Chapter 70 Care of Patients with Renal Disorders
Terms in this set (113)
Inherited disorder in which flui-filled cyst develop in the nephrons
Polycystic Kidney disease
Prevention of PKD
- No prevention
- Early detection
- Mangement of HTN
Prevalence of PKD
- White people
PKD clinical manifestation
- Abdominal or flank pain
- Nocturia - early manifestation
- Increased abdominal girth
- Bloody or cloudy urine
- Kidney stones
Diagnostics test for PKD
- UA - (protein, blood)
- Renal sonography
Inflammation of the renal pelvis and interstitium
- WBCs, CBC with high WBCs
S/s acute pyelonephritis
- Flank, back pain
- General malaise
- Burning, urgemcy, frequency
s/s chronic pyelonephritis
- Inability to conseve sodium
- Decreased urine concentration
Diagnostic test for pyelonephritis
UA (leukocyte esterase and nitrate)
Basic causes of Glomerulonephritis
- Anti-GBM antibodies
- Goodpasture's syndrome
- Nephrotic syndrome
- Acute poststreptococcal glomerulonephritis
Rare autoimmune disease against lungs/kidneys
Treatment of Goodpasture's syndrome
- Poor prognosis, immunosuppressant therapy, plasmaphoresis, renal transplant
Clanical manifestations of chronic glomerulonephritis
- Slurred speech
- asterixis (flapping tremor of the finguers)
- Yellowish color of the skin
Diagnostic test for chronic glomerulonephritis
- Monitor I&O (decreased urine output)
- GFR (low)
- Serum creatine (elevated)
- BUN (increase)
Condition of increased glomerular permeability that allows largers molecules to pass through the membrane into the urine.
Which is the main feature of nephrotic syndrome
Nephrotic syndrome clinical manifestation
- Increased coagulation
- Reduced kidney functions
Leading cause of End stage kidney disease
Polycystic Kidney Disease (PKD)
an inherited disorder in which fluid-filled cyst develop in the nephrons
pain on urination
the need to urinate excessively at night
protein in the urine
blood in the urine
the kidney enlarges as urine collects in the pelvis and kidney tissue
enlargement of the ureter
an obstruction that occurs low in the urinary tract due to decreased diameter of the urethra, causing bladder distention before hyroureter and hydronephrosis
the surgical creation of an opening directly in to the kidney; performed to divert urine externally and prevent further damage to the kidney when a stricture is causing hydronephrosis and cannot be corrected with urologic procedures
Urinary Tract Infection (UTI)
an infection in this normally sterile system
a bacterial infection in the kidney and real pelvis-- upper urinary tract
acute bacterial infection in the kidneys
a kidney disorder that results form repeated or continued upper urinary tract infections or effects of such infections
the reverse or upward flow of urine toward the renal pelvis and kidney
pockets of infection with pus, can occur anywhere in the kidney
stone removal from the kidney
removal of the kidney
removal and filtering of the plasma to eliminate antibodies
flapping tremor of the fingers or the inability to maintain a fixed posture with the arms extended and the wrists hyperextended
nephrotic syndrome (NS)
a condition of increased glomerular permeability that allows larger molecules to pass through the membrane int o the urine then to be excreted
Polycystic Kidney Disease
Inherited disorder; fluid-filled cysts develop in nephrons
Symptoms of Polycystic Kidney Disease
Increased abdominal girth
Abdominal or flank pain
- Cystic kidneys push on abdominal contents
- Decreased ability to concentrate urine
Bloody or cloudy urine
- Cyst rupturing
Interventions for Polycystic Kidney Disease
Acute and chronic pain
Hypertension and renal failure
Hydronephrosis, Hydroureter, and Urethral Stricture
Problems of urine outflow obstruction
Interventions for Hydronephrosis, Hydroureter, and Urethral Stricture
-Cystoscope to remove stone
Diverts urine externally
-Done when urologic intervention isn't possible
Bacterial infection in kidney and renal pelvis (upper urinary tract)
Acute symptoms of Pyelonephritis
Fever, chills, tachycardia, tachypnea
Flank, back, or loin pain
Nausea and vomiting, urgency, frequency, nocturia
General malaise or fatigue
Concept Map for Pyelonephritis
Assessment of treatment (for efficacy)
a type of kidney disease in which the part of your kidneys that helps filter waste and fluids from the blood is damaged.
