Renal Nursing Care
Mary Moon, RNC, FNP
Small molecules make easily movement by
diffusion in a cell
limited by the cell’s semi permeable
Coffee In liquid: Equally sweet
In air: Equally smell
0.9% Plasma NaCl
Solutes: materials-- sugar, salt.
Solvent: Liquid material that dissolve--water
Solution: A mixture of two.
Tonicity: A state of amount of dissolved material
Tonicity: By NaCl
From: 0.9% NaCl
99.1% H20 3% NaCl
Osmosis: [H20] [H20]
99.1 H20 will move
Hyper tonic into RBC.
0% NaCl will
A special type of diffusion between NACl & water.
Water: Small, unchanged molecules
NaCl: Changed molecules
*** Changed molecules are hard to move--- H20
move freely from a weaker solution to a more
NaCl: Electrolytes that regulate vascular osmotic
Purify (Filter) and reabsorb 5 inches long, level
with T12 and L1~L3
Urine: collected by the pelvis
20% to 25% of the resting cardiac output
(approx. 1200 mL per Min.) passes through
Liver: 27% Brain: 14% Heart:
Skeletal: 15% Skin: 6% Bone:
Each region of the nephron:
filtration, re absorption, and secretion.
(Bowman’s Capsule) (Tubules and Collecting Duct)
180 liters of filtrate a day Right one more
upper limit (transport maximum):
glucose 225 mg/min Functional unit of
(BS: 180 mg/dl)
1/4 of nephron
at higher concentration, needed for living.
glucose begins to be lost in urine.
Excretion of waste nitrogen (urea, uric acid, creatin)
protein--> ammonia--> harmless urea--> kidney
American food ( protein)
Detoxification of ammonia -->
¤ Liver, Kidney failure
H20 and electrolytes
¤[ ] = H20, lytes.
Is a clinical syndrome characterized by
a renal shut down--> acute tubular
necrosis, obstruction, acute tubular
insufficiency--> Most occur in
previously healthy individuals.
Generally follows an identifiable
trauma contact with a nephrotoxic
agent. The most cause of ARF is related
to surgical procedures.
Causes---> Consists of factors outside
the kidneys that impair renal blood
flow and lead to decreased glomerular
Problem corrected --> no ARF
Intravascular volume depletion, decreased CO,
vascular failure secondary to vasodilation or
obstruction---HTN, MI, severe dehydration, &
shock ( not enough volume circulating).
Reversible—can be corrected by establishing
renal perfusion & preventing necrotic renal
damage by fluid challenge
Conditions of actual damage to the renal
tissue leading to malfunctioning of
nephrons---> APN may lead ARF
Ex) acute tubular necrosis-
Kidney itself damaged to the kidney tissues and
structures & includes tubular necrosis,
nephrotoxicity & alterations in renal blood flow
Injuries @kidney glomeruli or tubules—90% due
to ATN--- glomerulonephrits, toxins, trauma,
crushing injuries, surgery, sepsis, CV collapse,
MOF, ABX like aminoglycosides, street drugs,
chemo, nephrotoxic drugs
Don’t get confused w/ prerenal caused by blood
volume—dehydration & hypovolemia
Mechanical Obs. Of urinary outflow. As the
flow of urine is blocked. Urine backs up into
the renal pelvis. The most common causes are
renal calculi, trauma, tumors.--> usually
anuria rather than oliguria
Ex) Calculi, bladder tumor. Stricture
Basement membrane is not destroyed.
Trauma to back, pelvis, perineum strictures,
spinal cord disease.
Obstruction of urine between the
kidney and the urethral meatus
Calculi BPH Tumors strictures
B/C the obstruction, urine backflows
A. High Risk
Hospital Pt. --> Massive trauma,
major surgical procedure, extensive
B. Industrial chemicals and
A. Onset phase
begins with precipitating event--
Hypovolemia, or nephrotoxin exposure
Ends when the oliguric-anuric phase
Time Span: Up to two days
urine output: 20% of normal.
A. Onset Phase
Initial injury to the kidney
Preventable with early intervention
UO:20% of normal
Unable to regulate electrolytes
B. Oliguric Phase
Spans the period when urine is less
than 400 cc/d
Time Span: 8-14 days (1-2 wks)
urine output: 5% of normal.
Can not excrete fluid or waste
Oliguria--> caused by reduction in
C. Diuretic Phase
Gradual increase in urine output of
1-3L up to 4-5 L/day. The high vol. Is
due to osmotic diuresis from high urea
urea H20 Capillary
H20 H20 H20 H20 H20 cells
and the adequate concentrating ability
Lab. Value stop rising, decreased SG:
Diluted urine and poss.
