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GU/Renal

Glomerulo – nephrosis - oozy BP low or normal, overall edema

nephritis - icky BP high; edema limited to eyes, hand, feet, sacral area

Nephritis – can be acute or chronic. 1-2% result in renal failure. More common in children.
Etiology – 1. Autoimmune – precipitated by diabetes, DIC, lupus.
2. Infectious– 2-3 weeks following a beta hemolytic strep infection; viral
infection;
Epstein Barr.
Pathophys. – an antigen-antibody reaction produces swelling and death of the capillary epithelial
cells within the glomerular tissue. Damage to the glomerular basement membrane allows protein,
sugar (above 180) and RBCs to penetrate through the filtration system and into the urine.

Urine output
Normal – 30-60 cc/hr.
Oliguria - < 400 cc/24 hrs.
Anuria - < 100 cc/24 hrs.

Manifestations: elevation of BUN and creatinine (more specific); proteinemia; edema (hands, feet,
eyes – periorbital edema, sacral area); hematuria; oliguria.
Fluid overload causes elevation in BP. An increase in intravascular fluid may result in
pulmonary edema.

Nsg Assessment – most important is daily weights.

Nsg, Dx.: Activity Intolerance; Fluid Vol Excess; Pt. Teaching (to take meds as prescribed; fluid
restriction – today’s intake = yesterday’s output); Risk for Infection; Alteration in Urinary
Elimination; Alteration in Skin Integrity (due to excess fluids and bed rest).

Pt. Outcomes: Free of Infection; Free of Fluid Vol. Excess; Knowledge of meds and treatments

Med. Tx: antihypertensives; diuretics; antibiotics (penicillin, erythromycin); bed rest; diet – low
sodium, low protein, high carbohydrate.

Chronic nephritis may occur after an acute episode, or it may be idiopathic. It progresses to renal
failure due to sclerosis of the glomerular filtration membrane. The kidney decreases in size.

Manifestations: HA, blurred vision

Tx. Steroids, I & O, diet

Nephrosis – nephrotic syndrome – a group of symptoms resulting from damage to the glomeruli, so
that they no longer filter properly. 25% develop renal failure.
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Etiology: infections; DM; sickle cell; pregnancy, systemic lupus, severe allergic reactions.
Pathophys: basement cell membrane becomes more porous and protein spills into the urine. Fluid
leaves the intravascular system and goes into the tissues, resulting in decreased plasma volume.

Manifestations: Fatigue, lethargy, anorexia, HA, nausea, decreased urinary output, proteinuria, skin
oozes fluid.
Nursing Dx:
a) Fluid Vol Excess - (fluid is in the wrong place – peripheral edema – normal or low BP)
b) Altered Nutrition R/T n & v and decreased blood protein
c) Activity Intolerance
d) Impaired Skin Integrity R/T severe edema and bed rest
e) Risk for Infection R/T steroids
a f) Risk for resp dysfunction R/T edema and abdominal girth
g) Altered Body Image R/T generalized edema
h) Ineffective Coping
i)Body Image Disturbance

Med Tx: Bed rest, steroids; increase protein .

Obstructions – stones, strictures, tumors. Any pressure can result in functional damage to the
kidney due to hydronephrosis or hydroureter. Hydronephrosis can occur without symptoms, or
with nausea, vomiting, local tenderness.
1. Kidney – due to ptosis, calculus, polycystic disease
2. Ureters – due to calculi, trauma; lymph node obstruction; ptosis of kidney (kinks ureter).
3. Bladder – tumors
4. Urethral – stricture or prostate (BPH or Ca)

