URINARY / RENAL SYSTEM

Physiology of the Kidney and Urinary Tract Urinary Tract Infection (UTI)Renal Calculi HypospadiaNephrotic Syndrome Glomerulonephritis Wilm’s Tumor (Nephroblastoma) Acute Renal Failure (ARF) Chronic Renal Failure (CRF) Dialysis Renal Tumor

A. Kidneys 1. Two bean – shaped structures located in the back of the abdominal cavity (retroperitoneal)

2. Structure a. Cortex. (1) Outer layer. (2) Contains blood vessels and nephrons. b. Medulla. (1) Inner layer. (2) Contains the collecting tubules. c. Pyramids. (1) Located within the medulla. (2) Contain the collecting apparatus and the tubules. d. Renal pelvis. (1) Funnel-shaped sac which collects the urine. (2) Calix (calices) drain the urine from the collecting ducts into the renal pelvis.

3. Blood supply. a. Twenty-five percent of cardiac output flows to the kidneys; approximately 1,200 ml per minute. b. Renal arteries arise from the abdominal aorta. c. Renal veins carry blood back into the inferior vena cava.

4. Function a. Excretory(1) Rid the body of metabolic wastes(2) Regulate fluid volume; normally 125 ml of fluid is filtered each minute (glomerular filtration rate), however only one ml is excreted as urine; average urine output is about 1440 ml. per day. (3) Regulate the composition of electrolytes. (4) Assist in maintaining acid-base balance.

b. Regulation of Blood Pressure (1) Juxtaglomerular cells are located in the afferent arteriole just before it enters the glomerulus. (2) The cells respond to a decrease in the blood flow (decrease in blood

pressure) by increasing the secretion of renin. (3) Renin acts on angiotensin 1 and converts angiotensin 2, which is a powerful vasoconstrictor. Peripheral resistance is increased, therefore blood pressure is increased c. Endcorine (1) Aldosterone production is stimulated by the increase in angiotensin 1, therefore sodium and water are retained to increase the circulating volume and increase the blood pressure. (2) Regulates red blood cell production through synthesis of erythropoietin; released in response to hypoxia. (3) Aids in calcium metabolism by activating vitamin D which promotes normal bone activity.

B. Nephron. 1. The functional unit of the kidney. 2. Composed of over a million nephrons. 3. Structure. a. Glomerulus - a network of capillaries encased in a thin-walled sac (Bowman's capsule). b. Tubular system. (1) Proximal convoluted tubule. (2) Loop of Henle. (3) Distal convoluted tubule. (4) Collecting duct.

4. Blood supply. a. Two capillary beds. (1) Glomerulus- high pressure capillary bed and filtration system located between two arterioles. (2) Afferent and efferent arterioles. b. Peritubular network--a low pressure, reabsorption system arising from the efferent arteriole. 5. Function. a. Filtration-occurs in the glomerulus via a semipermeable membrane. The membrane does not normally allow large protein molecules to be filtered out of the blood. b. Glomerular filtration rate (GFR) is the amount of blood filtered by the glomeruli in a given time (approximately 120-140 mL per minute). (1) Changes in GFR occur when the pressure gradients from the glomerular capillaries across the semipermeable membrane to the glomerulus are altered. (2) Pressure gradient changes occur when there is a variation in the systemic blood pressure (hypotension) a significant change in the pressure in Bowman’s capsule in the glomerulus (edema) and when ureteral obstruction occurs.

(3) The kidney response to changes in pressures is buffered by an autoregulatory mechanism in order to maintain a stable range of blood pressure. The autoregulatory mechanism maintains renal blood flow and the GFR within wide fluctuations of blood pressure. When the pressure range is outside the autoregulatory mechanism (hypotension/hypertension), the GFR will fluctuate with the systemic blood pressure

(4) If the glomerualr membrane is damaged, then plasma proteins will escape. A decrease in serum oncotic pressure, this results in water retention and edema formation.

c. Tubular reabsorption- After the glomerulus has filtered the blood, the tubules separate the water and solutes by osmosis and diffusion. Water moves across the semipermeable membrane and is reabsorbed or excreted in response to the concentration gradient of the solutes (sodium, potassium, chloride, urea, etc.). Only a small amount of the total water filtered out of the kidneys is excreted as urine. Solutes are also reabsorbed according to the concentration gradient. d. Tubular secretion-Regulates the potassium level and maintains the acid-base balance with other regulatory mechanisms.

C. Urinary tract. 1. The excretory system and its blood supply. 2. Ureters. a. Long, narrow muscular tubes which convey urine from the kidneys to the bladder. b. Slow, peristaltic waves propel urine along the ureter. c. Nerve supply-sympathetic constrictor fibers. d. Ureterovesical valve-prevents back-flow of urine into the ureters when the bladder contracts. 3. Bladder. a. A hollow muscular organ which acts as a reservoir for urine. b. As the bladder fills, the stretch receptors are stimulated. In the adult, the first urge to void will occur when 100 cc to 150 cc have collected, approximately 400 cc of urine will initiate a feeling of bladder fullness. c. Bladder capacity varies from 1,000 to 1,800 mi. 4. Voiding---stimulation is sent to the sacral area of the spinal column where the micturition reflex or voiding reflex is initiated. After toilet training, the cerebral cortex via the spinal column, allows for voluntary control of bladder contractions that initiate urination. 5. Urethra-a small membranous tube which conveys urine from the bladder to the exterior of the body.

System Assessment

A. External assessment. 1. Inspect skin for changes in color, pallor, turgor, and texture (urate crystals). 2. Assess face, abdomen, and extremities for edema. 3. Determine weight gain.

4. Palpate kidneys. a. Landmark--costovertebral angle (CVA) formed by the rib cage and the vertebral column. b. Kidney and bladder should be non-palpable.

