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Renal and Urinary

Acute kidney injury AKI caused by glomerulonephritis

(AKI) is classified as intrinsic or
intrarenal failure. This form of AKI
commonly manifests with
hypertension, tachycardia,
oliguria, lethargy, edema, and
other signs of fluid overload.

AKI from prerenal causes is

characterized by decreased blood
pressure or a recent history of the
same, tachycardia, and decreased
cardiac output and central venous
pressure.

- Clinical manifestations
associated with AKI occur as a result of metabolic acidosis. The nurse
would expect to note Kussmaul respirations as a result of the metabolic
acidosis because the bodily response is to exhale excess carbon dioxide.
- In the diuretic phase, fluids and electrolytes are lost in the urine. As a
result, the plan of care focuses on fluid and electrolyte replacement and
monitoring.
- In intrinsic failure, there is a fixed specific gravity and the urine tests positive
for proteinuria. In prerenal failure, the specific gravity is high, and there is very
little or no proteinuria. In postrenal failure, there is a fixed specific gravity and
little or no proteinuria.
- The kidneys normally receive 20% to 25% of the cardiac output, even under
conditions of rest. For kidney function to be optimal, adequate renal perfusion is
necessary. Perfusion can best be estimated by the blood pressure, which is
an indirect reflection of the adequacy of cardiac output.
- Serum myoglobin levels increase in crush injuries when large amounts of
myoglobin and hemoglobin are released from damaged muscle and blood cells.
The accumulation may cause acute tubular necrosis, an intrarenal cause of
renal failure.
- During the oliguric phase of acute kidney injury, serum creatinine levels
increase by approximately 1 mg/dL (88 mcmol/L) per day, and the BUN level
increases by approximately 20 mg/dL (7.1 mmol/L) per day. The specific gravity
of the urine is low and fixed, and the urine osmolarity approaches that of the
client's serum level, or about 300 mOsm/kg (300 mmol/kg). Urine output is less
than 100 mL in a 24-hour period.
- The diuretic phase of acute kidney injury is characterized by an increase
in urine output of more than 1000 mL in a 24-hour period. This increase in urine
output indicates the return of some renal function; however, blood urea nitrogen
and creatinine levels continue to rise during the first few days of diuresis. The
diuretic phase develops about 14 days after the initial insult and lasts about 10
days.
- Heart failure is referred to as a prerenal cause of acute kidney injury
because heart failure results in decreased blood flow to the kidneys. The kidneys
normally receive about 20% to 25% of the cardiac output and require adequate
perfusion to function properly. With a significant or prolonged decrease in blood
supply, the kidneys can fail.
- The excretion of potassium and maintenance of potassium balance are
normal functions of the kidneys. In the client with AKI or chronic kidney
disease, potassium intake must be restricted as much as possible (to 60 to 70
mEq/day). The primary mechanism of potassium removal during AKI is dialysis.
- The normal urine myoglobin level is negative. After extensive muscle
destruction or damage, myoglobin is released into the bloodstream, where it is
cleared from the body by the kidneys. When a large amount of myoglobin is being
cleared from the body, there is a risk of the renal tubules being clogged with
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myoglobin, causing acute tubular necrosis. This is one form of acute kidney
injury.
Acute rejection in Acute rejection most often occurs within 1 week after transplantation but
kidney transplant can occur any time posttransplantation. Clinical manifestations include fever,
clients malaise, elevated white blood cell count, acute hypertension, graft tenderness,
and manifestations of deteriorating renal function. Treatment consists of
increasing immunosuppressive therapy.
Removal of the transplanted kidney is indicated with hyperacute rejection,
which occurs within 48 hours of the transplant surgery.
Alkaline diet In some client situations, the health care provider may prescribe a diet that
consists of foods that yield either an alkaline or an acid residue in the urine. In an
alkaline residue diet, all fruits are allowed except cranberries, blueberries, prunes,
and plums.
Aluminum hydroxide Aluminum hydroxide may be prescribed for a client with CKD. It binds with
phosphate in the intestines for excretion in the feces, thus lowering phosphorus
levels. It can cause constipation. = It combines with phosphorus and helps
eliminate phosphates from the body.
Aluminum The client with CKD is almost certain to have a problem with constipation as a
hydroxide gel result of factors such as fluid restriction, fatigue that limits exercise, and dietary
restrictions. In addition, phosphate-binding antacids such as aluminum
hydroxide gel cause constipation as a side effect.
Aluminum intoxication Aluminum hydroxide may be prescribed as a phosphate-binding agent. Aluminum
intoxication can occur when there is an accumulation of aluminum, an ingredient
in many phosphate-binding antacids. It results in mental cloudiness, dementia,
and bone pain from infiltration of the bone with aluminum.
Arterial steal Steal syndrome results from vascular insufficiency after creation of a
syndrome fistula. The client exhibits pallor and a diminished pulse distal to the
fistula. The client also complains of pain distal to the fistula, caused by tissue
ischemia. Warmth and redness probably would characterize a problem with
infection. Ecchymosis and a bruit are normal findings for a fistula.
Arteriovenous fistula The nurse assesses the patency of
the fistula by palpating for the
presence of a thrill or auscultating
for a bruit. The presence of a thrill
and bruit indicate patency of the
fistula. Enlarged visible blood vessels
at the fistula site are a normal
observation but are not indicative of
fistula patency.

- General indicators that the client is

not experiencing infection include a temperature and WBC count within normal
limits.
- An AV fistula is the internal creation of an arterial-to-venous anastomosis. This
causes engorgement of the vein, allowing both the artery and the vein to be
easily cannulated for hemodialysis. Fistulas take 1 to 2 weeks to mature
(engorgement) or develop before they can be used for dialysis, so the
current method of access must remain in place to be used during that period.
- An AV fistula is a vascular access system that is required for
hemodialysis. It is a device established for clients who need long-term
hemodialysis. It is created by connecting an artery to a vein inside the body to
create a vessel that can handle the amount of blood flow necessary for effective
dialysis. Bleeding, clotting, and infection are risks with all vascular devices. It also
is very important to avoid any activity that would promote the status of blood or
increase the risk for infection. Taking the blood pressure in the affected arm,
carrying heavy objects in the arm, and lying on the arm at night could increase
the risk for clotting in the fistula. To check circulation of the fistula, the nurse
should palpate or feel for the thrill or auscultate (listen with a stethoscope) for the
bruit. It is important to do this at least daily to ascertain the patency of the
fistula. To avoid infection, that extremity is never used for peripheral intravenous
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access (placement of an intravenous line) or for blood draws. Strict aseptic

technique is used in accessing the fistula for dialysis.
Arteriovenous shunt An external arteriovenous shunt is a less common
form of access site but carries a risk for bleeding
when it is used because 2 ends of an external
cannula are tunneled subcutaneously into an artery
and a vein, and the ends of the cannula are joined.
If accidental disconnection occurs, the client could
lose blood rapidly. For this reason, small clamps are
attached to the dressing that covers the insertion
site for use if needed. The shunt site also should be
assessed at least every 4 hours. Checking the
shunt for the presence of bruit and thrill relates to
patency of the shunt. Although checking the results
of the prothrombin time is important, it is not the
priority nursing action.
= Ensure that small clamps are attached to the
arteriovenous shunt dressing.