Kidney stones may be anywhere in the pelvis or ureter; staghorn calculus – fills the renal pelvis.
a) Tx – depends on location and size
b i) Dietary - Uric acid and calcium stones – acid ash diet – low purine (limit fish, organ meats,
c certain medications). Oxalate stones – avoid food high in oxalate (tea, instant coffee, cola,
d beer, chocolate, citrus fruits, peanuts).
e ii) Fluid – increase to 3000 ccs/day to flush kidneys.
f iii) Lithotripsy – large stones are crushed by ultrasound and may take 6 weeks to pass. Monitor
g for pain, hemorrhage; temp. Hematuria common on first few voidings.
iv) Surgery – pyelolithotomy (renal pelvis); nephrolithotomy (renal parenchyma);
h ureterolithotomy (ureter).
Post op: In addition to Foley, pt. has nephrostomy or ureterostomy tubes – do not clamp
Nsg: 1. monitor to insure tubes remain patent and in place.
2. label and anchor tubes;
3. skin care: frequent dressing changes because wound often drains large amount of
urine – use Montgomery straps
4. check for BS and abdominal pain – bowel can be nicked during surgery
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5. record drainage from each tube separately.

Benign Prostatic Hypertrophy (BPH) – obstruction of the flow of urine; can result in stagnation
and infection. Seen in 50% of men 60 - 69 yrs. old and % rises with age. Symptoms depend on
degree of obstruction and duration, but include: intermittent and reduced force of stream; hesitancy;
urgency, dribbling; frequency (q 2 h) nocturia. Severe obstruction results in urinary retention
(bladder distended above the symphysis pubis), retention with overflow and hydronephrosis.
Monitor Foley for drainage – Do Not drain more than 1000 ccs of urine at a time – pt. may go into
shock due to the shifting of abdominal pressure. Clamp Foley and release in 30-60 mins.
Surgical Treatment:
1) Transurethral Resection of the Prostate (TURP) – cystoscope is inserted into the urethra and
prostate is chipped away.
Post OP: Pt will have a 3 way Foley with a 30 cc balloon (this applies pressure to site to
prevent hemorrhage) and a CBI (continuous bladder irrigation). Monitor to insure that what goes in,
comes out.
Nsg. Dx:
Pain R/T bladder spasms – make sure Foley is draining (if not irrigate with NS using
Toomey/catheter tip syringe); administer anticholinergic meds.
Fluid Vol Excess R/T TUR syndrome (rare) – monitor pt. for HA, confusion, changes in heart
rate; agitation and tremor.
Risk for Hemorrhage R/T surgery – monitor Foley for bright red blood and clots. Mild
hematuria is normal for 7-10 days.

2) Open Prostatectomy – Suprapubic, Retropubic, Radical – same as above, but pt. will also have a
cystotomy tube, in addition to Foley. Monitor and record drainage separately.

Renal Failure:
1) Acute is reversible at times and due to either ischemia or toxins

Ischemic (BP of 60-70 for renal perfusion) Toxic

blood loss arsenic
burns lead
Na and water loss mercury
acute MI solvents - carbon tetrachloride
cardiac arrhymias pesticides
CHF antibiotics (gentamycin)
septic shock toxic mushrooms
renal artery occlusion acute infections

2) Chronic – a progressive, irreversible destruction of renal structures - two phases

a) Oliguric – pt. is confused, lethargic, symptoms of fluid overload, edema, elevated
BP, BUN, K+, creatinine.
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b) Diuretic – 2 –14 days after oliguric phase.

Manifestations: Fluid Vol Excess – Na retention, edema, high BP, potential for CHF and pulmonary
edema. Pt. is anemic due to decreased production of erythropoietin by the kidneys and risk for
bleeding due to decreased adhesiveness of platelets (effects or urea). HA, fatigue, irritability and
depression develop slowly.

Nsg Dx: Fluid Vol Excess; Electrolyte Imbalance; Risk for Injury; Altered Nutrition; Knowledge
Deficit; Body Image Disturbance; Activity Intolerance R/T anemia.
Tx – Low Protein Diet, dialysis

Dialysis – the movement of fluid and particles across a semi-permeable membrane in order to
restore fluid, electrolyte and acid base balance, and to filter toxins, and to treat overdoses of certain
drugs.
Principles:
1) Diffusion – movement of particles (electrolytes, urea, creatinine) from an area of higher to lower
concentration.
2) Osmosis - movement of fluid (water) from an area of higher to lower concentration. The
dialysate solution contains glucose and pulls water to it.
3) Ultrafiltration – movement of fluid across a semi-permeable due to an artificially created
pressure gradient.