B. History. 1. Presence of renal or urological congenital defect. 2. Determine if client has ever been exposed to chemicals, especially carbon tetrachloride, phenol, and ethylene glycol as these are nephrotoxic chemicals. 3. Determine if client has received antibiotics which may he nephrotoxic –

aminoglycoside, amphotericin B, and.sulfonamides. 4. Assess dietary intake--determine increased levels of calcium intake. 5. Determine level of activity-immobility leads to demineralization of the bones which can be predisposing to infection and calculi formation. 6. Evaluate complaints of pain-.dysuria, flank, and costovertebral, or suprapubic. 7. Assess changes in pattern of urination-frequency, nocturia, urgency, enuresis, etc. 8. Assess changes in urine output- polyuria, oliguria, anuria. 9. Assess changes in urine consistency- hematuria, pyuria, diluted, concentrated, change in color. 10. Deternmine if client is on any medications that may affect urinary or renal function- LASIX or anticholinergies. 11. Determine if client has diabetes mellitus, hypertension, or allergies.

DISORDERS OF THE URINARY TRACT Urinary Tract Infections (UTI)

Stasis of urine in the bladder, and reflux of urine back into the original reservoir are the primary factors in causing UTI.

A. Upper urinary tract infections- Pyelonephritis, an inflammation of the renal pelvis and the parenchyma of the kidney. B. Lower urinary tract infection. 1. Cystitis- inflammation infection of the bladder. 2. Urethritis- inflammation of the urethra. C. Urinary tract infections occur in an ascending route up the urinary tract system.

Assessment 1. Causative bacterial organisms. a. E. coli (80 to 90 percent). b. Staphylococcus saprophyticus (11% in women). c. Proteus mirabilia. d. Pseudomonas aeruginosa2. Factors contributing to UTI. a. Adult female urethra is short; in close proximity to the rectum and vagina which predisposes it to contamination from fecal material. b. Ureterovesical reflux--the reflux of urine from the urethra into the bladder. This causes a constant residual of urine in the bladder after voiding and precipitates UTI. c. Vesicoureteral reflux (ureterovesical reflux)-the reflux of urine from the bladder into one or both of the ureters and possibly into the renal pelvis. d. Instrumentation-catheterization or cystoscopic examination. e. Stasis of urine in the bladder leading to urinary retention for any reason (clients with prostate disease). f. Obstruction to urinary flow congenital anomalies, urethral strictures, ureteral stones, or contracture of the bladder neck. g. Bladder hypotonia, mechanical compression of the ureters, hormone changes predispose the pregnant woman to increased urinary tract infections. h. Metabolic disorders such as diabetes. i. Sexual intercourse promotes development of UTI. j. Fecal contamination of the urethral meatus.

3. Clinical manifestations. a. Cystitis. (1) Frequency and urgency. (2) Suprapubic pain. (3) Burning on urination. (4) Hematuria (5) Fever, nausea, vomiting. (6) Often may be asymptomatic with bacteriruia.

b. Pyelonephritis. (1) Fever, chills, flank pain. (2) Painful urination (dysuria). (3) Pain and tenderness at the costovertebral angle. (4) Symptoms of cystitis.

4. Diagnostics. a. Urinalysis-pus, bacteria, and RBCs found in the urine. b. Urine test for culture and sensitivity- colony count of at least 100,000,colonies per ml of urine on a clean catch midstream or catheterized specimen indicates infection. c. Acute pyelonephritis. (1) Elevated WBC count. (2) Possible positive blood culture. (3) Intravenous pyelogram- indicates enlargement of involved kidney and abscess into renal tissue.

5. Complications. a. A lower urinary tract infection may result in an upper urinary tract infection. b. Chronic pyelonephritis may occur after repeated bouts of acute pyelonephritis.

Treatment 1. Medical. a. Suifonamides. b. Urinary Antiseptics. c. Urinary analgesics. d. Antispasmodics.

2. Dietary. a. Encourage fluid intake of 3.000 cc day. (1) A diluted urine causes less irritation. (2) The increase in flow of urine through the urinary tract system decreases the movement of bacteria up the urinary tract. (3) Discourage carbonated beverages and foods or drinks containing baking powder or baking soda. b. An acid ash diet to increase the acidity of the urine.

Nursing Intervention Goal: to obtain relief of pain, urgency, dysuria, and fever. 1. Administer antimicrobial agent as prescribed; antibiotics need to he taken the entire course which is usually ten to fourteen days. 2. Encourage eight to ten glasses of fluids daily.

3. Teach importance of voiding every two to three hours during the day to completely empty the bladder. 4. Sitz bath to decrease irritation of urethra.

Goal: to prevent recurrence of infection.1. Teach client to shower rather than bathe in tub. If client prefers to take a tub bath she should avoid bubble bath additives. 2. Explain importance of cleansing the perineal area from front to back after each bowel movement. 3. If intercourse seems to predispose to infection, encourage voiding immediately after intercourse. 4. Teach importance of long-term anti-microbial therapy to prevent recurrences. 5. Encourage and explain the need for follow-up care to prevent complications of chronic urinary tract infections. 6. Avoid caffeine and alcohol.

Renal Calculi

Stones may form anywhere in the urinary tract, the most common location for stones is in the pelvis of the kidney. If the stones are small, they may he passed into the bladder. A. Stones in the bladder may increase in size if there is urinary stasis and alkaline pH. B. Types of urinary calculi. 1. Calcium oxalate---tend to be small; along with calcium phosphate stones, compromise 95 percent of all upper urinary tract calculi. 2. Calcium phosphate--associated with primary hyperparathyroidism; precipitate out in an alkaline urine. 3. Uric acid--occurs most often in clients with Primary or secondary problems of uric acid metabolism (gout).

Assessment (Regardless of the type of stone formed, the clinical manifestations, diagnostics and treatment are essentially the same).

1. Risk factors/etiology. a. Infection. b. Urinary stasis.c. Immobility. d. Hyperkalemia and hypercalciuria due to hyperparathyroidism, renal tubular acidosis, or the excessive intake of vitamin D, milk, or other alkalotic agents. e. Excessive intake of dietary proteins which increase uric acid secretions. f. Excessive amounts of tea or fruit juices which elevate the urinary oxalate level. g. Increase incidence in males over 40 years old. h. History of inflammatory bowel disease, fat malabsorption, or familial oxaluria.