Benign prostatic - Decreased force in the stream of urine is an early symptom of benign
hypertrophy (BPH) prostatic hyperplasia. Nocturia, incontinence, and an enlarged prostate are
characteristics of BPH and need to be assessed for in all male clients over 50
years of age.
- Hematuria is not an early sign of BPH. Nocturia, decreased force of urine
stream, and difficulty initiating urine stream are all early signs of BPH.
- A transrectal ultrasound examination and PSA level determination help
to rule out the possibility of prostate cancer.
- Transurethral resection syndrome is caused by increased absorption of
nonelectrolyte irrigating fluid used during surgery. The client may show signs
of cerebral edema and increased intracranial pressure, such as increased
blood pressure, bradycardia, confusion, disorientation, muscle twitching, visual
disturbances, and nausea and vomiting.
Bladder cancer A complication of radiation therapy for bladder cancer is fistula formation. In
women, this frequently is manifested as a vesicovaginal fistula, which is an
opening between the bladder and the vagina. With this complication the client
senses that urine is flowing out of the vagina. In men, a colovesical fistula may
develop, which is an opening between the bladder and the colon.
Bladder emptying Measuring postvoid residual gives specific information about the ability of the
bladder to empty completely.
Bladder infection The ureterovesical junction is the point at which the ureters enter the
bladder. At this juncture, the ureter runs obliquely for 1.5 to 2 cm through the
bladder wall before opening into the bladder. This anatomical pathway prevents
reflux of urine back into the ureter and, in essence, acts as a valve to prevent
urine from traveling back into the ureter and up to the kidney.
Bladder repair A complication after surgical repair of the bladder is disruption of sutures, caused
by tension on them from urine buildup. The nurse prevents this from happening
by ensuring that the catheter is able to drain freely. This involves basic
catheter care, including keeping the tubing free from kinks, maintaining
the tubing at a level below the bladder, and monitoring the flow of urine
frequently.
Bladder trauma The presence of blood at the urinary meatus may indicate urethral trauma or
disruption. The nurse notifies the HCP, knowing that the client should not be
catheterized until the cause of the bleeding is determined by diagnostic testing.
Calcium oxalate Many kidney stones are composed of calcium oxalate. Foods that raise urinary
calculi oxalate excretion include spinach, rhubarb, strawberries, chocolate, wheat bran,
nuts, beets, and tea.
Candida urinary tract Candida infections, which are fungal infections, develop in persons who are on
infection (UTI) long-term antibiotic therapy because an alteration of normal flora occurs.
These infections also are commonly seen in clients with blood dyscrasias, diabetes
mellitus, cancer, or immunosuppression and in those with a drug addiction.
chlamydial infection - Follow-up cultures are typically done in 4 to 7 days to evaluate the effectiveness
of the medication.
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- Antibiotics are not taken prophylactically to prevent acquisition of

chlamydial infection. The risk of reinfection can be reduced by limiting the
number of sexual partners and by the use of condoms. In some cases, follow-up
culture is requested in 4 to 7 days to confirm a cure. The remaining options are
correct measures.
Causes of decreased Dopaminergic receptors are found in the renal blood vessels and in the
renal perfusion nerves. When stimulated, they dilate renal arteries and help modulate release of
the neurotransmitter dopamine. Renal artery dilation helps improve urine output
by increasing blood flow through the kidneys. Serotonin is a local hormone that is
released from platelets after an injury; it constricts arterioles but dilates
capillaries. Dehydration, not overhydration, would decrease renal perfusion. A
hemoglobin of 13.2 g/dL (132 mmol/L) is a normal value.
Chronic kidney
disease (CKD)

- The client with CKD may have several barriers to learning. The presence of
family members is helpful because they need to understand the disease and
treatment and may help reinforce information with the client after the formal
teaching session is over.
- The client with CKD often experiences a variety of psychosocial changes. These
changes are related to uremia and to the stress associated with living with a
chronic disease that is life threatening. Clients with CKD may have labile
emotions or personality changes and may exhibit withdrawal ,
depression, or agitation. Delusions and psychosis also can occur.
- Because of the potentially life-threatening outcomes associated with
hyperkalemia and hypocalcemia, they are the most relevant to nursing
management of the client with CKD.
- CKD is a condition in which the kidneys have progressive problems in
clearing nitrogenous waste products and controlling fluid and electrolyte
balance within the body. Cardiovascular symptoms of heart failure and
hypertension are caused by the fluid volume overload resulting from the kidneys'
inability to excrete water. Signs and symptoms of heart failure include jugular
venous distention, S3heart sound, pedal edema, increased weight, shortness of
breath, and crackles auscultated in the lungs. The typical signs and symptoms of
CKD include proteinuria or hematuria, not glycosuria.
- CKD is a condition in which the kidneys have progressive problems in their
ability to clear nitrogenous waste products and control fluid and electrolyte
balance within the body. Conservative treatment of CKD slows progression of the
disease and includes reducing the protein, sodium, potassium, and phosphorus in
the diet and controlling the blood pressure. It is important to reduce the sodium in
the diet. Salt substitutes usually are potassium-based and should not be
used by a client with CKD because of the risk of hyperkalemia.
- When a client experiences CKD, the blood urea nitrogen (BUN) and
serum creatinine levels rise. The client also experiences increased potassium,
increased phosphates, and decreased calcium. BUN and creatinine are the
byproducts of protein metabolism, so monitoring protein intake is important, with
care taken to include proteins of high biological value. Clients with CKD will have
protein restricted early in the disease to preserve kidney function. In end-stage
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disease, protein is restricted according to the client's weight, the type of dialysis,
and protein loss. With CKD, the nurse is concerned about fluid volume overload
and accumulation of waste products. Because of the kidneys' inability to excrete
fluid, it is important for the nurse to prevent as well as assess for early signs of
fluid volume excess. Infusing an intravenous (IV) solution into a client with CKD
significantly increases the risk for overload. If an IV access is needed, it usually
involves only a saline lock. Obtaining the client's daily weight is one of the most
important assessment tools for evaluating changes in fluid volume. The kidneys
also are responsible for removing waste products. The client also receives
phosphate binders, calcium supplements, and vitamin D to prevent bone
demineralization (osteodystrophy) from chronically elevated phosphate levels.
Conditions related Urge incontinence occurs when the client experiences involuntary loss of urine
to incontinence soon after experiencing urgency. = A client tells the nurse about a pattern of a
strong urge to void, followed by incontinence before the client can get to the
bathroom.
Total incontinence occurs when loss of urine is unpredictable and continuous.
Stress incontinence occurs when the client voids in increments of less than 50
mL under conditions of increased abdominal pressure.
Reflex incontinence occurs at rather predictable times that correspond to when
a certain bladder volume is attained.
Continuous CAPD closely approximates normal
ambulatory renal function, and the client will
peritoneal need to infuse and drain the
dialysis (CAPD) dialysis solution several times a
day. No machinery is used, and
CAPD is a manual procedure.

