt rate of glomerular filtration and
leveling of the BUN signal the diuretic phase. The convalescent stage begins
when the BUN becomes stable and ends when the patient has returned to his
noril~alactivity. This phase may take several months.
General Therapeutic Approach to Patient with Acute Renal Failure
a Excludc all speci!ically treatable causes of renal function including correction
oi' prz-renal and post-renal factors
e Attempt to establish a urine output
e C:ousen~ativetherapy

Decrease intake of nitrogen, water and electrolytes to match output

.-. Provide adequate nutrition

- A!tdr medication therapy

Maintain clinical monitoring (vital signs, intake and output record, body
weight, phj sical examination, etc.)
- Mainiain biochemical monitoring (BUN. creatinine, electrolytes, blood
counts, calciun~,phosphorus, etc.)
Provide dialytic therapy

Nursing Management
The patient and significant others ivill be very anxious. So frequent careful
expianatiolis should be given.
 Fluid and Electrolyte Balance Nursing Manapenlent of'
Palieul with Ilrological
Disorders
Restoratloll of fluid balance requires careful monitoring of the intake and
output, daily weight, B.P., pulse rate, skin turgor and mucous membranes.
Urine specific gravity is an indication of fluid balance. Heart sounds, breath
1
sounds and the patient's mental status may indlcate the presence of iluid
I imbalance. Fluid replacement may be done to avoid fluid overload.
Replacement is often calculated on the basis of urlne output plus 600 to 800
ml of insensible water loss that usually occurs in 21 hours.

The most dangerous electrolyte imbalance is hyperkalemia because of its

contribution to cardiac arrest. In addition to the kidneys' inability to excrete
potassium, this is released in greater quantities from thc body cells. When
acidosis is present and is further increased by rapld t~ssuecatabolism as in
'
fever. infection and trauma. Cation exchange resins may be administered orally
or rectally, to facilitate excretion of potassium. Sorbitol is also given to
prevent impaction and to ellrninate the sodium released by the exchange resins.
'
Potassium containing foods and medications are avoided. The adnlinistration of
50 per cent glucose, and regular insulin with sodium bicarbonate, if necessaiy,
or calcium gluconate intravenously can temnporarily prevent cardiac arrest in an
emergency.

Hyponatremia is usually an effect of hernodilution. So treatment is proper fluid

replacement. Hypocalcemia may require 1 V administration of calciurn
gluconate. Antacids containing niagnesium is avoided. Physostig~nine is used
for hypennagnesemia and I V nlagnesium sulphate for hypomagnese~nia.
Sodium bicarbonate is used to correct acidosis. In the meantime oxygenation is
supported.

Nutrition

A diet high in calories and low in protein, low in sodium and potassium, is
usually prescribed. Adequate carbohydrate intake relerses the process of
gluconeogenesis. If oral intake is not sufficient, tube feeding& or total
parenteral nutrition may be instituted.

Nursing Process

An overview of the nursing process for clients with acute renal failure is
given below in a tabular fonn (see Table 1.1).

/ Sugar /
Problem Assessment / Planningllmplementation ; Evaluation I

1 o l l g ~ n ~ Oliguria
I I I

1400 ml:day Hydration; Administer diuretic Regains

adults 150mllday (mann~tol,Furosenide); normal urine
output children Specific Monitor I & 0 and weight; output
phase) gravity 1,010 Prevent water intoxication
Begins Lowered CVP and pulmonary edema;
with Monitor CVP
decrease
in urine
output

Increased BUN ( Limit protein calories Renal function

1 to 10 day
(adults)
3-5 days
Increased
ci.%;'?7ine 1 (hyperalimentation) restored

(infant5
, chldren)
Urmllogai R?iirirrs, P!%stiesand
Retomsr'r w q ti^ - Surp~ry,
Check Your Progress 2
E~kdac-'~;.+J?z3' i~m~n111ogicaI
I,

$,,<, J- '- . q~g-*?ng 1) Define the following terms:

a) Acute renal failure

.........................................................................................

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1.5.2 Chronic Renal Failure

C hrdnic or irreversible renal failure (CRF) is a progressive reduction of
5~1lcrloningrenal tissue, so that the remaining kidney mass can no longer
nlsinta!n thtx body's internal e~lvironrr~ent.
It can develop insidiously over a
pcriad of many years or can occur as a result of acute renal failure fi-om
M hich the patient fails to recover. The end result for this patient is uraemia
and death or treatment by diaiysis and/or transplant.
Causes
The main causes of chronic renal failure cis chronic glorneruloJnephritis,
polycystic kidney disease, obstruction. rcpzated bouts of pyelonephriiis,
nephrotoxins. Systemic diseases such as diabetes, hypertension, lupus
ergrthemtitosus, polyarteritis, sickle cell disease and amyloid disease may also
produce renal failure.
The fsthogenesis
As the total glomemlar filtration rate falls and clearance is reduced the serum urea
nitrogen and creatiniric levels rise. Remaining hnctioning nephrons hypertrophy as
they have to filter a larger l o ~ dof solutes. One of the consequences of this is that
the kidneys lose their ability to concentrate urine adequately. In an attempt to
continue excreting the solutes, a large volume of dilute urine is passed (polyuria)
making the patient susceptible to volume depletion.
As with acute renal failure, there are many alterations in electrolyte balance in
chronic renal failure. The phosphate levels rise as phosphorus is not excreted.
Hyperphosphatemia dnves the calcium levels down and stimulates parathyroid
release. Low levels of calcium and increased parathyroid hormone promote
reabsorption of calcium from the bones, producing osteodystrophy or renal
'rickets', so called because it resembles vitamin D deficiency. Osteodystrophy in
children is manifested by bone pain, fra$tures and growth retardation. The kidneys
also lose the ability to regulate sodium and there may be hypernatremia if
accompanied by increased dietary intake of sodium or hyponatremia if dietary
levels are reduced and sodium is lost fiom vomiting or diarrhoea.
Nausea and vomiting are thought to be caused by retention of acid and urea.
Morning sickness, similar to tht associated with pregnancy, can occur. As these
wastes build up in blood, the client may appear pale and may complain of fatigue
and other factors associated with anaemia. Some adults have a foul breath and
body odour resembling the odour of urine. A crystalline substance sometimes
forms on the skin in late renal insufficiency and failure, which is referred to as
uraemic fiost. It is usually visible on the forehead initially and may become

