Nephrology Nursing

Nursing Managements of Urinary Dysfunction

1. Urinary Tract Infection
 Are caused by pathogenic microorganisms in the urinary tract.

 Lower UTI
o Cystitis
o Prostatitis
o Urethritis
 Upper UTI
o Pyelonephritis
o Nephritis
o Renal abscesses

 Epidemiology:
o Common in females
o Common site of nosocomial infection
 Risk factors:
o Inability or failure to empty the bladder completely
o Obstructed urinary flow caused by:
 Congenital abnormalities
 Urethral strictures
 Contracture of the bladder neck
 Bladder tumors
 Calculi in the ureters or kidneys
o Immunosuppression
o Catheterization
o Female
o Diabetes
o Neurologic conditions
o Gout

A. Lower UTI
o Pathophysiology:
 Ascending infection (E. Coli)
 Decreased Glycosaminoglycan (GAGA)
 GAG is a hydrophilic protein that exerts nonadherent protective effect against
various bacteria.
 GAG atracts water molecules, forming a water barrier that serves as a defensive
layer between the bladder and the urine.
 Urethrovesical reflux
 Ureterovesical or vesicoureteral reflux
o Etiology:
 E.coli = are the most common infective bacterial organism.
 Pseudomonas and Enterococcus
 Nosocomial infections during hospitalizations.
 Routes of Infection:
 Transurethral route (ascending infection)
 Bloodstream (hematogenous spread)
 Fistula from the intestine (direct extension)
o Clinical manifestations:
 Half of patients is asymptomatic
 Burning on urination
 Urinary frequency
 Urgency
 Nocturia
 Incontinence
 Suprapubic or pelvic pain
 Hematuria and back pain
 Urosepsis
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 Elderly people
 Generalized fatigue – most common subjective symptom
 Change in cognitive function
o Diagnostic Findings:
 Urine culture = useful in identifying the specific organism present.
 Colony count of at least 105 CFU/mL = bacteria (criterion used for diagnosis of UTI)
 Cellular studies:
 Hematuria
 Pyuria
 CT scan and UTz
 TransrectalUtz
 Cystourethroscopy
o Pharmacological Therapy
Anti-infective Nitrofuratoin (Macrodatin, Furadantin)
Bactericidal Cephalexin (Keflex)
Cephalosporin Cefadroxil (Duricef, Ultrasef)
Fluoroquinolones Ciprofloxacin (Cipro)
Ofloxacin (Floxin)
Norfloxacin (Noroxin)
Gatifloxacin (Zymar)
Penicillin Ampicillin (Principen)
Amoxicillin (Amoxil)
Trimethoprim- Co-trimoxazole (Bactrim, Septra)
Sulfamethoxazole
Urinary analgesic agent Phenazopyridine (Pyridium)

o Nursing interventions to relieve Pain:

 Appliaction of heat
 Antispasmodic and analgesic
 Drink liberal amounts of fluid
 Urinary tract irritants should be avoided
 Coffee, tea, spices, colas, alcohol
 Frequent voiding (q 2 – 3 hours)
o Nursing interventions to Prevent Infection in patients with Indelling Catheter:
 Using strict aseptic technique during insertion of the catheter
 Securing the catheter to prevent movement
 Frequent inspecting urine color, odor, and consistency
 Performing meticulous daily perineal care with soap and water
o Possible cuases of recurrent UITs:
 Strictures
 Obstructions
 Calculi
o Prevention of UTI is the primary consideration for persons at risk
 Women should cleanse and dry from front-to-back when completing perineal care.
 Limiting the number of sexual partners
 Urinating before and after sexual intercourse
 Shower rather than bathe in the tub.
 Voiding pattern:
 Void every 2 – 3 hours, and completely empty the bladder
 Diet
 Drinking six – eight glasses of water daily
 Drinking cranberry juice
 Medication history
 Vit. C, 1,000 mg daily
 Anticholinergic medications predispose patients to UTI.
A.1. Interstitial Cystitis
o Inflammation of the bladder wall that eventually causes disintegration of the lining and loss of
bladder elasticity.
o Clinical manifestations:
 Presents with urgency
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 Frequency = urinate 16x a day