Excessive diuresis when lab value
stops dropping. Ends when they
Time span: 10 days
U.O: Early 150%
Electrolytes are lost—deficit in
concentrating ability of tubules and
osmotic diuretic effect of increased
BUN, slowly increased excretion of
metabolic wastes, hypovolemia, loss
of Na, K, increased BUN initially then
gradually return to baseline
S/S: postural hypotension, tachycardia,
improving mental alertness and
activity, weight loss, thirsty, dry
mucous membrane, decreased skin
K replacement may require
D. Recovery Phase
Begins when lab. Values stabilize, ends
when renal function returns to normal.
Time Span: 4-6 mo.
Up to 12 mo.
Increased concentrating ability.
Urine SG -- 1.003-1.030
Mortality Rate: 30% to 60%
Most common cause of death secondary
Prevention of ARF
CHF, dehydration, shock. To minimize
1. Keep the patient hydrated (esp.
before and after OR)
2. Continuously monitor the
dosages and effects of ABX and
other drugs (nephrotoxic)
3. Assess renal function regularly
1. Correcting the underlying problem
2. Preventing infection
3. Treating fluid and electrolytes
4. Correcting metabolic acidosis
5. Treating clinically significant anemia.
How does one differentiate acute from chronic renal
1. History-medical records.
2. Hypo calcemia, hyper phosphatemia, anemia. --> has
been associated more often with CRF.
* Calcium, phosphorous, acid-base derangement
are often seen in ARF as early as 48-72 hours after onset
* Anemia: nonspecific indicator.
3. Reliable indicator of CRf
Small kidney with a decreased or absence of renal cortex
as assessed by UTZ (0.5 cm)
Abnormal: Kidney length of less than 9 cm
--> CRF or significant renal dz.
> 1.5 cm in renal length: unilateral/asymmetric renal dz.
Slow, progressive, irreversible damage
Diminished Renal Reserve ---50% of
nephrones are lost, asymptomatic, no S/S
Renal Insufficiency---75% nephrones lost,
azotemia, anemia, polyuria, nocturia
Renal Failure---pt needs temporary or
End Stage Renal Disease
An irreversible loss of nephrons. A symptomatic until 70-
90% of the nephron is destroyed.
(Divided into four stages)
1. Diminished renal reserve: nephron loss without the
loss of measured renal function. Normal BUN, CR, no sxs.
2. Renal insufficiency: a measurable decline in renal
function. Loss of ability to concentrate urine --> nocturia,
polyuria, often associated HTN fatigue, weak. Ha.
3. Renal failure /ESRD
4. Uremia: a clinical syndrome with severe decline in
renal function, associated with dysfunction of multiple
Etiology of CRF
1. 30%: Diabetic nephropathy
2. 26%: Hypertension
3. 14%: other urological disease (
hydronephrosis, polycystic kidney.)
4. Congenital malformations
5. Nephropathy associated with the human
6. Myeloma Kidney
Evaluation: To establish the degree of
To identify reversible factors
-infection, obstruction, volume deficit,
nephrotic drugs, less than optimal cardiac
output with, without HTN, uncontrolled
HTN, hypercalcemia and hyperuricemia
-orthostatic Bp. Pulse
-U/A with microscope/dipstick, serum
electrolyte, BUN, CR, CBC, evaluation of
post void residual, UTZ
U/A: the simplest, most cost effective evaluation
Urine SG: 1.010 or less
Urine pH: less than 7.0 8.0: the question of infection
Dipstick: glucose in DM or CRF
Proteinuria: the hall mark of intrinsic renal disease.
Nephrotic-range of proteinuria is seen in glomerular
lesions and 1-2 gm of protein excretion in interstitial
RBC: active renal dz of a glomerular or vascular
A. Most hypervolemic--> kidney can’t eliminate amount of
H20 and electrolytes. ** Hypovolemia
The main cause of anemia-->
Decreased production of erythropoietin by the kidney
C. Nutritional deficiency
Decreased RBC life
increased hemolysis of RBC bleeding from G I tract
dialyzer may contribute to the anemic state.
Folic Acid: Essential for DNA Synthesis and normal
maturation of RBC.
1) Hemodialysis: within 1-2 Hr. bring K+ to normal
2) Peritoneal dialysis: 4-8 hrs.
E. Phosphate binders
(aluminum or magnesium containing antacids)-->
An inverse relationship to bind excessive CA in ECF--
> Decreased serum Ca level phosphate binders-->
urinary acidifier to help prevent calcium stones
the major goal of nutritional management is to
decrease catabolism of the body’s protein. No more
than 0.8-1 gm of protein/kg/day.
the major goal of nutritional management is to
decrease catabolism of the body’s protein. No more
than 0.8-1 gm of protein/kg/day.