Cardiovascular and blood-related diseases include anaemia, hypertension anh

circulatory impairment. Anaemia may be caused by:

i) A failure of erythropoietin manufacture (produced primarily by the kidneys),

needed to stimulate production of red blood cells, and

ii) A reduced life span of RBCs because of destruction resulting fiom an

elevated BUN.
The clotting mechanism is also ineffective, causing problems with easy bruising.
and hemorrhages throughout the gastrointestinal system. Hypertension occurs often
in CKF, probably due to increased rennin production and excess circulating blood
volume. Circulatory impairment and oedema inay be progressive and can
eventually result in pulmonary oedema if they are not controlled. Pericarditis and
pleuritis may also accompany renal failure because of exposure to high levels of
metabolic wastes.
Nervous systein dysfunction may be evident (uraemic encephalopathy). Lethargy.
irritability and even psychosis can occur. As the BLW and creatinine levels rise
and the blood calcium level falls, tetany and szimres may become manifest.
Clients usually progress from n clouded sensorium and drowsiness to coma,
concurrent with developing acidcsis.
Peripheral neuropathy is also a result of increased .uric acid levels. Both sensory
and motor functions are disturhtd, but can be iinprcved with dialysis or renal '

As renal damage advances and the nunlbcr of f;rzt;oning nephrcas decline, the
total glomerular filtraticn rate decrzaszs i'wher and the body becomes ~nableto
get rid of water, salt zfid other waste products though the kidneys. When the
 Urutog:. fiornq. Plaqtics and glnnsenilar filtration rate i s below 101111 per minute, clinical uraemia i s evident.
Recunrtr~~ctRe Surgery,
lmmuno,ogiral The bod), becomes increasingly toxic until i t s status i s no longer compatible with
and Iraums UurGnp. life

Nursing Management

CRF can be managed conservatively with fluid adjustments and correction o f

electrolyte imbalances and with removal o f nitrogenous wastes by diet and drug
therapy.

l~ltimately.n~ostclients require o~lgoirigsupport o f kidney function with dialysis

or kidney tr;4nsplant. Nursing goal are established to:
if 54aintain renal function.
i ~ )Prornote safety and comfhrt, and
111) Preparc" the client for dialysis or kidney transplant as needed (see Table 1.2).

,l.luintaitting Renal Function

Refer to thc nursing care plan i n Table 1.2. As kidney failure ensues, the nurse
must be alert to changes in fluid and electrolyte status and the effects of
accumulatlor~o f nitrogenous wastes.

/ Alteration in fluid balance Po!yuiia, nocturia enuresis Restrict fluid intake Normal urinary output
Hypovolemia Dialysis
!
I Alteration in electrolyte / Increased serum potassium Limit potassium in diet ~ A r m a lpotassium levels
i balance due to EKG changes ~ialysis'
1 Hyperkalernia Increased serum phosphate Restrict calcium in diet Normal phosphate levels
!
Prevent absorption with

I
j Hyperphosphatemia Increased blood pressure
aluminium hydroxide
Restrict sodium in diet Nomal sodium levels
I1 Hypermaatremia
Edema
Hypovolemia Dialysis
Hypotension Replace lost sodium Normal calcium levels
1 Hypernatrernia Decreased serum calcium Dialysis
Administer vitamin D Normal acid-base levels
i
(calcitriol)
1 Hypocalcemia Hyperventilation Dialysis
Decreased pH Administer sodium
bicarbonate
i Metabolic acidos~s
I Decreased CO, combining
power
Dialysis

, Accumulation of metaboli

i
I
4I BUN
Increased creatinine
Uremia
( Dietary restriction of
1 protein Dialysis
I
Normal BUN, creatinine

Osterodyastrophy Lowered serum calcium 1 Limit protein and

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Absence of bone pain
and
("renai tickets") Bone pain / phosphorus in diet, fraciures
Osteoporosislfractures 1 especially restrict milk Normal calcium levels
Growth retardation in / Adm~nisteraluminium
children / hydroxide supplement
j calcium and vitamin D
i Protect from injury turn lncreased energy
 --- -- - -- -. - -. - .-- --- -
Assessment *&inp i m o n l EvaluatiM1
Fatigue, lethargy Decreased activity Promote rest I ~bsenceof vomiting
Anotexia. nausea Metallic or salty taste in Use antiemetrics
vomiting mouth, hiccoughs. emesis Give mouth care
Decreased salivation Thirst
Gastrointestinal bleeding Decreased hemoglobin Administer antacids to
gastrointestinal
Heme positive stools protect mucosa
Decreased hemoglobin
Anemia Decreased red blood cell
production
Decreased hemoglobin Administer androgenic Improved RBC count
Decreased red blood cell steroids packed red
production blood cells Iron
supplements
1 (Not relieved by dialysis)
Bleeding Hematuria, epistaxis Prevent injury Bleeding stopped
Bruising, bleeding, impaired Direct pressure to Inflammation
platelet function bleeding site Supportive Normal blood pressure
Chest pain, dysrhythmias treatment Diuretics
Increased Mood pressure Low-sodium diet
Antihypertensives
/