 Nocturia
 Dysuria
 Hematuria
 Pain = prominent as the bladder fills between voiding
 Suprapubic pain, urethra, area below the umbilicus, the lower back, or area around the
vagina
 Males: pain in the scotum, testes, or penis
 Females: pain can increase during sex, or during period
o Epidemiology:
 90% of cases occur in middle-aged women
o Etiology:
 Unknown
 Theories:
 Obstruction to lymphatic flow
 Thrombophlebitis secondary to acute infections
 Prolonged arteriolar spasm
 Neuropathic or endocrine dysfunction
o Pathophysiology:
 Poorly understood
 Bladder mucosa becomes thinned or denuded
 The exposed detrusor muscle is progressively damaged and develops fibrosis.
 The bladder losses its stretch capacity, and bladder pain is elicited as the bladder fills.
 Vesiculo-ureteral valvular incompetence develops.
o Two types:
 Ulcerative (classic)
 Nonulcerative (Messing-Stamey)

o Classic IC
 Mucosal ulceration (Hunner’s ulcer) with surrounding local areas of inflammation
 Seen during cystoscopic exam
 Hallmark sign
 Submucosalpetechiae
 Hemorrhage
 Demonstrate more fibrosis and scarring with progressive reduction in bladder capacity
o Nonulcerative IC
 Characterized by frequency, urgency, or pelvic pain
 No cystoscopic findings like in classic

o Diagnostic Tests:
 No laboratory test is definitive or of specific for IC.
 No urine cytology finding specifically suggests a diagnosis of IC.
 No serological or hematological abnormalities are known to be specific for IC.
 No known radiographic, ultrasonographic, or other imaging findings are specific
for IC
 The first step is to rule out other diseases that cause similar symptoms
 Cystoscopy can assist in the diagnosis.
 Involves an insertion of a hallow tube that contains lenses and a light into the
urethra and bladder.
 It allows the provider to directly visualize and examine the patient’s bladder.
 Most providers will fill the patient’s bladder with gas or liquid to test how well it
can stretch.
 Potassium sensitivity test
 Liquid that contains potassium is put into the bladder.
 After few minutes, the patient is asked to urinate.
 Plain water is then put into the patient’s bladder.
 If the potassium causes more pain or a greater need to urinate than the water
does, the person may have IC.
o Therapeutic Interventions:
 Nutrition
 Items to be avoided:
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o Alcohol
o Tomatoes
o Spices
o Chocolate
o Caffeinated drinks
o Acidic foods
o Artificial sweeteners
 Pharmacology:
 Pentosanpolysulfate sodium (Elmiron)
o Specific treatment for IC
o Oral tablet in 100 mg taken three times daily.
o The mode of action is not precisely known.
o It appears to offer protection against irritating substances.
o It reduces pain associated with inflammation and ulceration.
 Anti-inflammatory agents
o Cortisone acitate 1oo mg daily
o Prednisone 10-20 mg in divided doses daily for 21 days, then in
decreasing dose for another 21 days.
 Antihistamine
o Tripelennamine (Pyribenzamine) 50 mg 4x a day.
 Side effect: bladder discomfort
 Catheter instillation
 50 ml of 50% dimethyl sulfoxide (DMSO) and letting it dwell for 15 min.
 This is repeated every two weeks and offers symptomatic relief.
 Catheter bladder lavage
 Bladder lavage with increasing strengths of silver nitrate for symptom relief
 Surgery:
 Electrocoagulation = this therapy uses electrical energy converted to heat with
the tip of an electrode. This results in tissue being destroyed by burning. The
major use of this therapy is coagulation of bleeding vessels to obtain
hemostasis.
o Done with cystoscopy.
 Cystectomy with urinary diversion
o Done only in severe cases
 Alternative therapy
 Overdistension of the bladder with water to gradually improve the bladder
capacity.
o Requires anesthesia
 Electrical stimulation or exercises to train the bladder muscles

B. Upper UTIs
 Acute Pyelonephritis
o Is a bacterial infection of the renal pelvis, tubules, and interstitial tissue of one or both kidneys.
o Causes:
 Ascending infection due to incompetent ureterovesical valve or obstruction
 Bloodstream e.g., TB
o Clinical manifestations:
 Chills, fever, leukocytosis, bacteriuria,puria,
 Low back pain, flank pain, nausea and vomiting, headache, malaise, dysuria
 Urgency and frequency
 PE: tenderness in CVA
o Diagnostic tests:
 Utz and CT scan = used to locate an obstruction in the urinary tract.
 IV pyelogram
 Radionuclide imaging with gallium citrate and indium-111 = useful to identify sites of
infection that may not be visualized on CT scan or Utz.
 Urine C&S
o Medical Management:
 OPD = 2-week course of antibiotic agents
 IP = for pregnant patients.
 Parenteral antibiotic for 2 – 3 days
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 Relapse = 6 weeks of antibiotic therapy