2. Clinical manifestations. a. Sharp, sudden, severe pain. (1) May be described as "colic" either ureteral or renal. (2) Pain may be intermittent, depending on the movement of the stone. (3) Severe pain most often is precipitated by the movement of the stone into the ureter. There may be spasm in the ureter as it attempts to move the stone on

toward the bladder and the thigh. (4) Pain may radiate around the flank area, down into the genitalia, the bladder, and the thigh. b. Hematuria may be present from the traumatic effects of the stone on the ureter and in the bladder. c. Nausea and vomiting are common.

3. Diagnostics. a. Urinalysis. b. Serum calcium, oxalate, uric acid. c. KUB x-ray (kidney, ureters, bladder). d. Intravenous pyelogram and retrograde pyelogram. e. Cystoscopy. f. Renal stone analysis.

4. Complications. a. Recurrent stone formation.b. Infection. c. Renal failure.

Treatment 1. Medical. a. Increase fluid intake to decrease urine concentration. b. Medications that prevent the absorption of calcium (thiazide diuretics and phosphates). c. In uric acid stones, allopurinol (ZYLOPRIM). d. Dietary. (1) Decrease calcium intake in client with calcium stones. (2) Sodium may also be restricted, sodium increases the excretion of calcium in the urine.

(3) Decrease in protein intake or an alkaline ash diet for clients with uric acid stones.

2. Surgical. a. Basket extraction---transurethral insertion of a resectoscope which snags the stone and removes it. b. Nephrolithotomy-incision into the kidney with removal of the stone. c. Ureterolithotomy-incision into the ureter to locate a stone and remove it. d. Percutaneous stone extraction-insertion of a tube through the skin into the renal collecting system; with gradual dilation the stone is extracted with forceps or by a stone basket.

3. Extracorporeal lithotripsy. a. Client is supported on a frame and submerged in a tank of water. b. Shock waves travel through the water and are directed to the stone. The force of the shock wave shatters the stone and the remains are excreted in the urine. c. It is essential that the client remain absolutely immobile during the procedure which lasts about 30 to 45 minutes. d. Depending on the doctor and the status of the client as to the type of sedation or anesthesia. Procedure is not particularly painful, how-ever it is difficult for client to remain immobile for the time required.

e. Client may experience renal colic after the procedure--treat with spasmolytics.

Nursing InterventionGoal: to relieve pain. 1. Administer analgesics as prescribed-morphine or meperidine (DEMEROL). 2. Hot baths or moist heat on flank area. 3. Encourage fluid intake. 4. Strain all urine and inspect for blood clots and passage of stone.

Goal: to promote adherence to and understanding of therapeutic health care regimen. 1. Client should be instructed as to importance of adhering to dietary restrictions. 2. Explain rationale, dose, frequency, and important information relating to medication administration. 3. Teach symptoms of recurring stone formation such as hematuria, flank pain, or signs of infection. 4. Encourage a 3,000 cc per day fluid intake (un- less contraindicated). 5. Promote medical follow-ups periodically to evaluate for symptoms of infection and recurring stone formation.

Hypospadias and Epispadias

A. Hypospadias-The urethral opening is located be- hind the glans penis, or along the penile shaft. B. Epispadias-The urethral opening is located on the dorsal or upper side of the penis.

Assessment 1. Clinical manifestations. a. Visualization of defect. b. Often, penis is crooked in appearance,

Treatment Surgical correction of the defect. 1. Preferable time for repair is between 6 and 1 8 months. 2. Urethroplasty-If the defect is severe, the repair may be very involved and require several stages.

Nursing Intervention Goal: to provide emotional support and promote normal growth and development. 1. Be sure that the child is not circumcised as the foreskin is used in the repair. 2. Important not to delay repair as child in school may be viewed differently from peers. 3. Teach parents how to care for indwelling urinary catheter postoperatively. 4. Demonstrate to parents effective methods for restraining child to prevent him from pulling on urinary catheter postoperatively. 5. Discuss with parents appropriate play activities for the child. a. Avoid straddle toys. b. No swimming or rough activities, no playing in the sand box.

DISORDERS OF THE KIDNEYNephrotic Syndrome

Primarily occurs in children and is the outcome of other renal problems in which there is proteinuria, hypoalbuminemia, hyperlipedemia and edema.

A. Changes occur in the basement membrane of the glomeruli that allows the large protein molecules to pass through the membrane and he excreted. The loss of the albumin from the serum decreases the oncotic pressure in the capillary bed and allows fluid to pass into the interstitial tissues and into the abdominal cavity (ascites). B. The interstitial fluid shift causes hypovolemia, the renin-angiotensin response is stimulated, aldosterone secretion is increased, and the tubules begin to conserve sodium and water to increase the circulating volume. C. In the majority of children with the syndrome, the etiology is unknown; frequently there is no evidence of renal dysfunction or systemic disease.

Assessment1. Risk factors/etiology. a. History of renal dysfunction or systemic disease. (1) Glomerulonephritis. (2) Systemic lupus erythematosus. (3) Congestive heart failure. b. Increased incidence in children with allergic disorders such as asthma, bay fever and urticaria. c. Majority of children are male and between ages of 2 and 7 years. 2. Clinical manifestations. a. Edema. (1) Facial edema, especially periorbital edema. May be more pronounced in the morning, and subside some during the day.

(2) Generalized edema of the lower extremities may increase during the day. (3) Labia and scrotum may become very edematous. (4) Edema may progress to the level of severe generalized edema (anasarca). b. Proteinuria. c. Hypoalbuminemia. d. Gradual increase in weight. e. Volume of urine is decreased and may be dark or tea-colored f Irritability, fatigue, lethargy. g. Skin is pale and is prone to break down during the edematous stage h. Depending on the severity of the condition, the child may experience episode of hypertension. i. Child is malnourished due to decreased intake as well as loss of protein in the urine but may not appear so due to edema.

3. Diagnostics. a. Urinalysis-proteinuria. b. Decrease serum albumin. c. Creatinine clearance may he decreased with normal serum creatinine. d. Increase serum lipids--.cholesterol and low- density lipoproteins (LDL) are elevated followed later by increased triglyceride level.

4. Potential complications. a. Anasarca. b. Hypertension. c. Renal failure.

Treatment 1. Medical. a. Corticosteroid-prednisone. b. Diuretics---(frequently child is not responsive to the diuretics, may be used when the edema is severe or the child is hypertensive) spironolactone (ALDACTONE) in combination with furosemide (LASiX). c. Salt-poor human albumin for vascular insufficiency and severe edema. d. Prophylactic broad spectrum antimicrobial agents. c. Immunosuppressant therapy, usually cyclophosphamide (CYTOXAN) may be administered for up to two months to reduce the relapse rate and induce long-term remission.