-Connection with sore throat?
-Fluid retention / sodium retention
Acute Glomerulonephritis Laboratory assessment
-Blood in urine (hidden)
Collaborative Care for Acute Glomerulonephritis
Management of infection
Prevention of complications
Develops over period of 20 to 30 years or longer (cause not known)
Assessment of fluid overload
Interventions for Chronic Glomerulonephritis (similar to those of ESKD)
Slowing progression, preventing complications
Microvascular complication of type 1 or type 2 diabetes
First manifestation: persistent albuminuria (proteinuria)
Priority goals in prevention of ESKD
Autosomal Dominant form of PKD
Most common form of PKD
Half develop renal failure by age 50
Nearly 100% who inherit a PKD gene will develop renal cysts by age 30.
Autosomal Recessive form of PKD
Both parents must carry a mutated allele; both mutated alleles must be inherited.
Most die in early childhood.
A child has 1 in 4 chances of inheriting autosomal polycystic disease.
Abdominal or flank pain
Increased abdominal girth
Bloody or cloudy urine
PKD self management
Measure and record your blood pressure daily, and notify physician for consistent changes in BP.
Take temperature if you suspect a fever.
Weigh yourself everyday at the same time of day and with the same amount of clothing. Notify your doctor if you have a sudden weight gain.
Limit your intake of salt to help control your blood pressure.
Notify your doctor if your urine smells foul or has blood in it.
Notify your physician or nurse if you have a headache that does not go away or if you have visual disturbances.
Monitor bowel movements ot prevent constipation.
After Nephrostomy, notify the physician immediately when the drainage decreases or stops, drainage becomes cloudy or foul-smelling, the nephrostomy site leaks blood or urine, or the patient has back pain.
Acute Pyelonephritis s/s
Tachycardia and tachypnea
Flank, back, or loin pain
Tender costovertebral angle
Abdominal, often colicky, discomfort
Nausea and vomiting
General malaise or fatigue
Burning, urgency, or frequency of urination
Recent cystitis or treatment for UTI
Chronic Pyelonephritis s/s
Inability to conserve sodium
Decreased urine concentrating ability, resulting nocturia
Tendency to develop hyperkalemia and acidosis.
Assessment questions for a patient with suspected PKD
Family history of PKD or kidney disease.
assess for abdominal discomfort or constipation.
History of sexually transmitted disease.
Patient reports of sharp flank pain and blood in the urine?
A patient with nocturia. What is nocturia caused by
Decreased renal concentrating ability.
Which laboratory abnormality in the patient with PKD indicates disease progression?
If a patient is suspected of having PKD. Which diagnostic study has minimal risks and can reveal PKD?
The patient with PKD has Nocturia. What should the nurse encourage the patient to do?
Drink 2 liters of fluid a day.
Which medication is the best choice to control hypertension in the patient with PKD?
Permanent kidney damage can occur in what time frame?
In less than 48 hours.
Urinalysis shows tubular epithelial cells on microscopic examination. How would a nurse interpret this?
The obstruction is prolonged
What is a complication that could result from this condition
Damage to the nephrons
Active bacterial infection
Obstruction with reflex
Neurogenic impairment of voiding
Common to both acute and chronic pyelonephritis
Neurogenic impairment of voiding
Undergone manipulation of the urinary tract.
Testing to identify an abscess formation?
The less common manifestations of acute GN are more likely to occur in older adults; circulatory congestion often is present, causing acute GN to be easily confused with CHF.
Consideration for the older adult
Nephrotic Syndrome manifestations
Edema (especially facial and periorbital)
Reduced Kidney function.
Hypertension is more common in African Americans and American Indians, and the risk for ESKD from hypertension are also greater for these ethnic groups between 25 to 45 years of age.
What is the leading cause of end stage kidney disease?
What causes renal tissue changes in chronic glomerulonephritis?
trauma and elevated body temperature.
What is the underlying pathology of nephrosclerosis?
narrowing of the renal tubules.