Problem Assessment Planning implementation Evaluation

Uremia encephalopathy Irritability Initial seizure Improved levei of
. Lethargy precautions comsciousnosfi
Decreasing level of Dilantin for seizures
consciousness Dialysis
Delirium
Seizures
Kussmaul's respirations
Muscle twitching asteriixis
Coma
Peripheral neuropathy Numbness, tingling Dialysis Adequate circulation
I
Muscte weakness Nerve integrity
Dry, skin, prutitus / U"c acid crystals on skin 1 Skin care I Absence of uremic frost /
Uremic frost and hair Dialysis
Decreased estrogen,
testosterone 1 Amenorrhea, impotence.
loss of libido
1
Dialysis Normal levels

Promotifig Comfort and Safety

These include providing skin care fbr dry, itching slun that may have
uraemic frost and establishing a seizure precaution routine by padding
side rails and protecting the client fiom injury. If comatosed, the nurse
must maintain hygiene, establish a turning sct~edule, offer skin care and
maintain nutrition.

Preparing for Dialysis or Renal Transplantation

The decision to move fiom conscrvati\c: manapelnent to more definitive
therapy is based on the clienr'~senera1 health, Idooxatory data, etc. The
decision ]nay come quickly as the clipnt's calld~t~on rapldly deteriorates. Thc
deckion may also come as a relief with hope t'or an improved qualitv of life.
The nurse must support the patient far tlia1ysisit;anspla~~ta;ionprcrcedxres as
preparation is made for the same.
Urology, Burns, Plastics and
Reconstructive Surgery, Check Your Progress 3
Endoerinobgkal, Immunological
and 'lhuma Nursing .1) Define the following terms.
a) Chronic rend failure

c) Uraemic frost

2) Fill in the blanks with correct answers.

Low amount of sodium in the blood is known as .
a)
.........................................................................................................................
b) Anaemia in chronic renal failure is due to the deficiency of
.........................................................................................................................
3) List the nurse's responsibility in the following conditions.
a) Hyperkalemia
.........................................................................................................................
b) Uraernic fkost *

Peritoneal Dialysis
It involves the instillation of dialysate into the peritoneal cavity, allowing tinie for
substance exchange and then removal of the diaIysate. The membrane we make
use of here is the peritoneum itseIf. Its surface area in an average sized addt has .
been estimated to about one square metre. It is richly supplied with capillary
blood and acts as an efficient area for this exchange.

Indications
Acute and chronic renal failure
In patients with severe cardio-vascular disease or with bleeding tendencies,
for those with poor vascular access which makes them inappropriate for
haernodialysis
a For small children and the elderly Nursing hlanagernent'of
Patient with Urologieal
Disorders
a Useful for overdoses of drugs and toxins but its clearancc is much lower
than haemodialysis, hence, it may not be satisfactory.

Contraindications
a Acute renal failure complicated by hypercatabolism or heat stress

a Peritonitis (controversial)
a Recent abdominal or chest surgery or trauma

a Bowel distention
a Respiratory insufficiency

Technique
The technique for peritoneal dialysis involves preparing the patient and setting up
the equipment, inserting the catheter, instilling the dialysate, monitoring the patient
and removing the dialysate.

The catheter insertion may be done in the operating room or at the bedside under
local or gencral anestllesia. The preferred site for Insertion is about 3 to 5 cin
below the umbilicus, an area which is relatively avascular and has less fascia1
resistance. The tip of the catheter is usually positioned so that it lied decply with
the pelvic gutter; the correct position ill often give the patient the urge to
defecate. The catheter is generally sutured in place to avoid accidental
dislodgment.
The dialysate is usually allowed to nln into the peritoneal cavity by gravity flow,
although an electronic drip regulator may be used. The dialysate is wanned to
prevent chilling the patient and to dllate the peritoneal blood vessels, thus
facilitating substance exchange. Two lilres is usually instilled In adults, although
smaller amount may be needed at first until the paticnt adjusts. 'Dwell time' is the
period during which the dialysate is left in the cavity. Equilibrium between thc
dialysate and the body fluids usually occurs within 15 to 30 minutes with the
maximum change happening within the first 5 minutes. Therefore, the solution is
typically left in place 30 to 45 minutes and then allowed to tlow out tlvough the
catheter by gravity and siphon flow. Machines are available to automatically
handle the entire cycle. A dialysis period may take from 10 to 30 hours.

Perforat~onsof the bowel, puncture of abdominal aorta, oedetna of the anterior

abdominal well (all due to catheter), pain, plemal effusion, peritonitis,
hypenlatraemia, hypokalaemia and hyperglycaemia, dialysis disequilibrium,
pulmonary complications, etc.

ivztrsing Responsibilities in Peritoneul Dialysis

The nursing responsibilities can be divided .into three phases of dialysis-before,
during and after dialysis.

a Prepare the patient emotionally and physically

a See that the consent form is signed
Urology, Burns, Plastics and Weigh the patient
Reconstructive Surgery,
Endocrinological, Immunological
and Trauma Nursing
Check vital signs

Empty bladder
Assist with insertion of CVP catheter ECG monitoring is .also employed
Make the patient comfortable in supine position and set up the instruments

During Dialysis
Assist the physician in inserting the peritoneal catheter

After the procedure, if the fluid is not draining properly, move the patient
from side to side
a Then the outflow ceases, clamp off the drainage tube and infuse next
exchange ,
Take B.P and pulse every 15 minutes during the first exchange and every
hour thereafter

Maintain a record of patient's fluid balance

Promote patient comfort during dialysis by frequent back care, changing
position, etc.
Observe for breathing difficulty, abdominal pain and leakage around the
catheter.

After Dialysis
Take patient's temperature
Look for complications e.g. peritonitis and protein loss.