 Hydration

 Chronic Pyelonephritis
o Repeated bouts of acute pyelonephritis
o Clinical manifestations:
 Fatigue,
 headache,
 poor appetite,
 polyuria,
 excessive thirst, and
 weight loss
o Diagnostic:
 Elevated levels of creatinine clearance, BUN, and creatinine levels
o Complications:
 ESKD due to chronic inflammation and scarring
 Hypertension
 Formation of kidney stones
o Medical Management:
 Long-term use of antimicrobial therapy
o Nursing Management:
 Fluid I&O are carefully measured and recorded.
 3 – 4 L/day is encouraged
 Monitor temp q4H
 Patient education

2. Glomerulonephritis
 Is an inflammation of the glomerular capillaries leading to impairment of the kidney’s ability to filter
urine.
 Affects both kidneys equally.
 Etiology:
o Infections
o Immune diseases
o Inflammation of the blood vessels (vasculitis)
o Conditions that scar the glomeruli

o Infections
 Poststreptococcal glomerulonephritis
 Develops after an infection of group A beta hemolytic streptococcus usually in
the pharynx (strep throat) or skin (impetigo)
 Bacterial endocarditis
 Is known as a cause of glomerulonephritis.
 Persons with artificial heart valve are at greatest risk.
 Viral infections
 HIV
 Hep B and C viruses
o Immune diseases:
 Systemic Lupus Erythematosus (SLE)
 Is a chronic inflammatory disease due to autoimmunity disorder and is classified
as multisystemic disease.
 Has symptoms of arthralgias and skin rashes
 Goodpasture syndrome
 Is a rare immune lung disorder that may mimic pneumonia. It causes
hemorrhage in the lungs, as well as complications of glomerulonephritis.
 Diagnostic: serum anti-glomerular basement membrane (GBM) antibodies.
 Immunoglobulin A (IgA) nephropathy
 Is characterized by recurrent episodes of blood in the urine. This condition
results from deposits of IgA in the glomeruli.
 Men are more likely to develop this disorder than women.
o Vasculitis:
 Polyarteritis
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 Is a form of vasculitis that affects small and medium blood vessels in many parts
of the body, including heart, kidneys, and intestines.
 Wegener’s granulomatosis
 Is a form of vasculitis that affects small and medium blood vessels in the lungs,
upper airways, and kidneys.
 Present with a triad of sinusitis, pulmonary infiltrates, and nephritis.

 Pathophysiology:
o Immune complexes form in situ and deposit on the glomeruli, forming lesions. The glomerular
tuft appears swollen and infiltrated with polymorphonucleocytes.
o Nephromegaly = kidneys may be enlarged by 50%.
o Conditions that can scar the glomeruli:
 Hypertension, diabetic nephropathy, and glomerulosclerosis
 Hypertension damages the kidneys and impairs their ability to function normally.
 Glomerulonephritis can also cause high BP
 Glomerulosclerosis is characterized by scattered scarring of some glomeruli.
 Clinical manifestations:
o Onset of signs and symptoms appear in one to two weeks after a strep throat infection and
three to six weeks after an impetigo infection.
o First clinical symptoms:
 Dark urine, described as brown, tea, or cola-colored.
 Caused by hemolysis of red blood cells.
o Periorbital edema is noticeable upon waking.
 Result of defect in renal excretion of salt and water.
o Hypertension is present in approximately 80% of patients.
o Clusters of symptoms – hematuria, edema, and hypertension – known as nephritic syndrome.
o Flank pain due to stretching of renal capsule.
o Low urine output (oliguria)
 approximately 50% of patients
 15% of this group has UO of less than 200ml/day.
o Malaise
o Weakness
o Anorexia
o Nausea
o Vomiting
 Diagnostic tests:
o CBC
o Electrolytes
o BUN and creatinine
 Elevated levels reflect decrease GFR
o Urinalysis
 Presence of hematuria and proteinuria in 100% cases
 Urine osmolality is greater than 1,020 osm.
 Normal is 300 – 900 osm
o Cultures of the throat and skin to rule out strep infection
o Chest x-ray in patients with cough, with or without hemoptysis.
o Renal biopsy
 Planning and implementation:
o Major goals are control of edema and BP.
o Therapy is symptomatic.
 Nutrition to control edema:
o Low sodium diet (2 g per day)
o Fluid restriction (1 L per day)
o When levels of BUN and creatinine are elevated protein is restricted
o Carbohydrates are increased to provide energy and to prevent protein catabolism
 Pharmacology:
o Penicillin is indicated to eradicate strep infection
 Oral Pen G 250 mg 4x a day for 7 – 10 days
o Erythromycin
 250mg 4x a day for 7 – 10 days
 Indicated for patients with penicillin allergy
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o Furosemide (Lasix)
 Used to treat edema
 20 – 40 mg orally or IV q 6 – 8 hours
o Potassium-sparing diuretics
 Contraindicated because of an increased risk of hyperkalemia.
o Calcium channel blocker
 Amlodipine (Norvasc) 5 – 20 mg orally 2x a day
o ACE inhibitors
 Captopril (Capoten) 25 mg orally, 2 – 3x a day.
 Patient and family teaching:
o When patient is taking diuretics, advise to avoid high-potassium foods, such as banana and
avocados.
o Bedrest is required during acute phase of illness, or moderate activity should be taught to the
patient.
o Strenuous exercise can exacerbate proteinuria and hematuria.