1. NA-fluid restriction
*3. Anti HTN drugs
A. Ace inhibitors-- enalapril, captopril
B. beta-adrenergic--inderal (decreased rennin
C. Calcium channel blockers: diltiazem,
H. Neurologic Function
No. TX. Available without dialysis
neuro Change--> renal failure progress
AntiHTN: triamiterene spironolactone,
* 10 unit regular insulin + D 50 ampule.
NaHCO3 bolus or 75~ 100 cc/hr- hyperkalemia tx.
* Albuterol: Potassium lowering effect
Increased nitrogenous waste products,
electrolytes imbalances --> demylination of
nerve fiver, axonal atrophy.
** Safety: due to weak muscle
general depression of CNS--> lethargy, fatigue,
decreased concentration, dialysis dementia due
to aluminum toxicity
Complications: UGI bleeding
a major Cx and 3-7% of deaths. Superficial
mucosal abnormalities. Duodenitis and gastritis
TX: Cimetidine (H2-receptor antagonist)
Death is usually due to infection, G-I
bleed, myocardiac infarction. Kidney
can no longer remove toxic wastes
and water from blood. Two means
are mimicking the body’s lost
Uremia is a clinical situation in which
azotemia progress to systematic state.
Azotemia; an excess of urea or other
nitrogenous compounds in the blood.
Fetor: offensive odors
halitosis: offensive odors of the
CV: CHF, HTN, pericarditis, arrythmia,
hematopoietic anemia, peripheral/systemic edema.
Neuro: Drowsy, confusion, tremor, coma,
irritability, convulsion, twitching, peripheral
Integ: pallor, yellowish color, dryness, pruritis,
Hypocalemia, soft tissue, calcification, alteration in
coagulation, increased infection
GI: Anorexia, N/V, gastrtitis, uremic halitosis,
Resp: Pul. Edema, Pneumonia, Kussmaul Resp.
A motor disturbance by sustained
contraction of muscles.
Kussmaul Breathing--> Deep to
rapid breathing to increase excretion
--> a compensatory mechanism of a-
Nutrition in Renal Disease
Sodium: major ECF Caution, important in acid-
base balance, fluid balance, cell permeability, and
High NA+ Foods: Table salt, processed foods,
milk, fish, poultry, meat, eggs, carrots,k some
canned soup, beets, spinach, meat sauce, soy
sauce, salad dressings, potassium: major ICF,
important in acid-base balance, neuromuscular
activity, carbohydrate metabolism, and protein
High in K+ foods: meat, oranges,
potatoes, whole grains, bananas,
broccoli, beans, nuts, apricots, spinach,
dried fruits, melons, peas, fruit juices,
peaches, tomatoes, avocados, coffee,
wine, salt substitute, antibiotics.
Proteins: build, maintain, and repair
Protein sources: eggs, milk, fish, poultry,
grains, legumes (dry beans, lentils, split
peas, soy beans)
Calories (carbohydrates, fats): to meet
body’s need for energy and to attain or
maintain ideal body weight. Fats are also
important in maintaining skin integrity
and forming complex lipid compounds.
Carbohydrate source: fruits, vegetables,
cereals, sugar, hard candy, jelly beans,
Fat sources: butter, margarine, oil, cream,
bacon, meat fat, salad dressing, egg yolk,
olives, nuts, avocados.
Vitamins and mineral supplements:
Vitamin C, B Complex Vitamins, calcium,
phosphorus, and vitamin D.
Calcium sources: calcium carbonate (OS-
call, Tums), calcium acetate (Phos-Low),
supplements given between meals.
Phosphorous binding agents: Calcium
acetate (Phos-Low), aluminum hydroxide
gel (Amphogel), aluminum carbonate
(Basalgel) binding agents given with
Vitamin D source; Calciferol (Hytakerol),
Iron sources: ferrous sulfate, parental
Magnesium: not usually a problem
unless there is intake of
magnesium containing medicines
such as laxatives and antacids.
A. Decreased RRF (Reserved Renal Factor)
B: Aging kidney is less able to withstand
changes in hydration, solute, load, cardiac
output. Aging itself is the primary risk factor.