Haemodialysis

Haemodialysis is a process of cleaning the blood of accumulated waste products

by using an artificial kidney. Artificial kidneys are used in two main situations.
For temporary support of patients with acute reversible renal failure

For regular long term treatment of patients with end stage renal failure.
A less common indication is the removal of poisons which are usually self-
ingested.

Objectives
To extract toxic nitrogenous substances from the blood.

To remove excess water

Requirements for Haemodialysis

Access to the patient's circulation

Dialyzer, with semi-permeable membrane

Appropriate dialysate bath

Methods of Access to Patient's Circulation Nursing Management of
Patient with Urological
Disorders
Repeated haemodialysis require a permanent fonn of access to the circulation.
Two methods have advised to meet this need-the external shunt and the internal
fistula (see Figs. 1.5 and 1.6).

Cephalic vein
Cephalic vein I

I
~nastor~osrs
low forearm I
Radical artery
Brachial artery
Site for fistula Antecub~talfossa

Fig. 1.5: Internal Arteriovenous Fistula for Haemodialysis Blood Access

Renal artery

Big. 1.6: External Arteriovenous Shunt for Haemodialysis Blood Access

The External Arterio- Venous Shunt

It requires the surgical placement of two tubes of cannulas into the patient's
foream, upper arm or leg. The radial artery and cephalic vein are the most
common vessels used. The two tubes are brought out to the surface of the skin
and connected together with a 'U' shaped segment called shunt. Blood flows from
the patient's artery through the shunt into the patient's vein. The tube-leading to
the arterial cannula at the time of dialysis and flows back into the patient by way
of a tube connected to his venous cannula. Infection at the site and clotting are
frequent complications. The shunt survival various from two months to five years.

Internal Arteriovenous Fistula

The technique is to anastornose any peripheral artery and any large neighbouring
vein. The leaking of arterial blood into the venous system causes the veins to
become engorged. A large bore needle can then be inserted into a vein in the arm
so as to obtain a good blood flow which, with the help of a pump, is sent
through the dialyser and back through another large bore needle inserted further
up into the same or another vein. The patient enjoys a greater freedom from
anxieties associated with an external shunt. This process takes at least 1 to 2
weeks to develop enough for the site to be used: complications in such
anastomosis include infection and aneurysm formation.

Technique of Haemodialysis
Heparin is the anticoagulant universally employed to prevent blood clotting in the
extra-corporeal circuit. Generally total heparin requirements are found to be
between 1000 and 2000 I.U. There are several types of dialyzers available. These
include coil, parallel flow and hollow fibre.
Urology, Burns, Plastics and Compfications
Reconstructive Surgery,
Endocrinological, immunological
and Trauma Nursing
Acute circulatory ovcrload, haemorrhage, cardiac arrest, dialysis disequilibriu~n
syndrome, power cuts, ctc.

Nurse's Responsibilities in Haemodialysis

The dialyses is to be prepared by proper setting, rinsing and priming.

Bcfbw Diu/v.~i~~
Explain the procedure, weigh, take vital signs and record.

Aseptic technique must be practiced to connect dialyser to the patient. Watch the
patient and machine. Observation of the patient includes checking pulse and B.P.
every half hour and respiration every hour : Observe for hypotherrnia, cardiac
irregularity, twitching, headache. pruritus, etc. Observation of the machine includes
a sudden break in the circuit, high venous.pressure (due to kinking), low venous
pressure, low arterial pressure, failure of the hlood pump etc. Carefully tennillate
the dialysis.

Dietary management of patients on long-term haemodialysis includes restrictions

such as adjustment of protein, sodium and potassium and/or fluid intake.
Rehabilitation 1s mainly achieved by self-dialysis or by a renal transplant. The
psychosocial problems of pat~entssuch as grief. anxiety. sexual problems and
symptoms of stress must be tackled.

Check Your Progress 4

1) Define the followillg terms:
a) Peritoneal dialysis

........................................................................................................................
c) Dialysis disequilibrium
 Nursing Management of
2) List five principles of dialysis. Patient with Urological
Disorders

.......................................................................................................................
Differentiate between peritoneal dialysis and haemodialysis..

L
I 1.5.3 Renal Carcinoma
Renal cancers may arise from renal capsule, parenchyma, connective tissue or
fatty tissue or they may be neurogenic or vascular. Majority of tumors are
adenocarcinomas.
Cancer of kidney affects almost twice as many men women.

Risk Factors
Tobacco use
t

Occupational exposure to industrial chemicals

it Obesity

I1 '
Dialysis

i , Clinical Manifestations

The classic triad, occurring late in the course of the disease, is blood in the urine
(hematuria), pain and a mass in the flank. The usual sign that first calls attention
t to the turnour is painless, haematuria, which may be either intermittent and
microscopic or continuous and gross. There may be dull backache due to ureter
I
compression, extension of turnour into perianal area or hemorrhage into the
substance of the kidney.' Symptoms may also include colicky pain, unexplained
weight loss, increasing weakness and anemia.

Diagnostic Interventions
F Intravenous urography
!
Cystoscopic examination
Nephrotomograms
Renal angiograms
Ultrasonography
Computed tomography.
Urology, Burns, Plasticr and Management
Rcconstructive Surgew
Endocrinological, lntmunological
and Trauma Nursing
The goal of management is to eradicate the tumour hefore metastasis occurs.
Radical Nephrectomny: This includes removal of kidney and tumour, adrenal gland,
surrounding perinephric fat and lymph nodes. Radiation Therapy, hormonal therapy
or chemotherapy may be used alongwith surgery. lmmunotherapy may be helpful.
Renal Artejy Embolization: This hclps to occlude the blood supply to the tumour
and thus cause the death of tumor cells. After angiographic studies, a catheter is
advanced into renal artery and embolizing materials are injected into artery and
carried with the arterial blood flow to mechanically occlude the tumour vessels.
Biologic Therapy: Biologic response modifiers has helped in successful trcatrnent
of renal tumours. Patients may be treated with interleukin-2 (IL-2), a protein that
regulates cell growth. This may be used alone or in combination with lymphokine-
activated killer (LAK) Cells, which are white blood cells that have been
stimulated by IL-2 to increase their ability to kill cancer cells. Interferon is also
under investigation as a mode of therapy for treating advanced renal cancer.