Systemic conditions that could cause acute glomerulonephritis
Systemic lupus erythematosus
Which diagnostic tests and results does the nurse expect to see with acute glomerulonephritis?
Urinalysis revealing hematuria
Urinalysis revealing proteinuria
Microscopic red blood cell casts
24 hour urine for creatinine clearance decreased
Serum albumin levels decreased
Antistreptolysin - O titers increased.
A nurse is caring for a patient with nephrotic syndrome. What interventions are included in the plan of care for this patient?
Administer mild diuretics
Assess for edema
Administer antihypertensive medications
Assess the patient's hydration status.
Which ethnic group is mostly likely to develop end - stage renal disease related to hypertension?
After a nephrectomy, the patient has a large urine output because of adrenal insufficiency. What does the nurse anticipate the priority intervention for this patient will be?
IV fluid replacement because of subsequent hypotension and oliguria.
What change in diabetic therapy may be needed for the patient who has diabetic nephropathy?
Decreased insulin dosages
The nurse is caring for a patient with renal cell carcinoma. What symptoms and findings does the nurse expect to see in this patient?
palpable renal mass
Preventing Kidney and Genitourinary trauma
Wear a seat belt
Practice safe walking habits
Use caution when riding bicycles and motorcyles.
Wear appropriate protective clothing when participating in contact sports.
Avoid all contact sports and high - risk activities if you have only one kidney.
If the urethral opening is bleeding, consult with the physician before attempting urinary catheterization.
A patient is newly diagnosed with renal artery stenosis. What clinical manifestation does the nurse observe when the patient first seeks health care?
Urinary frequency and dysuria
Treatment for a renal artery stenosis?
Percutaneous transluminal balloon angioplasty
Renal bypass surgery
Synthetic blood vessel graft.
If a postoperative nephrectomy patient shows a marked and steady downward trend in blood pressure, the patient is more than likely to have an?
The patient has sustained renal injury. In order to assist the patient to undergo the best diagnostic test to determine the extent of injury, What does the nurse do?
Give an explanation of a CT
Which clinical manifestation in a client with renal impairment is associated with
polycystic kidney disease rather than an infectious process?
A. Flank pain
B. Periorbital edema
C. Bloody and cloudy urine
D. Enlarged or protruding abdomen
A protruding and distended abdomen is common because the cystic kidneys swell and
push abdominal contents forward and displace other abdominal organs.
The client is a 30-year-old man who has type 1 polycystic kidney disease (PKD-1).
He asks whether his children could develop this disease. What is the nurse's best
A. "Because there is no identifiable pattern of inheritance with this disease, your
children are not at an increased risk for developing polycystic kidney disease."
B. "Because the disease is sex-linked (x-linked) recessive, only your sons will be
C. "Because this is a recessive disorder, your wife would also have to have the disease
for your children to have polycystic kidney disease."
D. "Because this is a dominant disorder, each of your children would have a 50% risk of
having polycystic kidney disease."
Polycystic kidney disease type 1 (PKD-1) is transmitted as an autosomal dominant trait
and, therefore, is not gender-specific. If one parent has PKD-1, each child has a 50% risk
for the disorder. If both parents have PKD-1, the risk is even greater.
The client with polycystic kidney disease and hypertension is prescribed to take a
diuretic for blood pressure control. Which of the following statements by the client
indicates a need for clarification regarding this management?
A. "I will weigh myself every day."
B. "I will drink only 1 L of fluid each day."
C. "I will avoid aspirin and aspirin-containing drugs."
D. "I will avoid nonsteroidal anti-inflammatory drugs."
Diuretics for blood pressure control can lead to fluid volume depletion and decrease
blood flow to the kidney, further decreasing renal function. Fluid volume intake is not
restricted until the kidney no longer responds to diuretics.
What dietary modifications should the nurse teach the client with polycystic kidney
A. Increased protein intake, decreased potassium intake
B. Increased fiber intake, decreased sodium intake
C. Decreased fluid intake, increased magnesium intake
D. Decreased calcium intake, increased chloride intake
Major problems associated with PKD are constipation and hypertension. An increase in
dietary fiber and unrestricted fluid intake can help prevent or relieve constipation.