Mortality: 5-25% higher in older than
An artificial Semi permeable membrane acts like
the kidney-> diffusion and osmosis
Excess fluid is removed by creating a pressure
differential BTN the blood and the dialysate
(=balanced solution of electrolytes and fluid)
With a combination of positive pressure in the blood
compartment and/or negative pressure in the
2.5-4 hrs 3 times/week at home or dialysis center.
single, double, temporary
vascular access, 2-3 days
femoral, subclavian, internal
AV Shunt: Temporary while internal graft is
Grafts (looped graft)
Bovin--> relatively resistant to infectious
NSG: 14-16 G needle A thrill/bruit can
be felt by palpating
***** NO VENIPUNCTURE, BP ON THE
1. Hypovolemia/shock --due to rapid removal of vascular volume
* trendelenberg to improve cerebral blood flow
2. Analgesia: muscle cramps associated with significant discomfort
: neuromuscular hypersensitivity
Principle---sterile dialyzing fluid infused into peritoneal cavity
through a catheter
Surgically implanted in the pt’s peritoneal cavity.
* continuous 24
Inflow ---> dwell ---> outflow times/day
15-30 min. 4 hr/d 15-30 min. * at night 8 hrs
A living or cadaveric donor
the life expectancy for patients on dialysis is 6-
7 years < 60 years.
2-3 years > 60 years or diabetic
Survival years is 90% at 3 years with cadeveric
Ruptured AV Shunt
hypovolemia--shock-- cardiac arrest
1. Control bleeding
3. Pain relief
hematoma-arm, cold compression
To Control Bleeding
1. Tie a tourniquet above the AV or BP
cuff. Don’t release until OR.
* pressure DSG, Arm.
2. IV fluid, O2 2L
3. Notify MD/surgical team
4. Type and cross match ---cont.
monitor the pt for signs of shock.
5. Dopamin Drip
secondary to fluid overload
6. Strict I & O
7. H & H Q 4-6 H
8. Monitor circulatory, motor,
neurofunction below hematoma.
Infection of the kidney and renal
Every PN is secondary
Acute infection of the kidney, characterized by
acute inflammation and focal abscess, usually
unilateral, often accompanied by bacteremia.
Characterized by bacteriuria (generally >
100,000 colonies/ml) and pyuria. In acute
infections, a single infective pathogen usually
The result of repeated episodes of
APN leading to progressive renal
Scars are usually asymmetric and
irregular and involve the renal cortex
and pelvocalyceal system. Negative
urine cultures and no evidence of
Gram-neg Bacilli: Escheria coli,
Enterobacter, kebsiella, Serratia,
and Citrobacter species.
Gram-pos cocci: Staphylo. S
The most common cause of GU
Female- short urethra
altered flora d/t
antibiotics, birth control
(spermicide and diaphragm)
Direct extension from
- GU tract fistulas.
Rapidly over a few hrs. or a day
Temp>39.4 C (103)F
Sxs of cystitis may or may not
Generalized muscle tenderness
Marked tenderness on deep pressure on CVA or on
deep abd. Palpation
Pyuria with leukocyte casts
Bacteria on gram stains of unspun
Hematuria in acute phase of disease
Elderly: no classic sxs., urinary
incontinence (new onset), decreased
appetite, confusion, lethargy
Children: not clear, low grade fever,
irritable, decreased appetite, n/v,
diaper urine smells, no s/s of UTI
Older Children: abd. Pain,
frequency, flank pain,
dysuria, difficulty controlling
Severe PN-fever subsides
more slowly and may not
disappear for several days.
Even after appropriate
A. Relieve obstruction prn
(may be contributing to the
B. C & S--> antibiotics/long
C. Check Creatinine, CBC
may treat at home!
A. patient teaching
- 3 liters fluid/day
- check urine output
- prevent infections
- call MD
Inflammatory reaction in
infection (2-3 wks after)
with glomerular tissue.
increased porosity &
kidney congested, swollen
HA, malaise, edema, flank
CVA tenderness, SOB
increased SG, edema,
HTN, decreased UO,
increased BUN & Cr.
Protect kidney + treat CX
dec.protein diet & Na diet,
anti-HTN, fluids, diuretics
Conditions that manage glomerular
capillary membrane--- chronic GMN,
DM, SLE, pericarditis, allergic
reaction, CHF, pregnancy
Change in glom. Base membrane,
inc. porosity & loss of proteins--->
dec. albumin---> dec. serum
pressure-->edema& dec. plasma
---aldosterone--NA & H2O
Edema, proteinuria, dec. albumin,
inc. lipidemia, UO inc/dec-->
renal failure. Dec. appetite, fatigue
Dec. albuminemia, control
promote general health---
protein normal or inc, inc.
Edema---dec. NA, diuretics,
check K+RUA, renal labs.
, diet, bp
Patient education--> avoid infection,
fatigue, f/u medical care
Sx renal fail---MD
Nutrition Na & protein control. Small
Medication--- steroids, diuretics
Checks for SEs, resp. assess
patient teaching---meds, nutrition,
self assessment/fluids call MD--
inc. edema, DOE, fatigue, HA,