Nursing Management
Patency of catheters and drains to be ensured postoperatively
Intake output monitoring to be done strictly.
Analgesia to relieve pain.
0 Coughing and deep breathing exercises.
Follow up care to detect signs of metastases as well as to reassure, patient
and family about patients continued well being.
Yearly physical examination and chest X-ray.

1.6 MEDICAL MANAGEMENT

For acute, chronic and endstage renal diseases includes peritoneal dialysis,
heamodelyased and pharmoldogical management

1.6.1 Related Pharmacology

Drugs affecting urinary system may be categorized into two groups:
Diuretics

0 Antidiuretics

a) Diuretics

1) Thaizide and thiazide jike agents

2) Loop diuretics
3) Potassium sparing
4) Carbonic anhydrase Inhibitors
5) Osmotic agents.
The Actions, Uses, Side Effects and Nursing Iinplications are given in the
following table:
 - - --

Actions
- --

1) Thiazide 8 thiazide likt

Uses
Hypertension; Edematous
Sideeffects
Orthostatic Hypotension,
Nursing Implications
Check for allergies to
I
agents e.g. states associated with Electrolyte Imbalance; sulphonamides
Chlorothiazide, CHF, Pregnancy, kidney Hypokalemia, Anorexia, Monitor glucose 8
Hydrochlorothiazide, failure, liver disease; nausea, vomiting, potassium levels.
Polythiazide, decreased urine output in Glucose intolerance, Monitor closely in the
Cbpamide, etc+ lnhibit diabetics high glucose levels, Dry presence of renal or
Sodium 8 Chloride m o m , thirst. liver dysfunction
reabsorption in the
distal tubule & lower
peripheral vascular
resistance (PVR)

2) Loop Diuretics e.g. Edema, Congestive Heart Increased electrolyte Schedule the last
Furosemide, Failure, Renal or hepatic depletion, excessive dose early enough to
Ethacrynic acid, dysfunction, Hypertension. diuresis Abdominal pain, prevent nocturia
Mersalyl, etc. Block transient hearing loss, Avoid if anuria is
the reabsorption of
sodium in the loop of
Henle, the ascending
leucopenia,
1 Thrombocyto-penia,
Postural Hypotension.
- present.
Assess for allergy
Give I/M route by Z-
loop where the track method due to
greatest sodium pain at injection site.
reabsorption normally Educate patient for
occurs; also reduce - high K' foods
preload & aftertoad. - Report muscle
cramps
- Assess for
dehydration.

3) Potassium sparing Edema, Diuretic induced Hyperkalemia, Teach that high K+ diet is
agents e.g. hypokalemia, Hypotension, GI upset- contraindicated
Spironoiactone, Hyperaldosteronism, Nausea, vomiting,
Amiloride, Triamterene, Steroid-induced edema. diarrhea, abdominal Monitor other
etc. lnhibit pump cramps, weakness, medications for K'
mechanism that fatigue, numbness or sources.
normally exchanges tingling, paresthesia of
Potassium for Sodium hands & feet. Frequently monitor
in the distal Megalobiastic anaemia, complete blood count.
convoluted tubule,
spironolactone
antagonizes
Teach symptoms of
hyperkalemia & report
1
aldosterone, which these as soon as noticed
mediates Na+ & K'
exchange. This Keep tablets stored in
mechanism reduces dark containers.
sodium reabsorption I
while retaining K+.

4) Carbonic Anhydrase Glaucoma, Edema, Electrolyte imbalance, Assess for allergy to

Inhibitors e.g. Premenstrual Control, As Hemolytic anaemia, sulfonamides
Acetazola-rnide, Anticonvulsant. Frequent moderate
Monitor gtucose,
Ethoxzolamide Inhibit headaches,
Electrolytes & complete
enzyme carbonic nervousness, depression,
blood count levels.
anhydrase, which malaise, Nausea, I
prevents the secretion vomiting, Anorexia, Do notmix with fruit I
of Hydrogen ions 8 Hyperglycemia juices. 1
causes an alkaline
urine. The Na' is
1 1 Avoid I/M due to pafn ]
excreted along with
the bicarbonate. I '
I
Administer with antacids
to lower GI 'distress.
 - - -- -- .

Uses skhdws I~urrtnokrpllkra

5) Osmotic~e.g. Prevent oliguria, lower
I
Rebound ICP, irritation Contraindited in. -
Mannitol, bosorbide. Intra-cranial pressure (ICP) at IV side, Headache, Acute renal faitwe,
Glycerol. Increase Lowers intra ocular Thrombophlebitis, Congestive Heart failure,
osmotic pressure, pressure, lowers pressure Electrolyte Imbalance, lntrauanial Haemorrhage,
which decreases in cerebrospinal fluid, treat Circulatory overioad. Pregnancy or severe
water reabsorption. certain drug intoxications.

I 1 dehydratian
~ o n l t o rUrinary output
closely.
Monitor electrMytes .and
Blood urea N i n
Assess IN side fre+mtly
during administration;
Avoid @x&avasatkms
Ga not mix with b W
products ar other bntgs.

b) Antidiuretics
These are the drugs that reduce urine volume.
Examples: ,

Antidiuretic Hormone, Desmopressin

Thiazide diuretics
Miscellaneous-Chlorpropamide, Carbamazepine, etc.
Actions
Increase water permeability
Constricts blood vessels and can raise B.P.
Increase peristalsis in gut.
Induce platelet aggregation and hepatic glycogenolysis.