2. Dietary. a. Decreased sodium intake. b. Protein intake depends on stage of disease. If there is any indication of renal failure or azotemia, then protein is restricted. There controversy regarding the benefits of decreased protein intake. c. There is usually no fluid restriction.

Nursing Intervention Goal: to reduce edema and excess fluid retention,1. Support edematous organs such as scrotum.

2. Provide and encourage a salt-restrictive diet. 3. Administer salt-poor albumin as ordered h monitor closely for circulatory overload during and after administration. 4. Provide meticulous skin care; change position frequently and monitor good body alignment. 5. Cleanse and powder opposing skin surfaces frequently. 6. Daily weights, accurate intake and output measure abdominal girth.

Goal: to prevent infection. 1. Child susceptible to infection due to decreases immune state from steroid therapy. 2. Protect child from upper respiratory infections good pulmonary hygiene. 3. Prevent skin excoriation and breakdown, asses carefully for indications of infection.

Goal: to promote nutrition. 1. Encourage adequate protein intake. 2. Serve small quantities to children. 3. Encourage input from child in selecting foods from prescribed diet.

Goal: to assist parents to cope with chronic disease and teach them home care. 1. Instruct as to medical regimen. 2. Reassure parents of the course of the disease so that they do not become discouraged with the frequent relapses.

3. Impress upon them the importance of long-term care and to obtain medical assistance when relapse occurs. 4. Social isolation is often a problem due to frequent hospitalizations or confinement (high risk of infection which could precipitate an exacerbation).

Glomerulonephritis

An inflammatory reaction in the glomerulus as a result of an antigen-antibody response to the beta-hemolytic streptococcus. An immune complex is formed as a result of the antigen-antibody formation; the complex becomes trapped in the glomeruli. As a result of the edema in the glomeruli, the GFR is significantly decreased.

Assessment 1. Risk factors/etiology. a. The stimulus of the antigen-antibody reaction may be a Group A beta-hemolytic streptococcus infection of the throat (tonsillitis, pharyngitis), which ordinarily precedes the onset of the condition by usually ten days to three weeks. b. Scarlet fever and impetigo. c. Most common in children, but all age groups can be affected. 2. Clinical manifestations. a. Acute glomerulonephritis. (1) Disease may be mild with proteinuria- asymptomatic hematuria. (2) Headache and malaise. (3) Facial edema, periorbital edema. (4) Decrease in urine output (oliguria). (5) Mild to severe hypertension. (6) Tenderness over the costovertebral angle. (7) Tea or cola colored urine due to hematuria.

b. Chronic glomerulonephritis. (1) Proteinuria and hematuria. (2) Hypertension-nose bleeds, retinal hemorrhages, or uremic convulsions. (3) Feet are slightly swollen at night. (4) A yellow grayish pigmentation of the skin along with pale mucous membranes and anemia. (5) Occurs over months to years.

3. Diagnostics. a. Urinalysis. (1) Proteinuria. (2) Increased specific gravity. (3) Hematuria. (4) Red cell casts. b. CBC-decreased hemoglobin and hematocrit. c. Elevated BUN, creatinine, and albumin. d. Positive complement studies and ASO titer.

4. Complications. a. Chronic renal failure. b. Nephrotic syndrome.

Treatment 1. Medical. a. Diuretics are usually not effective. May he utilized if the child is severely edematous. b. Antihypertensives. c. Antibiotics--penicillin, if cultures indicate. 2. Dietary. a. Decrease sodium intake. b. Protein restriction if child is azotemic from prolonged decrease in urinary output. The anorexia the child experiences frequently limits the protein sufficiently. c. Foods containing high potassium are generally restricted during the oliguria phase.

Nursing Intervention Goal: to protect client's poorly functioning kidneys by preventing secondary infections. 1. Administer antibiotic therapy. 2. Bedrest for severe hypertension and significant edema; otherwise, activity as tolerated.

Goal: to maintain fluid balance. 1. Monitor intake and output; maintain diet and fluid restrictions as ordered. 2. Monitor renal function-cheek characteristics and color of urine, weigh client daily, and cheek blood pressure q 2 to 4 hours. 3. Administer antihypertensives as ordered. 4. Frequently the first sign of improvement is an increase in the urine output, then may progress to profuse diuresis.

Goal: to prevent complications and promote comfort. 1. Encourage verbalization of fears. 2. Decrease anxiety by explaining treatments. 3. Assess for complications related to hypertension, congestive heart failure, pulmonary edema, and chronic renal failure.

Goal: to promote long-term compliance with medical health care regimen; to promote understanding and implications of the disease process and home care. 1. Teach client identifying symptoms to be reported to physician-nausea, fatigue, vomiting, decrease in urinary output, or symptoms of infection. 2. Explain the need for rest, relaxation, and avoidance of people with respiratory infections. 3. Teach measures to prevent urinary tract infections. 4. Instruct client in regards to diet, fluid restrictions and medication therapy. 5. Teach client to dipstick urine to monitor for protein.

Wilm's Tumor (Nephroblastoma)

Nephroblastoma (Wilm's tumor) is one of the most common intra-abdominal tumors

of childhood and is associated with congenital anomalies, especially those of the genitourinary tract. The treatment and survival rate are based on the stage of the tumor at the time it is discovered.

Assessment 1. Risk factors/etiology. a. Increased incidence among siblings and identical twins-genetic inheritance. b. Associated with congenital anomalies such as hypospadias, cryptorchidism, microcephaly. c. Peak incidence is three years of age.

2. Clinical manifestations. a. Swelling or mass within the abdomen-firm confined to one side of the abdomen, causing vague pain. b. Abdominal pain as tumor enlarges. c. Hematuria, pallor, anorexia, weight loss and malaise are uncommon. d. Hypertension (63%).

3. Diagnostics. a. Physical exam. b. Abdominal and chest x-rays. c. CAT scan and IVP, and MRI. d. CBC-may indicate polycythemia (elevated hematocrit). e. Renal ultrasound.

