Medical-Surgical Nursing: Pyelonephritis and Glomerulonephritis PDF

Book Cover for Davis Advantage for Medical-Surgical Nursing: Making Connections to Practice, Third Edition. Chapter 62 Coordinating Care...

Book Cover for Davis Advantage for Medical-Surgical Nursing: Making Connections to Practice, Third Edition. Chapter 62 Coordinating Care for Patients With Renal Disorders Copyright ©2024 F.A. Davis Company  Pyelonephritis  Epidemiology Infection of the kidneys ‒ Common renal disease 12–13 cases annually per 10,000 in women 2–3 cases per 10,000 in men Young women most often affected ‒ Increased susceptibility to UTIs  Often related to sexual activity Elderly and Infants have increased risks as well ‒ Anatomic variations, hormone status Copyright ©2024 F.A. Davis Company  Pyelonephritis  Risk factors Major risk factor: multiple pre-existing UTIs ‒ Regardless of whether treated or untreated ‒ These infections may be caused by:  Sexual activity  Vesicoureteral reflux » Retrograde flow of urine from the bladder to the ureters  Obstructions » BPH, a stricture, or urinary stone  Long-term indwelling urinary catheter  “Pregnancy-Induced Acute Pyelonephritis” » Result of physiological changes associated with pregnancy Copyright ©2024 F.A. Davis Company Specifically hormonal changes and  Pyelonephritis  Pathophysiology Bacterial or viral infection leads to inflammation of renal parenchyma and urinary collecting system ‒ Most commonly bacterial ‒ E. coli most common culprit Copyright ©2024 F.A. Davis Company  Pyelonephritis Copyright ©2024 F.A. Davis Company  Pyelonephritis  Clinical manifestations May have classic UTI symptoms ‒ Painful and frequent urination, hematuria, urgency Fever, chills, nausea, vomiting Back or flank pain Costovertebral tenderness (CVAT) Enlarged kidneys on palpation Copyright ©2024 F.A. Davis Company  Pyelonephritis  Medical management—Diagnosis Laboratory testing ‒ UA, culture and sensitivity, blood culture, CBC  UA: pyuria, bacteriuria, and hematuria » WBC may be present in the urine  CBC: leukocytosis Imaging studies ‒ CT scan or ultrasound  Hydronephrosis, obstruction, etc Copyright ©2024 F.A. Davis Company  Pyelonephritis  Medical management—Treatment Hospitalization most often ‒ Pregnancy  reduce complications/preterm labor risks ‒ Severely ill clients with comorbid conditions Outpatient treatment for mild illness ‒ Those who can be stabilized with oral ATB and adequate hydration close supervision Analgesic/Antipyretics ‒ NSAID or narcotics, pyridium, meds for fever Hydration ‒ Increase PO fluids, IV fluids Antibiotics ‒ Oral or IV with oral after discharge Copyright ©2024 F.A. Davis Company  Pyelonephritis  Surgical management Emergency surgery may be indicated if fever/pain >48 hours or positive blood culture ‒ Abscess ‒ Obstructing calculi ‒ Structural anomaly Copyright ©2024 F.A. Davis Company  Pyelonephritis  Complications RT recurrent infections or poorly treated pyelonephritis ‒ Scarring ‒ Chronic kidney disease (CKD) ‒ Permanent damage ‒ Urosepsis  Bacteria can migrate to the bloodstream from the urinary tract  Widespread inflammation alters metabolism and can cause multisystem organ failure as a result of severe sepsis and septic shock  s/s: mental status change, fever, tachycardia, hypotension, oliguria, leukopenia Copyright ©2024 F.A. Davis Company  Pyelonephritis  Nursing management—Assessments Vital signs ‒ Fever, shock symptoms Pain level ‒ Back, flank, or groin pain is a diagnostic indicator of pyelonephritis  Continued pain assessment helps evaluate pain- control efforts Laboratory analysis ‒ UA ‒ CBC ‒ Blood cultures  + indicates septicemia an infection within the Copyright ©2024 F.A. Davis bloodstream Company  Pyelonephritis  Nursing interventions—Actions Administer antibiotics as ordered ‒ Important to eradicate the pathogen ‒ Following the prescribed antibiotic regimen helps to reduce antibiotic resistance Pain management ‒ To provide comfort to the patient Provide adequate hydration (oral, IV) ‒ Important in maintaining good urine flow to avoid urine stasis ‒ Hydration may also be necessary to maintain adequate circulating volume in the face of vasodilation associated with inflammation Copyright ©2024 F.A. Davis Company  Pyelonephritis  Nursing interventions—Teaching Explain disease condition to patient and family ‒ Signs, symptoms, treatment, medication