- CAPD is a form of peritoneal dialysis in which exchanges are completed 4 or 5

times daily. Peritonitis is a major complication of this type of dialysis. Peritonitis
can be recognized by cloudy dialysate outflow, fever, abdominal guarding
(board-like abdomen), abdominal pain, pain on inflow, malaise, nausea,
and vomiting. The client has the right to refuse medications, but it also is
important for the nurse to explain the importance of medications to the client.
Typically the dwell time during the night is for the entire time that the client
sleeps, which could be around 7 to 9 hours. The peritoneal site should have intact
skin. The skin grows around the peritoneal catheter cuff, and this prevents tunnel
(around catheter) infections.
Cystitis Water helps flush bacteria out of the bladder, and an intake of 6 to 8 glasses per
day is encouraged.
Cystoscopy Grossly bloody urine with clots
following cystoscopy is always an
abnormal finding and should be
reported to the HCP immediately. The
client may have clear or blood-tinged
urine after cystoscopy. If a contrast
agent such as methylene blue is used,
the urine may have an unusual bluish or
green tinge.

- The client is instructed that pink-tinged urine and burning on urination are
expected for 1 to 2 days after the procedure. Increased fluid intake is encouraged.
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Application of heat to the lower abdomen, administration of mild analgesics, and

the use of sitz baths may relieve discomfort. The client also is advised to avoid
alcoholic beverages for 2 days after the test.
- Client preparation for cystoscopy and possible biopsy includes informing
the client that intravenous fluids will be started the day of the procedure
to ensure adequate hydration and flow of urine.
- The main purpose of a cystoscopy is to inspect the interior of the bladder with a
tubular lighted scope (cystoscope). Pink-tinged urine is a normal finding after this
procedure, but bright red urine indicates hemorrhaging and is not a normal
finding.
Disequilibrium Disequilibrium syndrome is characterized by headache, mental confusion,
syndrome decreasing level of consciousness, nausea, vomiting, twitching, and
possible seizure activity. Disequilibrium syndrome is caused by rapid removal
of solutes from the body during hemodialysis. At the same time, the blood-brain
barrier interferes with the efficient removal of wastes from brain tissue. As a
result, water goes into cerebral cells because of the osmotic gradient, causing
increased intracranial pressure and onset of symptoms. The syndrome most often
occurs in clients who are new to dialysis and is prevented by dialyzing for shorter
times or at reduced blood flow rates.
Dialysis - A temperature of 101.2F (38.5C) is significantly elevated and may
indicate infection. The nurse should notify the health care provider (HCP).
- Disequilibrium syndrome may be caused by rapid removal of solutes from the
body during hemodialysis. These changes can cause cerebral edema that leads to
increased intracranial pressure. The client is exhibiting early signs and symptoms
of disequilibrium syndrome and appropriate treatments with anticonvulsive
medications and barbiturates may be necessary to prevent a life-threatening
situation. The HCP must be notified.
Effects As part of the normal aging process, the GFR decreases, along with each of
of aging on renal the other functional abilities of the kidney. Tubular reabsorption and urine-
function concentrating ability also decrease. The kidneys have decreased ability to
metabolize medications.
Effects The release of low levels of dopamine exerts a vasodilating effect on the renal
of dopamine on arteries, increasing urinary output.
the kidneys
End-stage renal Clients with ESRD are likely to experience mood swings or express hostility,
disease (ESRD) anger, and depression, among other responses. The nurse should acknowledge
the client's feelings, allow the client to express those feelings, and be supportive.
= Acknowledge the client's feelings. Assess the client and family's coping
patterns. Explore the meaning of the illness with the client. Give the client
information when the client is ready to listen.
Epididymitis - Typical signs and symptoms of epididymitis include scrotal pain and edema,
which often are accompanied by fever, nausea and vomiting, and chills.
Epididymitis most often is caused by infection, although sometimes it can be
caused by trauma.
- Altered body appearance is a problem when the client has either a verbal or a
nonverbal response to a change in the structure or the function of a body part.
- Common interventions used in the treatment of epididymitis include bed
rest with bathroom privileges, elevation of the scrotum, ice packs, sitz baths,
analgesics, and antibiotics.
Fluid balance For the client on a normal diet, the normal fluid intake is approximately 1200 to
1800 mL of measurable fluids per day. The client's output in the same period
should be about the same and does not include insensible losses, which are extra.
Insensible losses are offset by the fluid in solid foods, which also is not measured.
= Intake 1800 mL, output 1750 mL.
Furosemide Furosemide works by acting to excrete sodium, potassium, and chloride in the
ascending limb of the loop of Henle.
Glomerulonephritis In the client with glomerulonephritis, characteristic findings in the urinalysis
report are gross proteinuria and hematuria. The specific gravity is elevated, and
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the urine may appear dark and

smoky. Positive ketones are not
associated with this condition
but may indicate a secondary
problem.

Hemodialysis - Hemodialysis typically lowers the

amounts of fluid, sodium, potassium,
urea nitrogen, creatinine, uric acid,
magnesium, and phosphate levels in
the blood. Hemodialysis also
worsens anemia because RBCs
are lost during dialysis from blood
sampling and anticoagulation and
from residual blood left in the
dialyzer. Although all of these results
are expected, only the lowered RBC
count is nontherapeutic and worsens
the anemia already caused by the
disease process.
- Many medications are dialyzable,
which means that they are extracted
from the bloodstream during dialysis.
Therefore, many medications may
be withheld on the day of dialysis
until after the procedure.

- Heparin sodium is used during dialysis, and it inhibits the tendency of blood to
clot when it comes in contact with foreign substances. Dialysis cleanses the
blood of accumulated waste products is the purpose of dialysis. The
dialysate is warmed to approximately 100F to increase the efficiency of diffusion
and to prevent a decrease in the client's blood temperature. Dialysate is made
from clear water and chemicals and is free from any metabolic waste products or
medications. Bacteria and other microorganisms are too large to pass through the
membrane; therefore, the dialysate does not need to be sterile.
- The typical schedule for hemodialysis is 3 to 4 hours of treatment 3
days per week.
- Infection is a major concern with hemodialysis. For that reason, the use of
sterile technique and the application of a face mask for both nurse and client are
extremely important. It also is imperative that standard precautions be followed,
which includes the use of goggles, mask, gloves, and apron. The connection site
should not be covered; it should be visible so that the nurse can assess for
bleeding, ischemia, and infection at the site during the hemodialysis procedure.
- Limiting weight gain to 2 to 3 lbs (1 to 1.5 kg) between dialysis
treatments helps prevent the hypotension that occurs with the removal of large
volumes of fluid during dialysis.
- Muscle cramps during hemodialysis result from either too rapid removal of
water and sodium or neuromuscular hypersensitivity. The nurse corrects this
situation by either slowing down the ultrafiltration rate on the hemodialyzer
or administering hypertonic or isotonic normal saline.
- The client on hemodialysis should monitor fluid status between
hemodialysis treatments by recording I&O and measuring weight daily.
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Ideally, the hemodialysis client should not gain more than 0.5 kg of weight per
day.
- Following dialysis the client's vital signs are monitored to determine
whether the client is remaining hemodynamically stable. Weight is measured and
compared with the client's predialysis weight to determine effectiveness of fluid
extraction. = Vital signs and weight.
- Antihypertensive medications such as enalapril are given to the client
following hemodialysis. This prevents the client from becoming hypotensive during
dialysis and from having the medication removed from the bloodstream by
dialysis.
Heparin therapy Heparin is the anticoagulant used most often during hemodialysis. The
hemodialysis nurse monitors the extent of anticoagulation by checking the
partial thromboplastin time (PTT), which is the appropriate measure of
heparin effect.
Hydronephrosis Urolithiasis is the condition
that occurs when a stone
forms in the urinary system.
Hydronephrosis develops
when the stone has blocked
the ureter and urine backs
up and dilates and damages
the kidney.
Priority treatment is to allow
the urine to drain and
relieve the obstruction in the
ureter.