Hypertension is a serious problem, and a sodium restriction can be helpful.
Which client is at greatest risk for a hydroureter?
A. 68-year-old man with chronic hypertension
B. 68-year-old woman with diabetic nephropathy
C. 28-year-old woman with frequent cystitis
D. 28-year-old man with frequent renal calculi
A hydroureter is most commonly caused by obstruction in the mid to upper portion of the
urinary system. Large kidney stones (renal calculi) can block the flow of urine either in
the renal pelvis or in the ureter. The kidney continues to make urine and the volume
backs up into the kidney.
Which clinical manifestation in a client with a urinary tract infection alerts the nurse
to the possibility of acute pyelonephritis?
A. Burning on urination
B. Cloudy, dark urine
C. Fever and chills
Lower urinary tract infections (cystitis and urethritis) are rarely associated with systemic
symptoms of fever and chills.
The 48-year-old client with diabetes mellitus is being treated for her third episode of
acute pyelonephritis in the past year. She asks what she could do to help prevent these
infections. What is the nurse's best response?
A. "Test your urine daily for the presence of ketone bodies and proteins."
B. "Use tampons rather than sanitary napkins during your menstrual period."
C. "Drink more water and try to empty your bladder at least every 2 to 3 hours while
you are awake."
D. "Inject your insulin in larger doses or more frequently to keep your blood sugar
lower so the microorganisms have fewer nutrients for growth."
Clients with long-standing diabetes mellitus are at risk for pyelonephritis for many
reasons. Chronically elevated blood glucose levels spill glucose into the urine, changing
the pH and providing a favorable climate for bacterial growth. The neuropathy associated
with diabetes reduces bladder tone and reduces the client's sensation of bladder fullness.
Thus, even with large amounts of urine, the client voids less frequently, allowing stasis
and overgrowth of microorganisms. Increasing fluid intake (specifically water) and
voiding frequently prevent stasis and bacterial overgrowth.
The client has just been diagnosed with acute glomerular nephritis. Which question
should the nurse ask this client in attempting to establish a cause?
A. "Are you sexually active?"
B. "Do you have pain or burning on urination?"
C. "Has anyone in your family had chronic kidney problems?"
D. "Have you had any type of infection within the last 2 weeks?"
The most common cause of acute glomerular nephritis is the presence of a systemic
infection resulting in the formation of antigen-antibody complexes, which precipitate in
the kidney tissues.
The client with acute glomerular nephritis has periorbital edema. What additional
assessment should the nurse obtain or perform with this client?
A. Auscultate breath sounds.
B. Check blood glucose levels.
C. Measure deep tendon reflexes.
D. Test urine for the presence of protein.
Acute glomerular nephritis can cause sodium and water retention. When clients have
edema, they may also have circulatory overload with pulmonary edema.
The client with glomerular nephritis has a glomerular filtration rate (GFR) of 40
mL/min, as measured by a 24-hour creatinine clearance. What is the nurse's
interpretation of this finding?
A. Excessive glomerular filtration rate, client at risk for dehydration
B. Excessive glomerular filtration rate, client at risk for fluid overload
C. Reduced glomerular filtration rate, client at risk for dehydration
D. Reduced glomerular filtration rate, client at risk for fluid overload
The glomerular filtration rate refers to the initial amount of urine that the kidneys filter
from the blood. In the healthy adult, the normal glomerular filtration rate ranges between
100 and 120 mL/min, most of which is reabsorbed in the kidney tubules, so that the
normal urine output rate averages 30 to 60 mL/hr. A GRF of 40 mL/min is drastically
reduced, with the client experiencing fluid retention and a risk for hypertension and
pulmonary edema as a result of excess vascular fluid.