compliance  Early detection in order to obtain treatment in the early stages » Avoid the use of more aggressive ATB therapy, reduce ATB resistance due, and prevent further complications chronic pyelonephritis Instruct patient and family on how to avoid UTIs Copyright ©2024 F.A. Davis Company  Pyelonephritis  Nursing management—Nursing diagnoses Infection ‒ RT impaired urinary elimination Ineffective therapeutic regimen management ‒ RT inadequate knowledge of the disorder Copyright ©2024 F.A. Davis Company  Pyelonephritis  Nursing management—Evaluating care outcomes Avoidance of complications Free from symptoms Copyright ©2024 F.A. Davis Company  Acute Glomerulonephritis  Epidemiology A kidney disease that causes inflammation of the glomeruli the tiny filters in the kidneys Prognosis is dependent upon causative agent and extent of damage 3rd leading cause of renal failure in the US Caused by autoimmune disorders (Lupus) or infection (Strep) Acute ‒ Infection: most often seen in kids or young adults Chronic ‒ Infection or genetics: slower development with fever symptoms but may result in irreversible damage ‒ May also result from unresolved acute glomerulonephritis Copyright ©2024 F.A. Davis Company  Acute Glomerulonephritis  Risk factors Infections ‒ Recent strep Immune diseases ‒ Lupus ‒ Vasculitis Hypertension Diabetes Copyright ©2024 F.A. Davis Company  Acute Glomerulonephritis  Pathophysiology Inflammation of glomeruli within Bowman’s capsule of kidney ‒ Where first step of filtration and urine formation takes place Triggered by immunological mechanism ‒ Results in injury to glomerular membrane ‒ Decrease in filtration (decrease in GFR less than 125mL/min) ‒ Increase permeability to proteins Copyright ©2024 F.A. Davis Company  Acute Glomerulonephritis  Clinical manifestations Protein, blood, WBCs, and casts in urine ‒ As a result of the increased permeability Edema Decreased urine output Hypertension Elevated BUN and creatinine Copyright ©2024 F.A. Davis Company  Acute Glomerulonephritis  Medical management—Diagnosis Medical history Physical exam Laboratory tests ‒ UA  WBC, RBC, protein, casts ‒ CBC  Increased WBC ‒ BMP/CMP  Increased BUN and creatinine  Decreased albumin Copyright ©2024 F.A. Davis Company  Acute Glomerulonephritis  Medical management—Treatment Based on the cause of the disease and symptom management Primarily involves medications and supportive care ‒ Medications  ATB most-specifically PCN  Diuretics and antihypertensives » May need to be added to treat HTN ‒ Supportive care  Sodium and fluid restrictions to help with the edema  Reduction of dietary protein if BUN is elevated » To reduce the buildup of metabolic waste  Corticosteroids (sometimes!) » Not always recommended but may be indicated to modulate the inflammatory response triggered by autoimmune mechanism ‒ Plasmapheresis  May be considered to reduce the immune-triggered Copyright ©2024 F.A. Davis Company  Acute Glomerulonephritis  Complications 95% of pts recover with early treatment ‒ If left untreated or pt is unresponsive to treatment acute or chronic kidney disease may develop ‒ A rapidly progressive form of glomerulonephritis can progress to renal failure within weeks to months Copyright ©2024 F.A. Davis Company  Acute Glomerulonephritis  Nursing management—Assessment and analysis Clinical manifestations due to damage to Bowman’s capsule ‒ Hematuria ‒ Oliguria ‒ Periorbital edema ‒ Peripheral edema of lower extremities ‒ Generalized edema ‒ Ascites ‒ Abdominal or flank pain ‒ Hypertension Copyright ©2024 F.A. Davis Company  Acute Glomerulonephritis  Nursing management—Nursing diagnoses Impaired urinary elimination ‒ RT effects of damage to the glomerular membrane Ineffective therapeutic regimen management ‒ RT lack of knowledge regarding the treatment regimen Copyright ©2024 F.A. Davis Company  Acute Glomerulonephritis  Nursing interventions—Assessments Vital signs ‒ HTN due to fluid retention Daily weights ‒ Weight gain is associated with sodium & water retention Intake and output Measure abdominal girth Skin condition ‒ Edema can increase risk of skin breakdown Monitor dietary intake ‒ Loss of protein in the urine risk for malnutrition ‒ Excess sodium fluid retention Copyright ©2024 F.A. Davis Company  Acute Glomerulonephritis  Nursing interventions—Actions Administer medications as ordered ‒ BP, diuretics, steroids Maintain low-to-moderate protein diet ‒ Care must be taken to limit protein intake if the BUN is elevated, but a low-to-moderate protein diet may be needed to treat protein loss through the urine Dietary sodium and fluid restriction ‒ To prevent fluid retention, which can cause elevated BP and heart failure Copyright ©2024 F.A. Davis Company  Acute Glomerulonephritis  Nursing interventions—Teaching Overview of disease process ‒ Important for the pt and family to understand the disease process and the s/s associated with glomerulonephritis Prescribed medications ‒ Medication adherence must be emphasized Dietary restrictions Avoid infections ‒ Educated on avoiding exposure to infectious diseases, especially if on corticosteroids Copyright ©2024 F.A. Davis Company  Acute Glomerulonephritis  Nursing management—Evaluating care outcomes Based on improvements in kidney function and symptoms associated with glomerulonephritis ‒ Blood pressure WNL ‒ No edema ‒ Renal function WNL Copyright ©2024 F.A. Davis Company  Renal Cancer  Epidemiology One of the most common cancers ~63,000 new cases in the US per year ‒ ~14,000 people die from renal cancer each year Most common type: renal cell carcinoma (adenocarcinoma) ‒ Most often in males ages 50-70 ‒ Rates higher in African Americans, American Indians, Alaskan Natives  Unknown reasons Copyright ©2024 F.A. Davis Company  Renal Cancer  Risk factors Tobacco use Family history ‒ 1st degree relatives Obesity Hypertension Exposure to carcinogens ‒ Asbestos, herbicides, cadmium(batteries) , gasoline Diuretics Cystic disease caused by ESRD Copyright ©2024 F.A. Davis Company  Renal Cancer  Pathophysiology Usually in cortex or pelvis of kidney Malignant tumors in the kidney are more frequent than benign tumors Tumors compress underlying tissues ‒ Reducing circulation and damaging underlying tissues ‒ This compression leads to compromised renal function or renal failure 30% of malignant tumors have metastasized by the time of diagnosis ‒ Locations of mets include: long bones, lungs, and liver ‒ Extension of cancer into the renal vein and Copyright ©2024 F.A. Davis Company  Renal Cancer  Clinical manifestations Most patients are initially asymptomatic ‒ The eventual stretching, compressing, and invading of tumors within the renal structures can cause the classic triad:  Flank mass  Flank pain  Hematuria  Other symptoms may include: » Weight loss » Fatigue » HTN » Fever not related to infection » Anemia » If there is compression of the testicular vein due to the mass varicocele Copyright ©2024 F.A. Davis Company  Renal Cancer  Medical management—Diagnosis Ultrasound ‒ To differentiate between a solid mass, tumors, and cysts Angiography Percutaneous needle aspiration ‒ Minimally invasive procedure that uses a fine needle to extract cells from the body for diagnosis CT/MRI Radionuclide isotope scanning ‒ Used to detect metastasis Urine cytology ‒ Shows the presence of neoplastic or atypical cells Renal biopsy ‒ Utilized to look for cancerous tissue cells Copyright ©2024 F.A. Davis Company  Robson’s System of Staging Renal Carcinoma Copyright ©2024 F.A. Davis Company  Renal Cancer  Medical management—Medications Renal cancer is resistant to chemo Biological immunotherapy ‒ Interleukin-2, cytokines, interferon  Used to boost immune system and block growth of cells Radiation therapy ‒ Done for palliative measures if inoperative Copyright ©2024 F.A. Davis Company  Renal Cancer  Surgical management Tx for renal cancer usually involves surgery Partial nephrectomy ‒ Only if early detection or small stage cancer Radical nephrectomy ‒ Most often treatment ‒ Removal of the affected kidney, adrenal gland, surrounding tissues  Such as the fascia, part of the ureter, and Copyright ©2024 F.A. Davis draining lymph nodes Company  Renal Cancer  Complications Pain Reduces circulation needed by the tissues ‒ Renal system is highly-sensitive to reductions in circulating oxygenated blood and nutrients  If untreated, the reduced circulation can cause end-stage renal failure End-stage renal failure Copyright ©2024 F.A. Davis Company  Renal Cancer  Nursing management—Nursing diagnoses Acute pain ‒ RT renal cancer Impaired urinary elimination ‒ RT obstruction of tissues secondary to the tumor Ineffective therapeutic regimen management ‒ RT lack of knowledge regarding the disease