Thiazides induce a State of sustained electrolyte depletion so that glomerular

filtrate is more completely reabsorbed.

'General Nursing Implications

Assess weight (gadloss) at the same time each day in same clothes
preferably.
Monitor VO carehlly
Monitor food consumption and offer instructions according to K' rich or K+
sparing foods.
Avoid all alcohol products because of diuretic etTect and lowering of BP.
Assess for findings of hypokalemia and hyperkalemia. Monitor electrolyte
levels.
Administer early in the day to avoid nocturia.
Limit Na+ if uscd for hypertension.

Monitor Eulse and B.P.

 Instruct client for weight gain, edema, coughing. Nursing Management of
Patient with Urological
Disorders
Instruct client to take with or after meals if GI distress occurs and repsrt
nausea or vomiting.
Diuretics are sometimes abused by overweight clients.
Older adults may need lower doses and dietary counseling, as well as
accurate assessment of BP and electrolytes.

Check Your Progress 5

1) Name two of the loop diuretics.

I
1.7 RENAL SURGERY
Renal surgery is a very common procedure to provide the quality of life to
patient. In the following text you will learn about management of patient for renal
transplantation.

1.7.1 Renal Transplantation

(Renal transplantation or renal homograft is the surgical transfer of a human
kidney from one individual to another. This procedure is usually done as a
treatment for irreversible renal failure, but may also be done whenever bilateral
"
nephrectomy or removal of a solitary functioning is necessary. This may occur in
the case of trauma or renal malignancy. The primary limiting factor in the number
of transplants done is the availability of kidneys.
Preoperative preparation of both the donor and the recipient include all aspects
of general preoperative care. The patient should not have any infection.
Gastrointestinal ulcers are treated; any lower urinary tract malfunctions, must be
corrected. The transplantation operative procedure consists of placing the donor
kidney in the recipient's body. Although, the kidney is occasionally placed into the
thigh, it is usually positioned in the iliac fossa and the renal vessels are
anastomosed to the recipient's iliac vessels. The surgical procedure is done swiftly
to decrease the time the donor kidney is without a blood supply. Periods of
ischaemia longer than'30 minutes can damage the function of the newly
transplanted kidney.
Usually, the kidney begins to function immediately. There is usually a period of
diuresis for the first 8 to 24 hours owing to a defect in the proximal tubular
transport of sodium and glucose. Sometimes. adequate functioning is delayed a
few days. Haemodialysis may be performed until good function is established.
Urology, Burn$, Ylarticr and Complication of Kidney Transplantation
Reconstructive Sui-g~ry,
E:nducrit~olo~ical.
lmn~unolngirdl
ar~dlrauma Vurbing
i) Homografi Rejection Reaction
This is an immunologic attack against the foreign donor organ in an attempt to
get rid of it. The reaction is stitnulated by forclgn histocompatibility antigens.

Signs and Symptoms of Rejection: These are presented below under headings of
clinical signs, laboratory 'signs and radiological evidence:
-- - -- .- --- -. -
-Fratmy Signs
- -L~adiolo~ical
. - Evidence I

- Fever (without
4
- Leucocytosis; - An enlarged kidney;
an accompanying - increased BUN
infection) and serum - Renal scan may
- Weight gain creatinine show poor flow
(more than 2 levels; through the
pounds in a - increased kidney due to
24 hours proteinuria; Oedema;
period) - decreased - An arteriogram
- Anorexia urine sodium may show vessel
- Malaise level changes with
- Oedema irregularity and loss of
(Periorbital smaller vessels;
and of the - A prolonged
legs) circulation time;
- Enlargement and
of the graft - A poor nephrogram
with upper
pole
tenderness
- Decreased
urinary
output
-- Hypertension

Antirejection therapy revolves around the use of immunosi~ppr~ss~vedrugs which

block the body's normal immuni. responses, Amthioprine and prednisone or
methyl prednlsolone are the most frequently used drugs. Steriodsmay be given.

Cyciophospha~nideis sometimes used instc;lil of ozathioprine. The injection of

globulin (AL,G) or antilymy11oc:~i:e serclln ( A M ) causes a
a.ntily~npl~otyte
decreased response to specific antigciis. The adr!;i!iis!.ration of these agents
continues indefinitely, usually for the patients lifetime. Thc main problems with
iinmunosuppressive tlierapy are illcreased silsceptibility to infection and risk of
rna!ignancy.
Othci- co~nplicationsare given as under:

iii) Cirrliovascular-renal artery stenosis which may cuuse systemic

hypertension

iv) Pneutfionia
v) Skin Cnrcinoma.~

vi) Musculoslieletal problenrs--h~vperparatIi~~roidism,osteoporosis and

myoprrtlzy

vii) H~prodzdctiveproblems e.g. l*yrlvocele and testiczdar atrophy

vi i i) Steroid-induced cataract and g!suutima

Nursing Management Nursing Management nf
Patient with Zirological
Disorders
Nursing care is aimed at prevention, early recognition and treatment of the above
complications plus measures to facilitate maximum renal functions and help the
patient attain an optimal quality of life. Immediate postoperative care of both the
donor and recipient encompasses the care required by any patient having surgery.
Care of the donor is as for nephrectomy.