What is the pathologic process causing the decreased GFR associated with acute
A. Decreased renal-induced constriction of the renal arteries
B. Necrosis of 70% or more of the nephrons secondary to increased kidney interstitial
C. Scar tissue formation throughout the proximal convoluted tubule secondary to
toxin-induced collagen synthesis
D. Thickened capillary membranes secondary to immune complex deposition and
Most forms of glomerulonephritis are associated with accumulation of immune
complexes in the glomeruli and glomerular capillaries, thickening the capillaries and
impeding filtration. The immune complexes activate many mediators, including
complement, leukocytes, and coagulation proteins, responsible for the resultant renal
What clinical manifestation indicates to the nurse that the client with glomerular
nephritis being treated in the community is responding as expected to the prescribed
A. The client has lost 11 pounds in the past 10 days.
B. The client's urine specific gravity is 1.048.
C. No blood is observed in the client's urine.
D. The client is thirsty
Fluid retention is a major feature of glomerular nephritis. This weight loss represents
fluid loss, indicating that the glomeruli are performing the function of filtration.
The client has nephrotic syndrome with a normal glomerular filtration rate. What
dietary modification should the nurse teach this client?
A. Decreased intake of protein
B. Increased intake of protein
C. Decreased intake of carbohydrates
D. Increased intake of carbohydrates
In nephrotic syndrome, the renal loss of protein is significant, leading to
hypoalbuminemia and edema formation. If glomerular filtration is normal or near-normal,
the increased protein loss should be matched by an increased intake of protein.
What is the priority nursing diagnosis for the client with nephrosclerosis?
A. Risk for Impaired Skin Integrity
B. Risk for Infection
C. Disturbed Body Image
D. Deficient Knowledge
The major cause of nephrosclerosis is poorly controlled hypertension as a result of
atherosclerosis and/or diabetes. Control of the hypertension is essential to preserve renal
function and avoid the need for renal replacement therapy. Teaching the client the need
for and how to manage drug therapy for this condition is key to preventing complications.
In order to plan appropriate care, for which electrolyte imbalance should the nurse
monitor the client with renal cell carcinoma?
Renal cell carcinoma tissues frequently produce ectopic hormones, including parathyroid
hormone. The increased production of parathyroid hormone leads to decreased renal
excretion of calcium and an increase in the serum calcium concentration.
In assessing the client who had a radical nephrectomy for a renal cell carcinoma 6
hours ago, a nurse notes that the client's blood pressure has decreased from 134/90 to
100/56 and the urine output is 20 mL for this past hour. What is the nurse's best first
A. Position the client so that the remaining kidney is not dependent.
B. Measure the specific gravity of the urine.
C. Document the findings as the only action.
D. Notify the physician.
The radical nature of the surgery and proximity of the surgery to the adrenal gland put the
client at risk for hemorrhage and adrenal insufficiency. Hypotension is a clinical
manifestation associated with both hemorrhage and adrenal insufficiency. The
hypotension is particularly dangerous to the remaining kidney, which must receive
adequate perfusion to function effectively.
What should the nurse emphasize when providing home-going instructions to the
client who has undergone a nephrectomy?
A. "Be sure to limit your intake of fluid to no more than 2000 mL/day."
B. "Test your urine daily for ketone bodies and blood."
C. "You should never participate in contact sports."
D. "Avoid all alcoholic beverages."
The remaining kidney must perform the excreting and metabolic functions of two
kidneys. The kidneys are located in an injury-prone area posterior to the peritoneal cavity
and are poorly protected against trauma. Clients with one kidney should not participate in
The nurse is interviewing a client with a family history of polycystic kidney disease
(PCKD). Which of the following manifestations are typical of PCKD? (Select all that
B. Flank pain
F. Bloody urine
G. Increased abdominal girth
B, F, G
Rationale: Flank pain and abdominal girth size are related to the distention, and bloody
urine is seen with tissue damage secondary to the PCKD. The client may also have
constipation and hypertension.
The nurse is caring for a client with nephrotic syndrome. Which of the following
manifestations are typical? (Select all that apply.)
A. Proteinuria less than 3 g/24 hr
C. Fluid volume deficit
G. CVA tenderness
Rationale: Nephrotic syndrome is due to glomerular damage and is characterized by
proteinuria higher than 3.5 g/24 hr, hypoalbuminemia, edema, and lipiduria. The client
may also have hypertension from the fluid volume excess. CVA tenderness is present
with inflammatory changes in the kidney; dysuria and frequency are present with cystitis.
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