This is accomplished by placement of a percutaneous nephrostomy tube

to drain urine from the kidney and placement of a ureteral stent to keep
the ureter open.
Hyperkalemia The normal potassium level is 3.55.0 mEq/L (3.55.0 mmol/L). A potassium
level of 7.0 is elevated. The client with hyperkalemia is at risk of developing
cardiac dysrhythmias and cardiac arrest. Because of this, the client should be
placed on a cardiac monitor. The nurse should notify the HCP and also review
medications to determine if any contain potassium or are potassium retaining. The
client does not need to be put on NPO status. Fluid intake is not increased
because it contributes to fluid overload and would not affect the serum potassium
level significantly.
Ileal conduit The client scheduled for surgical creation
of either an ileal conduit or a reservoir
undergoes bowel preparation the night
before the procedure. Preparation can
include intake of copious clear liquids,
laxatives, enemas, and antibiotics,
depending on health care provider
preference. This is done primarily to
prevent infection because a loop of
bowel will be used to create the
urinary diversion.
Indwelling urinary A urine specimen is not taken from the urinary drainage bag. Urine undergoes
catheter chemical changes while sitting in the bag, so its properties do not necessarily
reflect current client status. In addition, it may become contaminated with
bacteria from opening the system.
Kegel exercises Kegel muscles strengthen the perineal floor and are useful in the prevention and
management of cystocele, rectocele, and enterocele. Several ways to perform
Kegel exercises are acceptable. One method entails starting and stopping the flow
of urine during a single voiding for about 5 seconds. Also, these exercises may be
done by holding perineal muscles taut for up to 10 seconds several times a day or
for 5 minutes 3 or 4 times a day. Residual urine should not be held in the bladder
for long periods because this could promote urinary tract infection.
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Kock pouch A Kock pouch is a continent internal ileal

reservoir. The nurse instructs the client
about the technique of catheterization.

Meperidine Meperidine hydrochloride is an opioid analgesic. Side effects of meperidine

hydrochloride hydrochloride include respiratory depression, orthostatic hypotension,
tachycardia, drowsiness and mental clouding, constipation, and urinary
retention.

Nephrectomy - The client who has had a nephrectomy may have pain with coughing
and deep breathing and other respiratory exercises because the location of
the incision is so close to the diaphragm. The nurse assists the client by offering
opioid analgesics when due, encouraging incentive spirometer use hourly, and
assisting the client to splint the incision during coughing.
- Fears about having only 1 functioning kidney are common in clients who must
undergo nephrectomy for renal cancer. These clients need emotional support and
reassurance that the remaining kidney should be able to fully meet the body's
metabolic needs, as long as it has normal function.
- After nephrectomy, the client may be in considerable pain. This is
because of the size of the incision and its location near the diaphragm, which
make coughing and deep breathing very uncomfortable.
Nephrotic syndrome - Controlling edema is a critical aspect of therapeutic management of nephrotic
syndrome. If the GFR is normal, dietary intake of proteins is needed to restore
normal plasma oncotic pressure and thereby decrease edema. Daily measurement
of weight and abdominal girth, and careful monitoring of I&O will determine
whether weight loss is caused by diuresis or protein loss. Dietary modifications
may include salt restriction and fluid restriction and are based on the client's
symptoms. Bed rest is prescribed to promote diuresis when edema is severe.
- Nephrotic syndrome describes a variety of signs and symptoms that
accompany any condition that markedly impairs filtration by glomerular capillary
membranes and results in increased permeability to protein. Hallmark signs and
symptoms of this syndrome include increased serum lipids, edema,
increased excretion of protein in the urine, and decreased serum albumin
levels.
Nephron The distal tubule and the collecting duct of the nephron require the
presence of ADH for water reabsorption. The hormone increases the
permeability of the membranes to allow water to flow more easily along the
concentration gradient. The glomerulus filters but does not reabsorb. The calices
are responsible for collecting the urine. The proximal tubule and the loop of Henle
reabsorb water without the assistance of ADH.
Nephrotoxicity The nephron is the functional unit of the kidney that is responsible for clearance of
excess fluid and waste products of metabolism. The renal pelvis and calices collect
urine to send to the ureter. The renal artery brings blood to the kidney for
filtering by the nephron.
Oncotic pressure The pulling pressure within the capillaries that is exerted by the plasma
proteins is referred to as the oncotic pressure.
Osmotic pressure is the movement of water along a pressure gradient.
Filtration pressure is the pressure that is exerted with ultrafiltration, in which
the pressure within the capillaries is greater than the pressure outside them; this
results in fluids being pushed across the membrane into Bowman's capsule.
Hydrostatic pressure in the capillaries allows fluid to be filtered out of the blood
in the glomerulus.
Ostomy care The skin around the stoma is cleansed at each appliance change using a gentle,
nonresidue soap and water. The skin is rinsed and then dried thoroughly. The
appliance should be changed early in the morning because urine production is
slowest from no fluid intake during sleep. The appliance is cut so that the opening
is not more than 3 mm larger than the stoma. An opening smaller than the stoma
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will prevent application of the appliance.

Generous fluid intake is encouraged to dilute the
urine, decreasing the intensity of odor.

Oxalate Oxalate is found in dark green foods such as spinach. Other foods that raise
urinary oxalate are rhubarb, strawberries, chocolate, wheat bran, nuts, beets,
and tea.
Percutaneous A nephrostomy tube is put in place after
nephrolithotomy percutaneous nephrolithotomy for
calculi in the renal pelvis. The client also
may have a Foley catheter to drain urine
produced by the other kidney.