Immediate Postoperative Period

Everyone involved is happy when urine is seer! met; stcadiiy through the
catheter and closed drainage system. However, early oliguri,: and anuria can occur.
They can be caused be caused by:
Obstruction of urinary flow-so check the catheter for patency. If the urine is
bloody and contains clots, the catheter needs to be irrigated gently, using
sterile technique.
Hypovolaemia-which may be due to blood loss during surgery or
postoperatively. In that case a bolus of intravenous fluids will increase the
. urinary output.
Thrombosis or stenosis of the renal artery or renal vein-partial obstru:.~!on of
the renal artery can occur from torsion or kinking of the vessels and it has to
be corrected surgically.
Acute tubular necrosis is seen more often in cadaver transplant in which the
ischaemia time is prolonged. Haemodialysis is needed until the kidney
function returns.
Ureteral leaks are mainly due to distal ureteral necrosis from ischaemia. This
can be seen in an intravenous pyelogram. A urine leak is a potentially serious
complication that can lead to infection and death. Hence, it must be treated
immediately. If small, a urethral catheter can be inserted to provide adequate
drainage until the site is healed. If large, surgical correction may be needed
e.g., reimplantation of ureter.
Protective isolation may be used. Monitor renal function and fluid balance.
Vital signs, CVP, weight hourly or half-hourly, urine output, and fluid intake
are measured. Laboratory determinations of haemoglobin, haematocrit. blood
urea nitrogen, creatinine and electrolytes will be followed closely. Care must
be taken to avoid obstruction of any ureteral or urethral catheters.

Coughing and deep breathing exercises are begun immediately. Dressing of

wound is done with aseptic precautions. Oral hygiene is important because of
the high incidence of stomatitis bacterial and fungal infections. Unless the
patient is demonstrating rejection or hypertension, there may be no dietary
restrictions.

Early ambulation is necessary to prevent cardio-vascular and pulmonary

complications and to stimulate gastrointestinal function.

Ps~ychologicalSupport
Many patients experience depression as they realize their continued vulnerability
to rejection. The importance of complying with recommended medical regimens
and follow-up evaluation schedules must be emphasized and periodically
reinforced. The patient will need to arrange activities and life style so as to avoid
infections and highly stressful situations. .
Urology, Burns, Plastics and
~ e c ~ n s t r u c t i vSurgery,
e Check Your Progress 6
Endocrinologica~ Immunological
and Trauma Nursing 1) Write four specific nursing problems of a patient with rend transplant and
the nursing interventions to solve them.

1.8 BENIGN PROSTATIC HYPERTROPHY

- -

Definition
In many patients more than 50 years of age, the prostate gland enlarges, extending
upward into the bladder and obstructing the outflow of urine by encroaching on
the vesicle orifice. This condition is called a benign hypertrophy of prostate
(BHP).

Clinical Manifestations
Urinary obstruction, hydroureter, hydronc~brosis,incomplete emptying and urinary ..
retention. Urinary tract infection may result frem urinary stasis. Nocturia,
abdominal straining on urination. terminal dribblicg. acute urinary retention and
recurrent UTIs may be the result. Ultimately, azotemia and renal failure can occur
with chronic urinary retention and large residual volumes. Generalized sympotoms
may include fatigue, nocturia, anorexia, nausea, vomitizg due to impaired renal
function and epigastric discomfort may result from distended bladder.

Diagnostic Interventions
History
Physical examination-digital rectal examination may be done.
Clinical manifestations.
Urinalysis and urodynamic studies
Renal function studies including serum creatinine.
Haematologic investigation and clotting profile
Assessment of cardio-respiratory function.
I Management Nr&g Management of
Qadeat wlth Urnlogical

I
1
Four different approaches may be used:
a) Trans urethral resection of Prostate (TURF) is the most common procedure
Mwrden

and can be carried out by means of an endoscopic instrument that has ocular
and surgical capability. The instrument is introduced directly through the
urethra to prostate, which can be viewed directly. The gland is then removed
I in small chips with an electrical cutting loop.
b) Suprapubic prostatectomy: This is one method of removing the prostate gland
I
I through an abdominal wound. An opening is made into the bladder, and the
I
gland is removed from above.
I c) Perineal prostatectomy involves the removal of gland through an incision in '
I
the perineum.
I
I ,
d) Retropubic prostatectomy is another technique and is more common than the
I
suprapubic approach. A low abdominal incision is made, and the prostate
gland is approached between the pubic arch and the bladder (without entering
1
the bladder).

Nursing Intervention
Assessment is based on:
- History
- Clinical manifestations
- Physical examination
Pre-operative management
- Reduce anxiety and Facilitate communication.
- Bed rest must be ensured.
- Analgesics to be administered.
- Monitor voiding patterns and clinical manifestations
- Catheterization to be done.
- Pre-operative enema to prevent post operative straining.
Post operative management
- Bed rest for 1st 24 hours.
- Warm compress'es to pubis or sitz baths to provide sympton~aticrelief of
spasms.
- Analgesics to relieve pain
- Monitor patient's vital signs
- Catheter irrigation and care is important
- Prevent infection by aseptic precautions during wound dressing
- Heat lamp may be directed to perineal area to promote healing.
- Sitz baths are encouraged to promote healing.
- Encourage walking and Perineal exercises.
- Prevent constip!;on and Encourage fluids.
- Eauszte and reassure that sexual activity may be resumed in 6 to 8
weeks.
urology, Burns, Plastics and Complications
Reconstructive Surgery,
Endoerinolo@caI, lmmunolo@cal lIaemorrhage
and Ttauma Numlng
0 Infection
a Thrombosis
Catheter obstruction

1.9 LET US SUM UP

The loss of kidney function may be sudden or may develop over a long period
both leading to a set of symptoms called uraemic syndrome. Unless the process is
halted (whether it is acute or chronic renal failure), the ultimate result is coma,
convulsions and dealth.
The first renal transplant was performed in 1930, but renal transplantation as a
tool for treating humans was essentially unexplored until 1956, when this was first
used successfully to transplant from one identical twin to another. Both dialysis
and transplantation have risks. The risks of transplantation are great which makes
one to ask why a patient chooses transplantation rather than haemodialysis. Many .
patients are willing to take the risks in an effort to return to more normal life, one
that is not controlled by machines. The nurses working in these units must listen
to these patients and support them.