Hemodialysis – the pts. blood is shunted through the dialyzer, using diffusion and ultrafiltration.

Vascular Access
1. External – AV shunt - commonly used for ARF. Can be used immediately and for about 2 mos.
2. Internal – AV fistula – vein and artery are connected causing the vein to enlarge.
3. Internal – AV graft – used if pt. has poor blood vessels – artificial connection.

# 2 & # 3 provide permanent, easy access, least chance of infection. They must heal 2-3 weeks prior
to being used. Complications include risk for infection, clotting, hemorrhage. Common sites are
lower forearm (blood vessels are close together); upper forearm, lower leg, upper leg.
Nsg - Check for patency – bruit (with stethoscope) and thrill (palpate); circulation (color, temp,
capillary refill, movement of fingers) and infection. Site cannot be used for anything else (increased
pressure from BP can cause a blowout).

Hemodialysis – usually done for 3-5 hrs. 2-3 times/week. May be done daily initially.
Before – Check weight, VS, Fluid Vol (edema, breath sounds) access for patency and
infection. Hold all HTN and meds containing nitro to prevent hypotension.
During – Monitor VS q 5-15 mins., initially then q 30 mins. Monitor comfort, provide for
diversion. Pt. may C/O HA, nausea due to changes in fluid and acid base balance. Postual
hypotension is common.
Physiological Imbalance:

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1) hypovolemia – decreased BP, tachycardia, diaporesis, cold, clammy, restlessness.
Put head flat and feet up (Modified Trendelenburg). Start IV with NS; monitor
LOC; Risk for Aspiration due to vomiting.
2) disequilibrium phenomenon – occurs very early or late in treatment due to excess
solutes being cleared from the blood more rapidly than from the CSF and brain.
Water moves inside the cells causing cerebral edema – monitor for confusion, n/v,
restlessness, seizures – can be fatal.

After – Take VS, pt. must wait a while before leaving; Teaching – care and monitoring of
access device; meds, diet, complications to look for.

Peritoneal Dialysis – the peritoneum acts as the semi-permeable membrane. Exchanges can be
done q 4 h or at night. Advantages – fewer dietary restrictions because protein is lost into the
dialysate; more pt. control; can be used for pts. who are hemodynamically unstable. Disadvantages:
potential for infection (abdominal pain, tenderness, fever, redness and drainage at site) and
peritonitis (n/v, rigid abdomen; temp, tachycardia); repeated infections result in adhesions.

Prior to catheter insertion instruct pt. to void to avoid puncturing the bladder.
Dialysate – 2 liters, body temp. Once it’s infused, clamp. The amount of time inside is called the
dwelling time. Pt. puts. bag on the floor to drain. If the tube is clogged, turn pt. from side to side
and palpate the abdomen. Monitor infused fluid and drained fluid carefully. Eg.

Time infused Amount Drained Plus (indictates amount unaccounted for)

1000 2000 1800 +200

1400 2000 2100 +100
1800 2000 2200 -100

Nsg – Monitor for C/O pressure, edema, SOB (due to fluid in abdomen;) – HOB up; hold infusion;
call MD, atelectasis (from pressure on lungs); infection (culture outflow); peritonitis – pt. should
not have severe pain.

CAPD – continuous ambulatory peritoneal dialysis – 4 – 5 exchanges in 24 hrs.

Kidney Transplant – one year success rate is 90% with a twin donor ; 70-80% with a family donor;
50-60% with a cadaver donor. Complication – rejection, and infection (due to immunosuppressive
agents).

Wilm’s Tumor – Ca of the kidney in children birth-18 mos. Develops from embryonic tissue.
Metastasizes to the lungs. Tx. Nephrectomy; radiation, chemo.

Azotemia- an increase in nitrogenous wastes

Deliruim – sudden onset, may be due to renal function, dehydration, sepsis, meds, constipation
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Dementia – gradual onset.