Treatment The survival rates greatly depend on the stage of the tumor at the time of diagnosis. If the tumor is diagnosed and treated in the early stages, there is a high survival rate.

1. Surgery. a. Surgery is frequently scheduled within 24 to 48 hours after the tumor is identified. b. Nephrectomy, including the adrenal gland. c. If both kidneys are involved, then one kidney is completely removed and the other is partially removed.

2. Medical. a. Pre and postoperative radiation therapy. b. Postoperative chemotherapy-actinomycin D, vincristine, adriamycin (over a six to fifteen-month period of time).

Nursing Intervention Goal: to avoid manipulation of abdomen preoperatively to prevent spread of metastases.

1. Handle child carefully when bathing to prevent trauma to the tumor site. 2. Prepare child and family for the surgery, including anticipation of a large incision and dressing. 3. Assess vital signs, especially blood pressure, for indications of hypertension. Goal: to assess kidney function, prevent infection, support and reassure child and parents postoperatively. 1. Usual postoperative care for abdominal surgery.

2. Assist with medical treatment and prepare family for therapies and their probable effects; prognosis is grave. 3. Assist the child in coping with side effects related to hair loss, nausea, vomiting, etc. 4. Vincristine is frequently used in chemotherapy; closely observe the child for the development of an ileus. 5. Prepare child for discharge emphasizing the usual needs for discipline and protection from infection.

Acute Renal Failure (ARF)

The loss of renal function may occur over several days or may occur over hours.

Phases of Acute Renal Failure 1. Oliguric phase. a. Urinary output decreases to less than 400 ml per day. b. Increase in BUN, creatinine, uric acid, potassium, magnesium, and presence of metabolic acidosis. c. Can last for 1 to 8 weeks. d. Often the patient may excrete two or more liters of urine daily-this is referred to as high output failure; occurs predominately after nephrotoxic antibiotics, burns, or traumatic injury.

2. Diuretic phase. a. A low gradual increase in urine output- three to five liters per day. b. Elevated serum creatinine, BUN. c. Decreased urinary creatinine clearance. d. Decrease in sodium, potassium, and water. e. May last for two to three weeks.

3. Recovery. a. May last from three to twelve months. b. Usually some type of permanent reduction occurs in glomerular filtration rate. c. Complications-secondary infection which is the most common cause of death.

Assessment 1. Risk factors/etiology. a. Prerenal (renal ischemia). (1) Hemorrhage. (2) Shock. (3) Burns. (4) Decreased cardiac output (especially in elderly). (5) Renal vascular obstruction --- renal vein or artery thrombosis.

b. Intrarenal (kidney tissue pathology). (1) Acute tubular necrosis-hemolytic blood transfusion reaction, severe crushing injury, nephrotoxic chemicals (carbon tetrachloride, arsenic, lead, mercury), nephrotoxic medication (aminoglycosides, antibiotics, and streptomycin).

(2) Acute glomerulonephritis and pyelonephritis. (3) Diseases that precipitate micro and microvascular changes (atheroselerosis, diabetes mellitus, hypertension).

c. Postrenal (obstructive problems). (1) Urinary calculi. (2) Benign prostatic hypertrophy (BPH). (3) Neoplastic disease. (4) Obstruction due to sulfonamide medication or strictures. (5) Trauma resulting in obstruction.

2. Clinical manifestations (multiple body systems affected). a. Urinary-decreased urinary output (Oliguria, less than 400 cc per day, except in elderly may be 600-700 cc/day). (1) Intrarenal and postrenal failure-fixed specific gravity is decreased, or increased sodium in the urine, very little proteinuria, "muddy brown" casts. (2) Prerenal failure-history of precipitating event, urine specific gravity may be high, high sodium concentration, and proteinuria (3) High output renal failure---the kidney no longer filters the urine. There is high urinary output, however, the urine is diluted and does not contain waste products from the filtering. b. Cardiovascular. (1) Initially hypotension followed by hypertension after fluid overload. (2) Congestive heart failure. (3) Dysrhythmia, frequency secondary to the increase in potassium. (4) Pericarditis, pericardial effusion. c. Respiratory. (1) Pulmonary edema due to congestive heart failure. (2) Kussmaul breathing due to metabolic acidosis. d. Gastrointestinal. (1) Nausea, vomiting, anorexia, and diarrhea. (2) Stomatitis and GI bleeding. e. Hematologic(1) Anemia occurring within the first two days. (2) Leukocytosis. (3) Inadequate platelet functioning. f. Neurologic. (1) Change in level of consciousness. (2) Memory impairment.(3) Convulsions. g. Fluid and electrolyte balance. (1) Fluid retention. (2) Hyperkalemia. (3) Hyponatremia (usually dilution). (4) Metabolic acidosis from accumulation of acid waste products.

3. Diagnostics. a. Elevated scrum creatinine, BUN, and potassium.

b. Urinalysis- proteinuria, casts, RBC, and "C, specific gravity is decreased.

Treatment 1. Medical. a. Identify and treat precipitating cause of acute renal failure (management varies according to prerenal, intrarenal, or postrenal disorder). b. Diuretic therapy-LASIX, EDECRIN, BUMM, MANNITOL. c. Decrease sErum potassium. (1) Administration of glucose and insulin- promotes potassium to move into the cells. (2) IV administration of soda bicarbonate- comets metabolic acidosis and causes electrolyte shift. (3) IV administration of calcium gluconate--antagonizes the adverse cardiac effects of hyperkalernia. (4) Administration of a cation -exchange resin (KAYEXALATE) by mouth or retention enema. 2. Dietary. a. Fluid restriction, intake may be carefully calculated with output. b. Protein, potassium, and sodium intake is regulated according to serum plasma levels. c. Increased carbohydrate intake, protein of high biologic value.

Nursing Intervention Goal: To maintain client in normal homeostasis and preserve renal function while the kidneys are repairing. 1. Accurate intake and output. 2. Daily weight (may lose .2 to .3 kg/day during oliguric phase). 3. Assess for hypervolemia during the oliguric Phase, fluctuations of sodium and potassium levels, cardiac dysrhythins. 4. Identify and monitor high-risk clients. 5. Evaluate for postural hypotension. 6. Support the client in relation to symptoms occurring in other body systems.