1.10 KEY WORDS

Azotaemia : Uraemia
Pyelonephritis : Inflammation which spreads outwards from the
pelvis to the cortex of the kidney
Osteodystrophy : Faulty growth of bone
Rickets : A disorder of calcium and phosphorus metabolism
associated with a deficiency of vitamin D and
beginning most often in infancy and early
childhood (6 months to 2 years)
Pericardiocentesis : Withdrawal of fluid from the pericardial sac by
insertion of a hollow needle or cannula
Pericardiotomy : Surgical removal of pericardium, thickened from
chronic inflammation and embarrassing the heart's
action.
Dialysis disequillibrium : This is one of the biochemical complications of
dialysis. It is thought to be caused by rapid
reduction of blood urea being followed by a much
slower reduction of urea and other solutes in the
cells. This leaves the osmotic pressure considerably
higher than in the blood and water will be drawn
across the blood-brain barrier of the meningeal
membrane into the brain. It causes cerebral oedema
and temporary disturbance of cerebral function.
The symptoms are mental confusion, restlessness
and in severe cases major epileptic seizures. .
 Nursing Management of
1.11 AZIU'SWRS TO CHECK YOUR PROGRESS Patlent with Urologkd

Check Your Progress 1

1) Nephron
2) Ultra filtration, reabsorption, excretion, maintenance of electrolyte and acid-
base balance, regulation of blood pressure, secretion of erythropoietic (Any
four).
Check Your Progress 2
1) a) Acute renal failure is defined as a rapid deteriorating condition of renal
bctions, resulting in the accumulation of nitrogenous waste in the
body. It is a reversible condition.
b) Uraemia represents the end stages of kidney failure where high levels of
nitrogenous wastes accumulate in the blood, producing a multitude of
symptoms.
c) In renal insufficiency, the GFR is 20 to 40 percent of normal and
hnctional loss appears as azotemia, abnormally high levels of
nitrogenous wastes.

b) acute tubul& necrosis.

Check Your Progress 3
1) a) Chronic renal failure is a progressive and irreversible deterioration of
renal function.
b) lsosthenuria means the inability of the kidney to concentrate urine
c) Uraemic frost consists of white or yellowish crystals of urate that are
secreted through the skin in a highly inefficient attempt by the body to
rid itself of accumulated waste products occurs in uraemic syndrome.
2) a) Hyponatraemia
b) Erythropoietin
3) a) Limit potassium to 40-60 meq/day, kayexalate enema, bed rest,
peritoneal or haemodialysis.
b) Skin care, dialysis

Check Your Progress 4

1) a) Peritoneal dialysis involves the instillation of dialysate into the
peritoneal cavity, allowing time for substance exchange and then
removal of the dialysate.
b) Haemodialysis is a process of cleaning the blood of accumulated waste
products by using an artificial kidney.
c) Dialysis disequilibrium is one complication of dialysis. The symptoms
are mainly mental confusion, restlessness and in severe cases major
epileptic seizures. It is thought to be caused by rapid reduction of blood
urea being followed by a much slower reduction of urea and other
' solutes in the cells.
2) Diffusion, osmosis and ultra filtration. The membrane principles and the
principles involved in the design of the dialysis fluid.
~roktgy,Ibms mstieE and 3) Peritoneal Dialysis Haemodialysis
~ t r a c t l v surgery.
t
a-. lmmuddc~l - Simple method - Complicated technique
a d lhumr Nor8h1g
- Efficient - More efficient method
- Easier treatment method for babies - More comfortable
and small children
- Action is not so fast as in - - Preferable for acute renal
haemodialysis failure accompanied by highly
catabolic stages

- Contraindicated in retro peritoneal - More efficient in the treatment

haemotoma, abdominal operations of acute poisoning

In general, peritoneal dialysis is the method of choice for uncomplicated

acute renal failure and because of the simplicity of the method it can be
employed in any hospital where there are no special facilities.

Check Your Progress 5

1) 1) Furosaminale
2) Ethacrynic' acid

2) 1) Congertive heart failure

2) Acute heart failure

Check Your Progress 6

1) Problems Nursing Intervention
a) OliguriafAnuria 1) Check the catheter for patency
2) Administer inigation with normal
saline if urine contains blood

3) lntake and output chart

b) Hypovolaemia I ) Monitor pulse, B.P.

2) W fluids as needed
c) Rejection of transplant 1) Monitor signs and symptoms
of rejection
2) lrnmunosuppressive agents,
steroids, ALG as prescribed '

d) Infection (Pneumonia) 1) Deep breathing; coughing exercises

2) Antimicrobials, reduce
immunosuppressive therapy

2) Advantages: Patient enjoys a greater fieedom from anxieties associated with

an external shunt.
Disadvantages: Infection and aneurysm.
 Nursing in Bums, Plmstics nnd
1.12 FURTHER READINGS
- - - - - - - - -
.
- - - - -
Reconstructive Surgery

Brunner &d Suddharths (1992), Textbook of Medical Surgical Nursing, 7th edn.,
J.B. Lippincott Co., Philadephia, pp. 1155-1156, 1178-1183, 1206-1207, 1216,
1325-1326.
Rollant, Paulette D. and Hill, Karen Y. (1996), Nursing Pharmacology, St. Luouis,
Mosby Year Book, Inc., pp. 179-90.
Tripathi, K.D. (1999), Essentials of Medical Pharmacology, Jaypee Brothers
Medical Publishers (P) Ltd., New Delhi, pp. 561-79.