Peritoneal dialysis - If outflow drainage is inadequate, the

nurse attempts to stimulate outflow by
changing the client's position. Turning the client
to the side or making sure that the client is in
good body alignment may assist with outflow
drainage. The drainage bag needs to be lower
than the client's abdomen to enhance gravity
drainage. The connecting tubing and peritoneal
dialysis system are also checked for kinks or
twisting and the clamps on the system are
checked to ensure that they are open. There is
no reason to contact the HCP. Increasing the flow rate should not be done and
also is not associated with the amount of outflow solution.
- An extended dwell time increases the risk of hyperglycemia in the client
with diabetes mellitus as a result of absorption of glucose from the dialysate and
electrolyte changes. Diabetic clients may require extra insulin when
receiving peritoneal dialysis.
- Reduced outflow from the dialysis catheter may be caused by the
catheter position, infection, or constipation. Constipation may contribute to a
reduced outflow because peristalsis seems to aid in drainage.
- Complications of a peritoneal catheter include infection, perforation of the
bowel or bladder, and bleeding. Brown-tinged returns suggest bowel
perforation, which usually is accompanied by severe abdominal pain and
diarrhea. Cloudy or opaque returns suggest possible infection. Urine-colored
returns suggest possible bladder perforation.
- Peritoneal dialysis may be the treatment option of choice for clients
with severe cardiovascular disease. Severe cardiac disease can be worsened
by the rapid shifts in fluid, electrolytes, urea, and glucose that occur with
hemodialysis. For the same reason, peritoneal dialysis may be indicated for the
client with diabetes mellitus. Contraindications to peritoneal dialysis include
diseases of the abdomen such as ruptured diverticula or malignancies; extensive
abdominal surgeries; history of peritonitis; obesity; and a history of back
problems, which could be aggravated by the fluid weight of the dialysate. Severe
disease of the vascular system also may be a relative contraindication.
- The major complication of peritoneal dialysis is peritonitis. Strict aseptic
technique is required in caring for the client receiving this treatment.
- Increasing the glucose concentration makes the solution more
hypertonic. The more hypertonic the solution, the higher the osmotic pressure
for ultrafiltration and thus the greater the amount of fluid removed from the
client during an exchange.
 11

Peritonitis The signs of peritonitis include fever, nausea, malaise, rebound abdominal
tenderness, and cloudy dialysate output.
Polycystic kidney Polycystic kidney disease is a genetic
disease familial disease in which the kidneys
enlarge with cysts that rupture and scar
the kidney, eventually resulting in end-
stage renal disease. Treatment
options include hemodialysis or
kidney transplant. Clients usually
undergo bilateral nephrectomy to
remove the large, painful, cyst-filled
kidneys.

- The most common findings with polycystic kidney disease are hematuria
and flank or lumbar pain that is either colicky in nature or dull and
aching. Other common findings include proteinuria, calculi, uremia, and palpable
kidney masses. Hypertension is another common finding and may be associated
with cardiomegaly and heart failure.
- Individuals with polycystic kidney disease seem to waste rather than retain
sodium. Unless the client has problems with uncontrolled hypertension,
increased sodium and water intake is needed. Antihypertensive medications
are prescribed to control hypertension. Genetic counseling is advisable because of
the hereditary nature of the disease.
- The client with polycystic kidney disease should report any signs and
symptoms of urinary tract infection, such as frequent urination, burning on
urination, and elevated temperature so that treatment may begin promptly.
Lowered blood pressure is not a complication of polycystic kidney disease, and it
is an expected effect of antihypertensive therapy. The client would be concerned
about increases in blood pressure because control of hypertension is essential.
The client may experience heart failure as a result of hypertension, and thus any
symptoms of heart failure, such as shortness of breath, are also a concern.
Prostatism Signs and symptoms of prostatism include reduced force and size of urinary
stream, intermittent stream, hesitancy in beginning the flow of urine, inability to
stop urinating, a sensation of incomplete bladder emptying after voiding, postvoid
dribbling of urine, and an increase in episodes of nocturia. These signs and
symptoms are the result of pressure of the enlarging prostate on the client's
urethra.
Prostatitis The client with bacterial prostatitis has a swollen and tender prostate gland that is
also warm to the touch, firm, and indurated. Systemic symptoms include fever
with chills, perineal and low back pain, and signs of urinary tract infection, which
often accompany the disorder.
- Treatment of prostatitis includes medication with antibiotics, analgesics, and
stool softeners. The nurse also teaches the client to rest, increase fluid intake,
and use sitz baths or warm tub baths for comfort. Antimicrobial therapy is always
continued until the prescription is finished.
Prostatectomy - The Valsalva maneuver (bearing down) is avoided after prostatectomy
because it increases the risk of bleeding in the postoperative period. An
acceptable exercise is to tighten the abdominal, gluteal, and perineal muscles as if
trying to prevent urination. Another acceptable exercise is to tighten the rectal
sphincter while relaxing the abdominal muscles; this prevents the Valsalva
maneuver from occurring.
- A daily intake of 2.5 L of fluid should be maintained to limit clot
formation and prevent infection. Driving a car and sitting for long periods are
restricted for at least 3 weeks. The client should be instructed to avoid lifting
objects heavier than 20 pounds (9 kg) for at least 6 weeks. Passing small pieces
of tissue or blood clots in the urine for up to 2 weeks after surgery is expected
and does not necessitate contacting the HCP.
Purines Clients who form uric acid calculi should be placed on a low-purine diet.
Their intake of fish and meats (especially organ meats) should be
restricted. Dietary modifications also may help adjust urinary pH so that stone
 12

formation is inhibited. Depending on health care provider prescription, the urine

may be alkalinized by increasing the intake of bicarbonates or acidified by
drinking cranberry, plum, or prune juice.
Pyelonephritis Risk factors associated
with pyelonephritis
include diabetes mellitus,
hypertension, chronic renal
calculi, chronic cystitis,
structural abnormalities of
the urinary tract, presence
of urinary stones, and
presence of an indwelling
urinary catheter or frequent
catheterization.

- The client is taught to adjust the activity level according to the amount
of edema. As edema decreases, activity can increase. Correspondingly, as edema
increases, the client should increase rest periods and limit activity. Bed rest is
recommended during periods of severe edema. The client with nephrotic
syndrome usually has a standard limit set on sodium intake. Fluids are not
restricted unless the client also is hyponatremic.
- Clients with acute pyelonephritis should be instructed to try to maintain
an acid ash diet, which may be of some benefit. Also, they should increase fluid
intake to 3 L per day; this helps relieve dysuria and flushes bacteria out of the
bladder. However, for clients with chronic pyelonephritis and renal dysfunction, an
increase in fluid intake may be contraindicated. Medications such as vitamin C
help acidify the urine. Juices such as cranberry, plum, and prune juice will leave
an acid ash in the urine. Caffeine, alcohol, chocolate, and highly spiced
foods are avoided to prevent potential bladder irritation.
Radiation skin The client undergoing radiation therapy should avoid washing the site until
instructed to do so. The client should then wash, using mild soap and warm or
cool water, and pat the area dry. No lotions, creams, alcohol, or deodorants
should be placed on the skin over the treatment site. Lines or ink marks that are
placed on the skin to guide the radiation therapy should be left in place. The
affected skin should be protected from temperature extremes, direct sunlight, and
chlorinated water (as from swimming pools).
Renal artery Renal artery embolization may be done instead of radiation therapy to
embolization shrink the kidney tumor by cutting off its blood supply and impairing its
overall vascularity. A secondary benefit is that it reduces the risk of
hemorrhage during surgery. This procedure can be accomplished in a number of
ways, including placement of an absorbable gelatin sponge, a balloon, a metal
coil, or any of various other substances.
Renal assessment Bladder trauma or injury should be considered or suspected in the client with
low abdominal pain and hematuria. The client is afebrile.
Glomerulonephritis and pyelonephritis would be accompanied by fever and
are thus not applicable to the client described in this question.
Renal cancer would not cause pain that is felt in the low abdomen; rather, the
pain would be in the flank area.
Renal function studies The creatinine level is the most specific laboratory test to determine
renal function. The creatinine level increases when at least 50% of renal
function is lost.
Renal scan No specific precautions are necessary after a renal scan. Urination into a
commode is acceptable without risk from the small amount of radioactive material
to be excreted. The nurse wears gloves to maintain body secretion
precautions.
Renal transplantation - The client receiving immunosuppressive medication therapy must learn and use
infection control methods for use at home. The client self-monitors urine output
and its characteristics on a daily basis. The client must learn proper hand-washing
technique and should take the temperature daily to detect early infection. This is
especially important because the client also takes corticosteroids, which mask
 13