Goal. To prevent infection. 1. Avoid indwelling catheter if possible. 2. Assess for development of infectious processes. Client at increased risk due to compromised immune system.

Goal: to prevent skin breakdown. 1. Frequent turning and positioning, inspect the skin for problem areas. 2. Beds and protective devises to prevent pressure areas (decubitus ulcers). 3. Frequent range of motion and activities to increase circulation.

Goal: To provide emotional support. 1. Always explain procedures. 2. Provide honest information regarding progress of condition. 3. Encourage client to express fears and concerns regarding condition.

Chronic Renal Failure (CRF)

CRF is a progressive, irreversible reduction in renal function such that the kidneys are no longer able to maintain the body environment. The GFR gradually decreases as the nephrons are destroyed. The nephrons left intact are subjected to an increased work load, resulting in hypertrophy and inability to concentrate urine.

Stages of chronic renal failure. 1. Diminished renal reserve. a. Normal BUN and serum creatinine. b. Absence of symptoms. 2. Renal insufficiency. a. GFR is 25 percent of normal. b. BUN and serum creatinine increased (azotemia). c. Fatigue and weakness, mild anemia.. d. Headaches, nocturia, and polyuria. 3. End-stage renal failure (uremia). a. GFR is less than 10 percent of normal. (1) Severe azotemia. (2) Hyperkalemia, hypernatremia and hyperphosphatemia. (3) Metabolic acidosis. b. Urinary system-specific gravity of urine fixed at 1.010, proteinuria, casts, pyuria, hematuria, oliguria eventually leads to anuria. c. Endocrine system--hyperparathyroidism, amenorrhea, infertility, sexual dysfunction (impotence), decreased libido, hypothyroldism. d. Hematologic system--anemia and bleeding. e. Cardiovascular system-hypertension, CHF, ASHD, pericarditis, pericardial effusion. f. Gastrointestinal system--anorexia, nausea, vomitting, ammonia (uremic fetor) odor to the breath, gastrointestinal bleeding, and peptic ulcer disease. g. Metabolic system--hyperglycemia, hyperlipidemia, gout, hypoproteinemia. h. Neurologicsystem-general central nervous system depression and peripheral neuropathy. i.Musculoskeletal system-renal osteodystrophy, tissue calcification. j. Integumentary system-sallow yellow/gray discoloration, pruritus, and uremic frost. k. Psychological changes-emotional liability, withdrawal, depression and psychosis.

Assessment 1. Risk factors/etiology. a. Chronic glomerulonephritis and pyelonephritis. b. Chronic hypertension.c. Diabetic nephropathy. d. Nephroselerosis and renal artery disease. e. Polycystic kidney disease. f. Renal disease secondary to nephrotoxic drugs or chemicals. g. Lupus erythematosus.

2. Diagnostics. a. Increased BUN and serum creatinine level.

b. Decreased urinary creatinine clearance. c. Elevated blood sugar and triglycerides. d. Increased scrum potassium. e. Anemia (decreased hemoglobin and hematocrit).

Treatment 1. Medical. a. Measures to reduce scrum potassium (see discussion under acute renal failure). b. Administer antibypertensives(ALDOMET, APRESOLINE, INDERAL, CATAPRES). c. Diuretics-Thiazide diuretics may be used early, the loop diuretics, (LASIX), are used later.

2. Dietary. a. Problems with the client losing body weight, both adipose tissue and muscle mass. b. Restricted protein intake, may vary from just a decrease in protein intake, to a specific 20 to 40 gm per day. c. Protein should be of a high biologic value, this enhances the utilization of the amino acids, and forms less nitrogen waste products. d. Water restriction-adjusted according to urinary output-if no urine output 100 cc/day. e. Sodium and potassium restriction-based upon laboratory values. f. Keto acid supplements-help maintain a positive nitrogen balance (Shohl's solution).

3. Surgical-.kidney transplant. a. Recipient criteria: candidates are evaluated on an individual basis as to how well they would benefit from the transplant. (1) Candidates are usually under 70 years old, have a life expectancy of at least two more years, and have reasonable expectations that the transplant will improve the quality of life. (2) Clients with uncontrolled malignancies, COPD, severe cardiac problems, severe systemic diseases are not good transplant candidates. b. Donor criteria: live related donors (LRD) provide the best possible match; when they are not available, then cadaver donors are considered. (1) Either type of donor must he evaluated for adequate tissue matching. (2) The cadaver donor must meet the criteria for brain death. (3) The cadaver donor should be free from all systemic diseases, and have normal renal perfusion and function.

Nursing Intervention Goal: to assist the client to maintain homeostasis.

1. Evaluate adequacy of fluid balance. a. Daily weight. b. Postural hypotension. c. Level of fluid intake. d. Discuss with the client how to monitor the fluid intake and plan for the allocated amount to be distributed over the day. 2. Encourage adequate nutritional intake within dietary guidelines. a. Relieve GI dysfunctions prior to serving meals.

b. Plan diet according to client preferences if possible. c. Advise client that most salt substitutes contain potassium and should not be used. 3. Prevent problem of constipation. a. Include bran in diet. b. Stool softeners. 4. Avoid use of sedatives and hypnotics, increased sensitivity to these medications due to decreased ability of kidney to metabolize them. 5. Monitor electrolyte balance, especially level of potassium. 6. Assess cardiovascular status to determine how effectively the client is compensating with the increased fluid load, and increased work load on the heart from the chronic anemic state. 7. Assess client for bleeding tendencies related initially to decrease in production of erythropoietin, and decreased platelet adhesiveness. 8. Evaluate client for pruritus and assist with measures to decrease the skin irritation and itching.

Goal: to provide emotional support and promote psychological/equilibrium. 1. Encourage client to express concerns. 2. Recognize that the long-term management of a chronic disease may lead to anxiety and depression. 3. Encourage ventilation of feelings regarding life style changes. 4. Make available to client and family members other renal clients who are undergoing the same treatment approaches.