3. Nephrotic Syndrome
 Nephrosis
o Symptoms: heavy proteinuria, hypoalbuminemia, edema, hypercholesterolemia, and normal
renal function.
 Epidemiology:
o 15x more common in children than in adults.
 Described as a disease of children and is relatively rare.
o Incidence rate is among children younger than 16 years.
 Etiology:
o primary Causes:
 SLE or rheumatoid arthritis
 Sickle cell disease
 Diabetes mellitus
 Amyloidosis
 Malignancy, such as leukemia, lymphoma, Wilm’s tumor, or pheochromocytoma
 Toxins, such as bee sting, poison ivy or oak, or snake venom
 Medications
 Probenecid, Fenoprofen, Captopril, lithium, or warfarin, heroine use
o Secondary causes:
 Infection with GABHS, syphilis, malaria, TB, or viral infections, including varicella, Hep B,
HIV, and infectious mononucleosis.
 Pathophysiology:
Etiology
↓
Causes the membrane to become porous
↓
Damaging the kidneys’ glomeruli
↓
Allows passage of albumin into urine
↓
Decreased serum albumin
↓
Decreased osmotic pressure
↓
Capillary hydrostatic pressure becomes greater than osmotic pressure
↓
Increases fluid shifts from intravascular to interstitial spaces (edema)
↓
Plasma volume decreases
↓
Stimulates the secretion of aldosterone to retain water and sodium
↓
Continues to pass out of the capillary into the tissue, leading to greater edema

 Clinical manifestations:
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o Edema
 The major clinical manifestation, present in about 95% of cases
 Present in dependent parts, such as ankle or legs
 Pitting in nature in adult
 In children, periorbital edema is present
o Pleural effusion
o Ascites
o Anasarca
o Foamy urine = due to lowering of specific gravity
o Anorexia
o Irritability
o Fatigue
o Abdominal discomfort
o Diarrhea
 Diagnostic tests:
o Urinalysis
 Reveals positive protein, usually exceeds 100 mg/ dL – 1000 mg/ dL
 Dipstick tests may reveal as high as +3 - +4
o Serum albumin
 Less than 2 g/ dl (hypoalbuminemia)
o Serum cholesterol
 Hyperlipidemia
o Chest x-ray
 Reveals pleural effusion
 Nutrition
o Sodium-restricted diet
 (2-3 g/ day)
o Moderate intake of protein
o Fluid restriction is unnecessary
 Pharmacology:
o Glucocorticoid therapy
 The primary agent of choice in treating nephrotic syndrome
 Oral prednisone or prednisolone 2mg/ kg/day
 The daily dose is split into two doses and given daily for 4 – 8 weeks
 Antibiotic therapy should be initiated when patient becomes febrile
o Loop diuretic therapy
 Furosemide, orally, 1 – 2 mg/ kg/ day
o Salt-poor albumin
 Infused IV, 1g/kg for 2 – 4 hours
o Pneumococcal vaccine

4. Renal Tuberculosis
 Is the most common site of extrapulmonary TB.
 This infection can result in cessation and destruction of renal mass, leading to renal functional loss and
failure.
 Etiology:
o Tubercle bacilli
 Pathophysiology:
TB of the lung
↓
Bacilli reach the kidneys via bloodstream
↓
Healing process lead to stricture, obstruction, secondary calculi, and infection
↓
Renal failure