signs and symptoms of infection. All medications should be taken exactly as

prescribed.
- Both the kidney donor and the kidney recipient need thorough medical and
psychological evaluation before transplant surgery. Separate teams evaluate
the donor and the recipient to avoid a conflict of interest in providing care
for the 2 clients.
- Intravenous fluids are managed very carefully after nephrectomy and renal
transplantation. Fluids are usually given according to a formula that takes
into account the previous hour's urine output.
Transurethral - Frank bleeding (arterial
resection of the or venous) may occur
prostate (TURP) during the first day after
surgery. Some hematuria
is usual for several days
after surgery. A urinary
output of 200 mL more
than intake is adequate.
A client pain rating of 2
on a 010 scale indicates
adequate pain control. A
rapid pulse with a low
blood pressure is a
potential sign of
excessive blood loss.
The HCP should be
notified.

- If the bladder irrigation is infusing at a sufficient rate, the urinary

drainage through the Foley tubing should be pale pink. Dark pink urine
indicates that the rate of the irrigation solution should be increased. Tea-colored
urine is not seen after TURP but may be noted in a client with other renal
disorders such as renal failure. Bright red bleeding and clots could indicate a
complication, and if this is noted, it should be reported to the health care
provider.
- The client who suddenly becomes disoriented and confused after TURP
could be experiencing early signs of hyponatremia. This may occur because the
flushing solution used during the operative procedure is hypotonic. If the solution
is absorbed through the prostate veins during surgery, the client experiences
increased circulating volume and dilutional hyponatremia. The nurse should notify
the HCP of these symptoms.
Ureterolithotomy After ureterolithotomy, a ureteral catheter is put in place. Urine flows freely
through it for the first 2 to 3 days. As ureteral edema diminishes, urine leaks
around the ureteral catheter and drains directly into the bladder. At this point,
drainage through the ureteral catheter diminishes. Immediately after surgery,
absence of drainage usually is caused by blockage from blood clots,
mucous shreds, chemical sediment, or catheter displacement.
Ureterostomy Following ureterostomy, the stoma should be red and moist.
Uremia Uremia usually is accompanied by nausea, anorexia, and an unpleasant taste in
the mouth. Most clients experience more nausea and vomiting in the morning.
Therefore, to maintain optimal nutrition, it is best for these clients to eat a
diet that is high in calories with frequent snacks and a light breakfast in
the morning and larger meals later in the day. Dietary management usually
is aimed at restricting protein, sodium, and potassium.
Urethritis Urethritis in the male client often results from chlamydial infection and is
characterized by dysuria, which is accompanied by a clear to mucopurulent
discharge. Because this disorder often coexists with gonorrhea, diagnostic tests
are done for both and include culture and rapid assays. = Dysuria and penile
discharge.
Uric acid calculi With a uric acid stone, the client should limit intake of foods high in purines.
Organ meats, sardines, herring, and other high-purine foods are eliminated from
the diet. Intake of foods with moderate levels of purines, such as red and white
meats and some seafood, also is limited. Avoiding the consumption of milk
and dairy products is a recommended dietary change for calculi
 14

composed of calcium stones but is acceptable for the client with a uric
acid stone.
Urinary diversion The best initial positive step in learning to care for an ostomy and to accept it as a
part of the self is to be able to look at the ostomy. Once the client is able to look
at the ostomy and touch it, the client can proceed more successfully to learn
about ostomy care.
Urine acidification Acidification of the urine inhibits multiplication of bacteria. Fluids that acidify the
urine include prune, apricot, cranberry, and plum juice. Carbonated drinks should
be avoided because they increase urine alkalinity. Two glasses of milk a day can
make the urine more alkaline, which could aid in the development of kidney
stones.
Urolithiasis (struvite Urolithiasis (struvite stones) can result from chronic infections. They form in urine
stones) and chronic that is alkaline and rich in ammonia, such as with a urinary tract infection.
urinary tract Teaching should focus on preventing infections and ingesting foods to make the
infections urine more acidic. Foods such as currants, blueberries, and cranberries are acidic.
The client should wear cotton, not synthetic, underclothing to prevent the
accumulation of moisture and to prevent irritation of the perineal area, which can
lead to infection. Antibiotics are not associated with chronic urinary tract
infections.

Pediatrics

Bladder exstrophy In bladder exstrophy, the bladder is exposed and

external to the body. In this disorder, one must take
care to protect the exposed bladder tissue from
drying, while allowing the drainage of urine. This is
accomplished best by covering the bladder with
a nonadhering plastic wrap.

- The highest priority is impaired tissue integrity

related to the exposed bladder mucosa.

- Bladder exstrophy is a congenital anomaly characterized by extrusion of the

urinary bladder to the outside of the body through a defect in the lower abdominal
wall. The cause is not known, and a higher incidence is seen in male newborns.
- This defect requires surgical repair, which takes place within the first 1 to 2 days
of life. During the next 3 to 5 years, urine drains freely from the urethra as there
is no sphincter mechanism. This time period allows the bladder to gain capacity
while the child grows. Then, subsequent surgical repair is done to create a
sphincter mechanism.
 15

Cryptorchidism Cryptorchidism is a condition in which 1 or

both testes fail to descend through the
inguinal canal into the scrotal sac. Surgical
correction may be necessary. All vigorous
activities should be restricted for 2 weeks
after surgery to promote healing and
prevent injury. This prevents dislodging of
the suture, which is internal. Normally, 2-
year-olds want to be active; allowing the
child to decide when to return to his play
activities may prevent healing and cause
injury. The parents should be taught to
monitor the temperature, provide
analgesics as needed, and monitor the
urine output.

- Diagnostic tests for this disorder are performed to assess urinary and kidney
function because the kidneys and testes arise from the same germ tissue.
- When a child returns from surgery, the testicle is held in position by an
internal suture that passes through the testes and scrotum and is attached
to the thigh. It is important not to dislodge this suture, and it should be
immobilized for 1 week. The most common complications are bleeding and
infection. = Prevent tension on the suture.
Nocturnal enuresis Primary nocturnal enuresis occurs in a
child who has never been dry at night for
extended periods. The condition is
common in children, and most children
eventually outgrow bed-wetting without
therapeutic intervention. The child is
unable to sense a full bladder and does not
awaken to void. The child may have
delayed maturation of the central nervous
system. The condition is not caused by a
psychiatric problem.

= Primary nocturnal enuresis is usually

outgrown without therapeutic intervention.

Epispadias Epispadias is a congenital

defect involving abnormal
placement of the urethral
orifice of the penis. The
urethral opening is located
anywhere on the dorsum of the
penis. This anatomical
characteristic facilitates entry
of bacteria into the urine.