Goal: to provide preoperative care for kidney transplant. 1. Maintain client's metabolic state as close to homeostasis as possible-continue with dialysis. 2. Tissue typing and antibody screening is con- ducted to determine histocompatibility of the donor and the recipient. 3. Administer immunosuppressant drugs- IMURAN, and prednisone, and cyclosporin. 4. Conduct routine preoperative procedures.

Goal: to provide postoperative care for the kidney transplant. 1. Administer immunosuppressant therapy (therapy is continued indefinitely). 2. Assess for renal graft failure-rejection. a. Acute rejection-.occurs within four days to four months; symptoms are oliguria, edema, and BUN, increasing blood pressure, swelling and tenderness over transplant site. b. Chronic rejection-.occurs over months or years; associated with obstruction of the renal blood vessels; symptoms include proteinuria, hypertension, and increasing serum creatinine. graft tenderness, malaise. 3. Prevent and monitor for infection. a. Important to make distinction between infection and rejection as impaired renal function and fever occur in both. b. Symptoms of septicemia-infection, shaking, chills, fever, tachycardia, leukocytosis, and tachypnea.

4. Promote adaptation and psychological support in the successful transplant. a. Often there is a continual fear of possible rejection.

b. The concern of the client and the family is related to long-term usage of immunosuppressant medication which puts a tremendous psychological stress on the family unit. c. Refer client to community and national agencies: National Association of Patients of Hemodialysis and Transplantation, Inc., and The National Kidney Foundation.

Dialysis

The passage of particles (ions) from an area of high concentration to an area of low concentration across a semipermeable membrane. 1. Water, by osmosis, will move toward the solution in which the ion concentration is the greatest. 2. When dialysis is utilized, the semipermeable membrane used has pores large enough for waste products and water to move through, but too small for blood cells and protein molecules to pass through. B. Indications. 1. Fluid volume overload. 2. Serum potassium greater than 6 Meq/L. 3. BUN greater than 120 mg/DI. 4. Uremia and metabolic acidosis. C. Types of dialysis 1. Hemodialyis – circulation of the client’s blood through a compartment that contains as artificial semi – permieable membrane that is surrounded by a dialysate fluid which removes excess body fluid by creating a pressure differential between the blood and the dialysate solution.2. Peritoneal – utilization of the peritoneal cavity and the peritoneum as the semi permeable membrane that removes excess fluid.

a. Continuous Ambulatory Peritoneal Dialysis (CAPD) – the dialysate is infused into the abdomen and remains thee for 4-6 hours. The dialysate is removed by gravity drainage after the prescribed time. Most clients prefer to do dialysis at night.

b. Continuous Cycle Peritoneal Dialysis (CCPD) – similar to CAPD except that it requires a peritoneal cycling machine. Three cycles are usually done at night and in the morning.

c. Intermittent Peritoneal Dialysis – is performed on the peritoneal cycling machine for 10 – 14 hours, three to four times a week. It can be done at night.

Nursing Intervention Goal: To remove waste products of metabolism and excess fluid, to maintain a safe level of concentration of electrolytes; maintain a normal Ph and adequate buffer system. Potential for Infection related to peritoneal catheter, or vascular access site. Potential Impaired Breathing Patterns (peritoneal dialysis) related to pressure of the dialysate fluid in the abdomen during the infusion and dwell time. Potential Alteration In Nutrition. Less Than Body Requirements related to anorexia, protein loss in dialysate fluid (peritoneal). Altered Family Processes related to change in life style secondary to client's treatment schedule. Powerlessness related to dependency on dialysis for survival.

Potential Altered Home Health Management related to inadequate knowledge regarding diet, peritoneal or vascular access site care, fluid restrictions, infection, control of fluid intake, daily monitoring of status.

1. Peritoneal dialysis. a. Prepare client for procedure, establish baseline criteria of lab values, weight, vital signs. b. Provide support and information to the client when the peritoneal catheter is inserted. (1) Permanent peritoneal catheters are fitted with a device to keep them in place. Types of permanent peritoneal catheters are the Tenckhoff and Goretex catheters. Client should he taught how to care for the area around the catheter. (2) Temporary peritoneal catheters are inserted and usually a purse string suture holds them in place. c. Type of peritoneal dialysis being utilized and the physical stability of the client determine how long each cycle of dialysis will take. (1) Cycle is initiated with the inflow of the dialysate into the abdominal cavity. The client should be carefully observed on the initial infusion to determine how well he will tolerate the additional fluid in the abdominal cavity. Initial infusion should be slow. (2) The dialysate remains in the abdomen for a prescribed time frame, and is allowed to drain by gravity. The specific time for it to drain is usually specified in the doctor's orders. (3) One exchange constitutes infusion, dwell time, and drainage. (4) The dialysate should be warmed to body temperature before infusing. (Do not use a microwave oven.) d. Complications: possible bowel perforation from catheter insertion, peritonitis, bleeding, hypoalbumineniia, and general discomfort, hyperglycemia in diabetic clients.

2. Hemodialysis. a. Vascular access site must he established. Access may be temporary or permanent access. (1) External arteriovenous shunts- catheters are inserted into an artery and into a vein and are connected together on the outside of the arm in a "U" pattern. (2) Internal arteriovenous fistulas-an artery and a vein in the arm are anastomosed either directly or via a graft. Access is achieved via 2 large gauge needles inserted into the fistula site. (3) After the creation of an internal fistula, it must heal prior to being used for dialysis. Some grafts may be used in 48 hours. b. Evaluate access site for patency. Depending on the type of vascular access utilized as to the appropriate method to determine paten- cy. c. Do not take blood pressure or obtain blood samples from the extremity that has a vascular access site.

Goal: to provide emotional support and promote psychological equilibrium. 1. Encourage client to express feelings of anger and depression. There is an increase in the rate of suicides in dialysis clients. 2. Encourage appropriate coping skills.

3. Clients on dialysis are in limbo, they do not know if they are going to get better or not. Frequently they have ambivalent feelings about dialysis; it maintains their life, however, it severely restricts their life style.

Renal Tumor

The majority of renal tumors are malignant, occur more frequently in men age 50 to 70 years of age. Most often the tumor begins in the renal cortex where it can actually become quite large before it begins to compress the adjacent renal tissue. The most common areas of metastasis are the lungs and bone, especially the mediastinum.

