UNIT NINE
708
Understanding the Urinary System
Table 37.4 Glomerulonephritis Summary
ACUTE KIDNEY INJURY OR CHRONIC KIDNEY DISEASE
Signs and Symptoms
Fluid volume overload Hypertension Electrolyte imbalances Edema Periorbital edema Flank pain
Kidney disease is diagnosed when the kidneys are no longer functioning adequately to maintain normal body processes and homeostasis. This results in dysfunction in almost all body systems because of imbalances in fluid, electrolytes, and calcium levels as well as impaired RBC formation and decreased elimination of waste products. Kidney disease can be acute (acute kidney injury) with sudden onset of symptoms, or it can be chronic (CKD), occurring gradu- ally over time. For more information on the kidney, visit the American Kidney Fund (www.kidneyfund.org), the National Kidney Foundation (www.kidney.org), and the American Association of Kidney Patients (www.aakp.org). Acute Kidney Injury Acute kidney injury (AKI) is the sudden (hours to days) loss of the kidneys’ ability to clear waste products and regulate fluid and electrolyte balance. Rapid accumulation of toxic wastes from protein metabolism in the blood ( azotemia ) occurs. Serum creatinine level and serum urea level (mea- sured by BUN) are elevated. AKI may or may not be asso- ciated with reduced urine output. Many patients with AKI recover completely; others have a decline in kidney function. Pathophysiology AKI has three major mechanisms of injury: hypoperfu- sion, direct tissue injury, and hypersensitivity reactions causing renal inflammation. Rapid damage to the kidney causes waste products to accumulate in the bloodstream. The patient may become oliguric depending on the cause. Potassium imbalances may lead to arrhythmias and require immediate dialysis. AKI can affect other organs, leading to organ dysfunction. AKI may progress through four stages (if urine output decreases), with an intrarenal cause taking a longer recovery time because there is actual renal damage. NURSING CARE TIP To protect patients’ kidneys, be aware of the following: Patient’s Renal Function • Estimated glomerular filtration rate (eGFR; best indicator) • Serum creatinine • Serum blood urea nitrogen (BUN) levels
Diagnostic Tests
Urinalysis shows red cells, white blood cells, protein, and casts Urine dark or cola-colored Foamy urine Serum creatinine elevated Serum blood urea nitrogen (BUN) elevated Renal biopsy Symptomatic treatment NSAIDs Steroids Antibiotics prophylactically as needed
Therapeutic Measures
Complications
Chronic kidney disease
Priority Nursing Diagnoses
Excess Fluid Volume
levels may be elevated. Kidney ultrasound, x-ray, or biopsy may be done to determine abnormal kidney shape, size, blood flow, inflammation, or scarring of the glomeruli. Therapeutic Measures Most cases of acute glomerulonephritis resolve sponta- neously in about a week, but some cases progress to CKD. Sodium and fluid restrictions may be ordered, along with diuretics to treat fluid retention. Medications may be given to control hypertension. If associated with a streptococcal infection, antibiotics are given. If fluid overload is severe, dialysis may be required. Nursing Care Nursing care for a patient with glomerulonephritis focuses on symptom relief. Vital signs are monitored because the patient may be critically ill. During the acute phase, rest is encouraged. Edema is controlled with fluid and sodium intake restrictions. Protein intake may be restricted if the kidneys are not filtering protein waste products (as shown by increased serum BUN and serum creatinine levels). Additional care is discussed in the section on CKD. Teaching the patient how to prevent glomerulonephritis is important. Antibiotics for diagnosed streptococcal throat infections should be prescribed to prevent glomerulonephritis.
Nephrotoxic Substances • Diagnostic contrast agents
• Medications, such as IV aminoglycosides (gentamicin [Garamycin], tobramycin [Tobrex]), amikacin (Amikin), cisplatin (Platinol), and vancomycin [Vancocin]).
• WORD • BUILDING • azotemia: azo—nitrogenous waste products + temia—blood
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