process Copyright ©2024 F.A. Davis Company  Renal Cancer  Nursing management—Assessment and analysis Symptoms caused by size of mass and compression of renal tissue Copyright ©2024 F.A. Davis Company  Renal Cancer  Nursing interventions—Assessments Vital signs ‒ HTN may accompany renal cancer ‒ Tachycardia may be an indicator of pain Pain ‒ Commonly present because of the size of the mass and compression of the underlying tissue Preoperative assessment(read notes down below) Postoperative assessment ‒ Hypotension and tachycardia  may reflect dehydration ‒ Fever  may indicate surgical site infection ‒ Decreased O2  may indicate post-op Copyright ©2024 F.A. Davis Company  Renal Cancer  Nursing interventions—Actions Administer medications as ordered  Postoperative Administer pain medication as ordered Administer IV hydration as ordered/encourage oral hydration as ordered Encourage respiratory exercises Appropriate care of catheters, stents, nephrostomy tubes, or drains Perform wound care as ordered Copyright ©2024 F.A. Davis Company  Renal Cancer  Nursing interventions—Teaching Diagnosis Procedures or diagnostic tests ‒ Pre and post IV pyelography p. 1515  Also called IV urography » Examines the urinary tract ‒ Pre and post renal biopsy p. 1517 Medication education Resources Copyright ©2024 F.A. Davis Company  Renal Cancer  Nursing management—Evaluating care outcomes Pain control Clean incision Adequate elimination Free from blood or signs of infection Copyright ©2024 F.A. Davis Company  Renal Trauma  Epidemiology Most accidents involve males less than 30 years old Usually due to blunt force trauma ‒ Perforation, tearing, contusions, rupture Copyright ©2024 F.A. Davis Company  Renal Trauma  Pathophysiology Depends on mechanism, force, and speed of impact Can range from contusion/hematoma to shattered kidney UO may be reduced or absent in response Hematuria may be present Copyright ©2024 F.A. Davis Company  Renal Trauma  Medical management—Diagnosis Ultrasound CT scan IV pyelogram MRI Renal arteriography Both kidneys should be assessed and findings compared UA evaluated for the presence of blood CBC and chemistry labs bleeding and renal function Copyright ©2024 F.A. Davis Company  Renal Trauma  Medical management—Treatment Stabilize patient Surgical repair if needed ‒ Perforation or laceration Control bleeding ‒ Small bleeds heal by rest Shock prevention Promote urinary drainage Pain control Copyright ©2024 F.A. Davis Company  Renal Trauma  Surgical management Exploratory laparotomy: ~9% ‒ Surgical exploration to determine the extent and type of damage Nephrectomy: ~11% require ‒ Indicated in cases of severe bleeding  Due to damage of the kidney itself or severe renovascular injury Copyright ©2024 F.A. Davis Company  Renal Trauma  Complications Most significant: the extent of damage to the function of the kidney Bleeding is also a major concern ‒ In rare cases, renal shattering can occur, leading to major renal vascular laceration  As a result, the patient may experience significant hemorrhage » Can be life-threatening Copyright ©2024 F.A. Davis Company  Renal Trauma  Nursing management—Assessment and analysis Clinical manifestations depend upon extent of patient trauma ‒ Gross hematuria ‒ Flank pain ‒ Flank mass ‒ Back/flank bruising ‒ Signs of blood loss  Hypotension, tachycardia Copyright ©2024 F.A. Davis Company  Renal Trauma  Nursing management—Nursing diagnoses Acute pain ‒ RT renal trauma Impaired urinary elimination ‒ RT trauma or blockage of the ureters or urethra Copyright ©2024 F.A. Davis Company  Renal Trauma  Nursing interventions— Assessments Vital signs ‒ Hypovolemia ‒ Pain Pain Urine output and color ‒ Oliguria  may indicate an obstruction ‒ Hematuria  may indicate extensive damage and bleeding Laboratory values ‒ UA, renal function (CMP), Hgb/Hct (CBC) Copyright ©2024 F.A. Davis Company  Renal Trauma  Nursing interventions—Actions Administer pain medications as ordered Administer fluids as ordered Provide incision care as ordered Encourage rest Copyright ©2024 F.A. Davis Company  Renal Trauma  Nursing interventions—Teaching Education about condition Diagnostic tests Medications Copyright ©2024 F.A. Davis Company  Renal Trauma  Nursing management—Evaluating care outcomes Stable vital signs Absence of bleeding Adequate urinary output Pain control Copyright ©2024 F.A. Davis Company