Assessment 1. Clinical manifestations. a. Palpable abdominal mass.b. Hematuria, flank pain. c. Weight loss, weakness and anemia, hyper- tension. 2. Diagnostics. a. IVP and sonogram. b. CAT scan. c. Renal arteriography. d. Renal biopsy.

Treatment 1. Medical. a. Radiation therapy. b. Chemotherapy. 2. Surgical-nephrectomy.

Nursing Intervention Goal: to provide preoperative nursing care 1. Instruct client that flank incision will be on affected side and that surgery will be performed in a hyperextended, side-lying position. 2. Often, postoperatively client experiences muscle aches and discomfort due to surgical positioning. 3. Instruct client that they may receive radiation or chemotherapy or both after surgery.

Goal: to provide postoperative care. 1. Urinary output is important to assess; catheters should he labeled and drainage recorded accurately. 2. Due to the level of the incision, respiratory status is important. Encourage coughing and deep breathing as well as incentive spirometry every two hours while client is awake. 3. Assess for abdominal distention and paralytic ileus which is due to reflex paralysis of intestinal peristalsis and manipulation of the bowel during surgery. Goal: to provide supportive nursing care in relation to malignancy.

KIDNEY TRANSPLANT

1. Definitions:- the surgical implantation of a donated, allogenic kidney to restore

kidney function in a client with end-stage renal failure- tranplantation of a kidney from a donor to recipient to prolong the life

of person with renal failure

2. Sources of donor selection a. Living relative with compatible serum and tissue studies, free from systemic infection, and emotionally stable b. Cadavers with good serum and tissue crossmatching; free from renal disease, neoplasms, and sepsis; absence of ischemia/trauma.

3. Rejection of the grafted kidney is a significant problema. Attempt to minimize: tissue typing before transplantation (must indicate high

degree of histocompatibility)b. Types of rejection1. hyperacute; occurs on the operating room table2. acute: first episode can occur 5-7 days after transplant: subsequent episodes

can occur within the first year3. chronic rejection continues despite repeated attempts at immunosuppression4. rejection ratesa. 20%-25% of cadaver graftsb. 5%-10% of live donor graftsc. greatly increased by the presence of diabetes

5. Immunosuppressive drugs are given to all transplant recipients; a. Azathioprine (Imuran): assess for manifestations of anemia, leucopenia, thrombocytopenia, oral lesions. b. Cyclophosphamide (Cytoxan): assess for alopecia, hypertension, kidney/liver toxicity, leucopenia c. Antilymphocytic globulin (ALG), antithymocytic globulin (ATG): assess for fever, chills, anaphylactic shock, hypertension, rash, headache. d. Corticosteroids (prednisone, methylprednisolone sodium succinate/ Solu-Medrol): assess for peptic ulcer and GI bleeding, sodium/water retention, muscle weakness, delayed healing, mood alterations, hyperglycemia, acne.

Nursing ProcessAssessment1. Metabolic state

2. Tissue histocompatibility3. Immunological defense status4. Psychological and emotional status5. Potential sources of postoperative infection (carious teeth, infected donor

kidneys) since client will be immunosuppressed6. Age; desires of the client regarding this risk-filled procedure

Planning, Implementation, and Evaluation

Goal 1: Client will be adequately prepared pre-operatively to maximize the chances of a successful outcome.

Implementation1. Refer to” Perioperative period,”2. Maintain accurate I & O: adhere to fluid restriction; daily weights.3. Know that the client may need to undergo pre-operative hemodialysis to

achieve an optimal metabolic state.4. Protect client from possible sources of infection (reverse isolation).

EvaluationClient is able to describe the postoperative routine.

Goal 2: Client will be psychologically prepared for the surgery.

Implementation

1. Refer to “Perioperative Period,”2. Allow client the opportunity to discuss feelings and concerns regarding

the surgery and its chances of success.3. Answer client’s questions as honestly and completely as possible. 4. Allow client an opportunity to discuss any ambivalent feelings about

the donor (may be a very close relative).5. Know that significant others also need support and information.

EvaluationClient experiences only a moderate level of anxiety preoperatively; expresses realistic hope regarding outcome of transplant.

Goal 3: Client will be free from postoperative complications.

Implementation:1. Refer to “Perioperative Period,”2. Assess fluid and electrolyte balance carefully.a. Measure urine output (may range from massive diuresis (live donor) to

aneuresis (cadaver donor).b. May require hemodialysis.c. Monitor I & O hourly and adjust IV fluid administration accordingly.3. Protect client from infection.a. Give Foley catheter care.b. May be in reverse isolation.c. Monitor temperature4. Observe for signs of acute rejection of transplant.

a. Oliguria, anuriab. Fever (temperature greater than 37.4 C)c. Increased blood pressured. Swollen, tender kidneye. Flu symptoms5. Maintain integrity of venous access.6. Encourage frequent and early ambulation.7. Provide mouth care and nystatin (Mycostatin) mouthwashes for candidiasis.

EvaluationClient has vital signs within normal limits; output equivalent to fluid intake; remains free from infection.

Goal 4: Client will take medications correctly.

Implementation1. Teach client that immunosuppressive drugs are the main defense against

transplant rejection.2. Teach side effects and complications of these drugs and that withdrawal (if it

is ever appropriate) must be done gradually.3. Tell client that he is more susceptible to infection while taking these drugs and

to notify physician at the first sign of a cold or infection.4. Teach client how to avoid or at least decrease exposure to sources of infection.EvaluationClient lists side effects of all drugs; know when to call physician regarding drug-related problems; states an awareness of administration schedule and importance of maintaining it.

Goal 5: To inform/observe the patient about the signs and symptoms of rejection

Implementation1. Assess for signs of rejection. Include decreased urinary output, fever, pain/tenderness over transplant site, edema, sudden weight gain, increasing blood pressure, generalized malaise, rise in serum creatinine, and decrease in creatinine clearance.2. Provide client teaching and discharge planning concerninga. Medication regimen; names, dosages, frequency, and side effectsb. Signs and symptoms of rejection and the need to report immediatelyc. dietary restrictions: restricted sodium and calories, increased proteind. Daily weightse. Daily measurement of I & Of. Resumption of activity and avoidance of contact sports n which the transplanted kidney may be injured.