 Clinical manifestations:
o Most are asymptomatic
o Frequency, dysuria, urgency, hematuria, and flank pain
 Diagnostic tests:
o History taking
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o
Acid-fast bacillus (AFB) smear and culture
o
Tuberculin test
o
CXR
o
IVP
o
Bacilli culture from urine
 Definitive diagnosis
 Pharmacology:
o RIPES
 Rifampicin
 Isoniazid
 Pyrazinamide
 Ethambutol
 Streptomycin

5. Urinary Tract Calculi (Urolithiasis)

 Refers to stones in the urinary tract.
 Epidemiology:
o Males are more afflicted than females
 Etiology:
o Unclear
o Factors directly contributing to stone formation:
 Acidic urine
 Concentration of elements in the urine (dehydration)
o Increased rate of calcium absorption in the gut
o Higher body mass index, particularly in women
o Gout
o Primary hyperparathyroidism
 Types of stones:
o Calcium
 Composes the majority of renal stones
 Calcium oxalate, calcium phosphate
 Less soluble in higher pH (alkaline) urine
o Struvite stones
 Composed of magnesium, phosphate, and ammonia
 Present as staghorn calculi lodged in the pelvis of the kidney
o Uric acid stones
 Less than 5% of all urinary calculi
 Form only in individuals with persistently acid urine, with or without hyperuricosuria
o Cystine and xanthine stones
 Associated with hereditary factors.
 Form only in individuals with an autossomal recessive disorder of cystinuria
 Less soluble in lower pH (acidic) urine
o Indinavir (Crixivan), Acyclovir (Zovirax), Triamterene = due to medication
 Clinical manifestations:
o Sudden onset of unilateral flank pain
o Radiation of pain depends on the location of stones:
 Upper ureter =pain may radiate anteriorly to the abdomen
 Lower ureter = pain can radiate to the ipsilateral testicle in men or ipsilateral labium in
women
 Ureterovesicular junction = urinary frequency and urgency
o Shock-like symptoms:
 Cool, diaphoretic skin
o UTI symptoms
o Fever, nausea, and vomiting
 Diagnostic tests:
o CBC
 Reveals leukocytosis because of infection
o Urinalysis
 Reveals red and white blood cells
o Helical CT scan
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 The imaging modality of choice, because of the ability to visualize uric acid stones, even
without radiocontrast.
 Planning and implementation:
o Management for calculi focuses on relieving pain, destroying or removing the renal stones, and
preventing continued formation of calculi
o Nutrition:
 Increasing fluid intake to 2.5 – 3 L, as well as drinking even at night
 Calcium and vitamin D intakes are limited
 Animal proteins should be limited to prevent uric acid stones
 Limit intake of spinach, rhubarb, beet greens, nuts, chocolates, tea, bran, almonds,
peanuts, and strawberries, they significantly increase urinary oxalate levels
 Lemonade and most fruit juices except for grapefruit can dilute substances in the urine.
 Avoid softdrinks
 Foods that alkalinize urine to prevent uric acid and cystine:
 Fruits
 Green vegetables
 Legumes
 Milk
 Milk products
o Pharmacology:
 NSAIDs or narcotics
 Antispasmodics, alpha-blockers, injection with lidocaine, NSAIDs combined with nitrates
 Thiazide diuretics are administered for calcium calculi
 Potassium citrate are administered for uric acid and cystine stones
 Allopurinol (Zyloprim)
 Surgery:
o Extracorporeal shock wave lithotripsy (ESWL)
 Least invasive surgery, most effective for stones smaller than 2 cm, located in the renal
pelvis, and composed of calcium oxalate dihydrate, uric acid, or struvite.
 This procedure uses ultrasonic waves that disintegrate or break the stone into sandlike
particles.
 This is not indicated for morbid obese individuals
 Hematuria is common after lithotripsy procedure
o Percutaneous nephrostolithotomy
 Is more invasive procedure necessary for large stone burdens or stones that cannot be
removed cystoscopically.
 Involves insertion of nephroscope through a small incision in the flank.
o Pyelolithotomy
 Incision into the renal pelvis to remove a stone.
o Ureterolithotomy
 Removal of stones in the ureter
o Cystostomy
 Removal of bladder calculi