Glomerulonephritis - Glomerulonephritis refers to a group of kidney disorders characterized by

inflammatory injury in the glomerulus. Gross hematuria, resulting in dark,
smoky, cola-colored or brown-colored urine, is a classic symptom of
glomerulonephritis. Blood urea nitrogen levels and serum creatinine levels may
be elevated, indicating that kidney function is compromised. A mild to moderate
elevation in protein in the urine is associated with glomerulonephritis.
Hypertension is also common due to fluid volume overload secondary to the
kidneys not working properly.
- Glomerulonephritis refers to a group of kidney disorders characterized by
inflammatory injury in the glomerulus. Group A -hemolytic streptococcal infection
is a cause of glomerulonephritis. Often, a child becomes ill with streptococcal
 16

infection of the upper respiratory tract and then develops symptoms of acute
poststreptococcal glomerulonephritis after an interval of 1 to 2 weeks.
- In glomerulonephritis, activity is limited, and most children, because of fatigue,
voluntarily restrict their activities during the active phase of the disease.
- Guilt is a common reaction of the parents of a child diagnosed with
glomerulonephritis. Parents blame themselves for not responding more quickly
to the child's initial symptoms, or they may believe they could have prevented the
development of glomerular damage.
- The child with acute glomerulonephritis will have an excessive accumulation of
water and retention of sodium, leading to circulatory congestion and edema.
Excessive fluid volume would be a focus for this disease process.
- Bed rest is required during the acute phase, and activity is gradually increased
as the condition improves.
Hemolytic-uremic Hemolytic-uremic syndrome is thought to be associated with bacterial toxins,
syndrome chemicals, and viruses that result in acute kidney injury in children. Clinical
manifestations of the disease include acquired hemolytic anemia,
thrombocytopenia, renal injury, and central nervous system symptoms. A child
with hemolytic-uremic syndrome undergoing peritoneal dialysis because of anuria
would be on fluid restriction. Pain is not associated with hemolytic-uremic
syndrome, and potassium would be restricted, not encouraged, if the child is
anuric. Peritoneal dialysis does not require an arteriovenous fistula (only
hemodialysis).
Hypospadias Hypospadias is a congenital defect involving
abnormal placement of the urethral orifice of the
penis. In hypospadias, the urethral orifice is
located below the glans penis along the ventral
surface. The infant should not be
circumcised because the dorsal foreskin
tissue will be used for surgical repair of the
hypospadias.

= Circumcision has been delayed to save tissue

for surgical repair.

- After hypospadias repair, the parents are instructed to avoid giving the
child a tub bath until the stent has been removed, to prevent infection.
Nephrotic syndrome - Nephrotic syndrome is defined as massive proteinuria, hypoalbuminemia,
hyperlipemia, and edema. Other manifestations include weight gain; periorbital
and facial edema that is most prominent in the morning; leg, ankle, labial, or
scrotal edema; decreased urine output and urine that is dark and frothy;
abdominal swelling; and blood pressure that is normal or slightly decreased.
- Nephrotic syndrome is a kidney disorder characterized by massive proteinuria,
hypoalbuminemia, edema, elevated serum lipids, anorexia, and pallor. The child
gains weight.
- A child with edema from nephrotic syndrome is at high risk for skin
breakdown.
- Nephrotic syndrome is a kidney disorder. Clinical manifestations of
nephrotic syndrome include edema, proteinuria, hypoalbuminemia, and
hypercholesterolemia in the absence of hematuria and hypertension.
- A no-added-salt diet is indicated. High-sodium foods such as pickles, chips,
and cured meats should be avoided.
Orchiopexy The most common complications associated with orchiopexy are bleeding and
infection. Discharge instruction should include demonstrating wound
cleansing and dressing and teaching parents to identify signs of infection, such
as redness, warmth, swelling, or discharge.
Urine specimen Attaching a urinary collection device to the infant's perineum for collection.
 17

Renal and Urinary Medications

Aluminum The client who is receiving aluminum hydroxide should take the medication with meals.
hydroxide The phosphate-binding effect of this medication is most effective when it is taken with
food.
Benign prostatic In the client with benign prostatic hyperplasia, episodes of urinary retention can be
hypertrophy triggered by certain medications, such as decongestants, anticholinergics, and
antidepressants. These medications lessen the voluntary ability to contract the bladder.
The client should be questioned about the use of these medications if he has urinary
retention. Diuretics increase urine output. Antibiotics and antlipemics do not affect
ability to urinate. = Decongestants
Bethanechol - Bethanechol chloride can be hazardous to clients with urinary tract obstruction or
chloride weakness of the bladder wall. The medication has the ability to contract the bladder
and thereby increase pressure within the urinary tract. Elevation of pressure within the
urinary tract could damage or rupture the bladder in clients with these conditions.
- Cholinergic overdose of bethanechol chloride produces manifestations of excessive
muscarinic stimulation such as salivation, sweating, involuntary urination and
defecation, bradycardia, and severe hypotension.
- Administration of bethanechol chloride with food can cause nausea and vomiting. To
avoid this problem, oral doses should be administered 1 hour before meals or 2
hours after meals.
- The normal adult dosage of bethanechol chloride ranges from 10 to 50 mg given 3 to
4 times daily.
- The injectable form of bethanechol chloride is intended for subcutaneous
administration only.
- Bethanechol chloride is a cholinergic medication that is used for urinary retention.
This medication should not be used for clients with asthma because it can
precipitate bronchoconstriction by activating muscarinic receptors.
- Bethanechol is a cholinergic medication. Administration of bethanechol could result in
cholinergic overdose. The antidote is atropine (an anticholinergic), which should
be readily available for use if overdose occurs.
Bumetanide Bumetanide is a loop diuretic that places the client at risk for hypokalemia.
Ciprofloxacin - Ciprofloxacin is prescribed for treatment of mild, moderate, severe, and complicated
infections of the urinary tract, lower respiratory tract, and skin and skin structure. A
single dose is administered slowly over 60 minutes to minimize discomfort and
vein irritation.
- Ciprofloxacin and other fluorquinolones can exacerbate muscle weakness in
clients with myasthenia gravis. Accordingly, clients with a history of myasthenia
gravis should not receive these medications.
- The health care provider should be contacted immediately if the client
develops any tendon pain, swelling, or inflammation because of the risk of tendon
rupture. Exercise is contraindicated until tendon rupture is ruled out. Fluorquinolones
such as ciprofloxacin need to be discontinued at the first sign of any tendon pain,
swelling, or inflammation.
Cyclosporine - Cyclosporine is an immunosuppressant. Nephrotoxicity can occur from the use of
cyclosporine. Nephrotoxicity is evaluated by monitoring for elevated blood urea
nitrogen and serum creatinine levels. The normal blood urea nitrogen level is 10 to
20 mg/dL (3.6 to 7.1 mmol/L). The normal creatinine level for a male is 0.6 to 1.2
mg/dL (53 to 106 mcmol/L) and for a female 0.5 to1.1 mg/dL (44 to 97 mcmol/L).
- A compound present in grapefruit juice inhibits metabolism of cyclosporine
through the cytochrome P450 system. As a result, consumption of grapefruit juice can
raise cyclosporine levels by 50% to 100%, thereby greatly increasing the risk of
toxicity.
- The client needs to be instructed to dispense the oral liquid into a glass
container using a specially calibrated pipette. The client should not use any other
type of dropper to calibrate the amount of prescribed medication.
Dutasteride Dutasteride promotes regression of prostate epithelial tissue and thereby decreases
mechanical obstruction of the urethra.
Epoetin alfa - Epoetin alfa is synthetic erythropoietin, which the kidneys produce to stimulate red
blood cell production in the bone marrow. It is used to treat anemia associated
with chronic kidney disease.
 18

- Epoetin alfa is erythropoietin that has been manufactured through the use of
recombinant DNA technology. It is used to treat anemia in the client with chronic
kidney disease. The medication may be administered subcutaneously or intravenously
as prescribed.
Furosemide To administer medication by IVP, the IV tubing must be pinched above the injection
port so that the medication does not go back up the tubing during injection. Most IVP
medications should be injected slowly. = Pinch the IV tubing above the injection port,
and inject slowly over 1 to 2 minutes.
Levofloxacin - Levofloxacin can prolong the client's QT interval, which would be noted on
electrocardiogram. This warrants a call to the HCP because a prolongation in the QT
interval can lead to torsades de pointes, a lethal dysrhythmia.
- Levofloxacin is a fluoroquinolone antibiotic and is used for a variety of
infections, including UTI. Adverse effects include peripheral neuropathy,
rhabdomyolysis, tendonitis, tendon rupture, Clostridium difficile infection, muscle
weakness in clients with myasthenia gravis, and photosensitivity. Levofloxacin can also
prolong the client's QT interval, leading to dysrhythmias. Pain in the back of the leg
could be indicative of tendonitis and therefore risk for tendon rupture.
Metronidazole Harmless darkening of the urine may occur, and the client should be told of this effect.
Methyldopa Methyldopa is metabolized by the kidneys and requires careful dosage adjustment
according to the client's renal function to prevent hypotension.
Nitrofurantoin - Nitrofurantoin can induce 2 kinds of pulmonary reactions: acute and subacute. Acute
reactions, which are most common, manifest with dyspnea, chest pain, chills, fever,
cough, and alveolar infiltrates. These symptoms resolve 2 to 4 days after discontinuing
the medication. Acute pulmonary responses are thought to be hypersensitivity
reactions. Subacute reactions are rare and occur during prolonged treatment.
Symptoms (e.g., dyspnea, cough, malaise) usually regress over weeks to months
following nitrofurantoin withdrawal. However, in some clients, permanent lung damage
may occur. = The client is experiencing a pulmonary reaction requiring cessation of the
medication.
- Nitrofurantoin imparts a harmless brown color to the urine and the medication should
not be discontinued until the prescribed dose is completed.
- Nitrofurantoin is contraindicated in clients with renal impairment.
- For treatment of acute UTI, the adult dosage is 50 mg every 6 hours. For
prophylaxis of recurrent UTI, low doses are used, such as 50 to 100 mg at bedtime for
adults.
- Nitrofurantoin is an antibacterial used to treat urinary tract infections.
Although rare, the medication can cause an asthmatic exacerbation in those with a
history of asthma. Therefore, the priority baseline assessment should include
questioning the client about a history of asthma and checking lung sounds.
- Nitrofurantoin is an antibacterial used to treat urinary tract infections. The nurse
would instruct the client to take the medication with food to reduce any gastrointestinal
upset that the medication can cause.
- Nitrofurantoin is a urinary antiseptic (not a sulfa-based medication) and
should be taken with meals to decrease the incidence of GI side effects. Food
or milk decreases the GI upset.
Oxybutynin - Toxicity (overdosage) of oxybutynin produces central nervous system excitation, such
as nervousness, restlessness, hallucinations, and irritability.
- Bladder spasms after prostatectomy are treated with antispasmodic medications, such
as oxybutynin.
- When medication therapy for overactive bladder is indicated, anticholinergic agents
are the medications generally prescribed.
- Oxybutynin is an anticholinergic. Anticholinergic side effects include dry mouth,
constipation, tachycardia, urinary hesitancy, urinary retention, mydriasis, blurred
vision, and dry eyes.
Phenazopyridine - Phenazopyridine is a urinary analgesic. It is effective when it eliminates pain and
burning with urination.
- The pain experienced with pyelonephritis usually resolves as antibiotic therapy
becomes effective. However, clients may be treated for urinary tract pain with
phenazopyridine, which is a urinary analgesic.
Propantheline Propantheline bromide is contraindicated in clients with narrow-angle glaucoma,
bromide obstructive uropathy, gastrointestinal disease, or ulcerative colitis.
Purine Probenecid is a medication used for clients with gout to inhibit the reabsorption of uric
acid by the kidneys and promote excretion of uric acid in the urine. Uric acid is
 19

produced when purine is catabolized. Clients are instructed to modify their diets to limit
excessive purine intake. High-purine foods to avoid or limit include organ meats,
roe, sardines, scallops, anchovies, broth, mincemeat, herring, shrimp,
mackerel, gravy, yeast, wine, and alcohol.
Sulfamethoxazole Sulfonamides can intensify the effects of warfarin, phenytoin, and
sulfonylurea-type oral hypoglycemics (e.g., glipizide, glyburide). The principal
mechanism is inhibition of hepatic metabolism. When combined with sulfonamides,
these medications may require a reduction in dosage to prevent toxicity.
Tacrolimus - Tacrolimus is a potent immunosuppressant used to prevent organ rejection in
transplant clients. It is important that the medication be taken at 12-hour intervals to
maintain a stable blood level to prevent organ rejection.
- A fasting blood glucose level of 200 mg/dL (11.1 mmol/L) is significantly elevated
above the normal range of 70 to 110 mg/dL (4 to 6 mmol/L) and suggests an adverse
effect.
Tamsulosin - Tamsulosin hydrochloride is used to relieve mild to moderate manifestations that
hydrochloride occur in benign prostatic hypertrophy. The medication also improves urinary flow rates.
- Tamsulosin hydrochloride is a medication that will relieve mild to moderate
manifestations of BPH and improve urinary flow rates. The medication should be
administered 30 minutes after meals because food decreases the peak plasma
concentration and lengthens the time to achieve peak plasma medication
concentrations.
Trimethoprim- - Each dose of trimethoprim-sulfamethoxazole should be administered with a full glass
sulfamethoxazole of water, and the client should maintain a high fluid intake to avoid crystalluria.
- Clients taking trimethoprim-sulfamethoxazole should be informed about early signs
and symptoms of blood disorders that can occur from this medication. These include
sore throat, fever, and pallor, and the client should be instructed to notify the health
care provider (HCP) if these occur.
- Trimethoprim-sulfamethoxazole may be administered by intravenous infusion but
should not be mixed with any other medications or solutions. Trimethoprim-
sulfamethoxazole is infused over 60 to 90 minutes.
- Trimethoprim-sulfamethoxazole is a combination medication. The client takes each
dose with 8 oz (235 mL) of water and drinks several extra glasses of water each day.