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Part III: Nursing management for patients with Renal disorders

Lecture Outlines
Assessment and diagnostic test
Cardinal signs and symptoms
Urinary tract Infection
Renal stone
Prostatic hyperplasia
Acute and End stage of renal failure.

Learning Objectives
At the end of this lecture, the students should be able to:
1. Describe the diagnostic studies used to determine upper and lower
urinary tract function.
2. Identify the assessment parameters used for determining the status
of upper and lower urinary tract function.
3. Identify factors contributing to upper and lower urinary tract
infections
4. Initiate education and preparation for patients undergoing
assessment of the urinary system.
5. Develop a teaching plan for the patient undergoing treatment for
renal calculi (kidney stones).
6. Describe prostate gland: it's causes, clinical manifestations, and
medical and surgical management
7. Describe the causes of acute and chronic renal failure and compare
and contrast treatment options: hemodialysis, peritoneal dialysis,
and continuous renal replacement therapy.
8. Describe the nursing management of the hospitalized patient on
dialysis.

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9. Use the nursing process as a framework for the care of patients
with acute and chronic renal failure.

Diagnostic Tests for Patients with Renal Disorders

Ultrasound, CT Scan, MRI, IVP (Intravenous Pyelogram), Renal scan,
Renal Arteriogram are some commonly used methods to image the
kidneys.

Imaging studies of kidney are used to
1. Study the location and size of the kidneys.
2. To identify presence and the size of obstruction.
3. To visualize blood supply to the kidneys.
4. To detect and characterize any malformations such as cysts, tumors.

Intravenous pyelogram (IVP)

The IVP is called as intravenous pyelogram. It involves the intravenous
injection of iodinated contrast material which is filtered at the glomerulus
and gets concentrated within the tubules. It provides an opportunity to
determine:
the number of kidneys, their size, their configuration and if there are
any filling defects.
It allows visualization of the ureters and the bladder.
It help to detect obstructions in the urinary tract such as kidney
stones or tumours.
IVP is contraindication in case of pregnancy, very young children,
and in people with renal impairment.

Ultrasound image
Ultrasonography represents a major advance in the non-invasive
visualization of the kidney. The principal used is that of ultrasound waves
which generate an echo when their passage is impeded by tissues air fluid
etc. it is used to:

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1. Determine the size of the kidneys.
2. See if there is any obstruction to the flow of urine
3. Evaluate cysts and tumours. Numerous cysts in both kidneys
usually signifies polycystic kidney disease. Solid renal masses may
signify the presence of tumour.

CT Scan
Uses

Detect cyst, and tumours.
Haemorrhage. or
Infections.


Renal Arteriography
Renal arteriography means the visualization of the renal arteries by the
injection of dye into the arteries. It is mainly used to:
diagnose any narrowing of the renal arteries (renal artery stenosis)
which are commonly seen in advanced atherosclerosis or people
who are smokers.



Renal Scan

The renal scan provides information about :

a. the blood flow within the kidney.

b. Delayed excretion of the agent which may signify intrinsic renal
disease.

c. decreased blood flow or,

d. obstruction to the flow of urine.


Cystourethrogram
A cystourethrogram is an X-ray test that takes pictures of
thebladder and urethra while thebladder is full and while urinating.

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A thin flexible tube (urinary catheter ) is inserted through urethra
into the bladder. A liquid material that shows up well on an X-ray
picture (contrast material) is injected into the bladder through the
catheter, then X-rays are taken with the contrast material in the
bladder. More X-rays may be taken while urine flows out of the
bladder, in which case the test is called a voiding
cystourethrogram (VCUG).
If X-rays are taken while contrast material is being injected into
the urethra, the test is called a retrograde cystourethrogram
because the contrast material flows into the bladder opposite the
usual direction of urine flow.

Purposes of A cystourethrogram
1. Find the cause of repeated urinary tract infections.
2. Look for injuries to the bladder or urethra.
3. Find the cause of urinary incontinence.
4. Check for structural problems of the bladder and urethra.
5. Look for enlargement (hypertrophy) of the prostate or narrowing
(stricture) of the urethra in men.
6. Find out if urine is flowing the wrong way, from the bladder back
towards the kidneys (vesicoureteral reflux).
7. Look more carefully at abnormalities first found by intravenous
pyelography.
Cystoscopy
cystoscopy is a procedure used to see inside the urinary bladder and
urethra .

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Cystoscopy may use to :
learn the causes of signs and symptoms such as blood in the urine,
frequent urinary tract infections, incontinence, overactive bladder
and painful urination.
diagnosing bladder cancer, bladder stones and bladder
inflammation (cystitis).
indicating an enlarged prostate (benign prostatic hyperplasia).

Urinalysis
the urine sample you provide will be assessed for pH, color, cloudiness
and cell content This test can help detect cells, bacteria or chemicals
within the urine that are suggestive of illness.
Urine Culture
Urine culture is used to evaluate the presence or type of bacteria within
the urine. This test is typically in case of a bacterial urinary tract
infection

Blood Urea Nitrogen (BUN)

A deciliter of normal blood contains 7 to 20 milligrams of urea. A BUN
more than 20 mg/dL might indicate that kidney function is impaired.
Dehydration and heart failure may also cause BUN to become elevated.


Urinary Tract Infection
Learning Objectives
On completion of this chapter, the learner will be able to:
Identify factors contributing to upper and lower urinary tract
infections (UTIs).
Use the nursing process as a framework for care of the patient with
a UTI.

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Infections of the urinary tract
Urinary tract infections (UTIs) are group of infections caused by the
presence of pathogenic microorganisms in the urinary tract, with or
without signs and symptoms (the normal urinary tract is sterile above
the urethra). UTIs are generally classified as infections involving the
upper or lower urinary tract and further classified as uncomplicated or
complicated, depending on other patient-related conditions.
Classifying Urinary Tract Infections
Lower UTIs include:
bacterial cystitis (inflammation of the urinary bladder).
bacterial Prostatitis (inflammation of the prostate gland), and
bacterial Urethritis (inflammation of the urethra).
There can be acute or chronic nonbacterial causes of inflammation in
any of these areas that can be misdiagnosed as bacterial infections.
Upper UTIs are much less common and include acute or chronic
Pyelonephritis (inflammation of the renal pelvis).
Interstitial nephritis (inflammation of the kidney), and ,
Renal abscesses.
The normal urinary tract is sterile except near the urethral orifice.
- The bacteria most commonly responsible for urinary tract infections
are Escherichia Coli (E.coli).
- The majority of U.T.I.s arise by ascent of bowel organisms from the
perineum.

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- In male the length of urethra and anti-bacteria properties of the
prostatic secretions tend to world off ascending urethral infection.

Contributing Factors for Urinary Tract Infection
1. Anyobstructed urinary flow caused by:
Congenital abnormalities.
Urethral strictures.
Contracture of the bladder neck.
Bladder tumors.
Calculi (stones) in the ureters or kidneys.
Compression of the ureters
2. Decreased natural host defenses or immunosuppression
3. Instrumentation of the urinary tract (eg, catheterization, cystoscopic
procedures).
4.Urethrovesical reflux refers to reflux (flowing back) of urine from the
bladder into the urethra.
5. Stasis of urine in the bladder.
6. Sexual intercourse play a role in the ascent of organisms from the
perineum into the bladder in women.
7. Fecal soiling of the urethral meatus is another common way in which
bacteria are introduced into the urinary tract.

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Common Symptoms of UTIs
1. Pain
Genitourinary pain is usually caused by distention of some portion of
the urinary tract as a result of obstructed urine flow or inflammation and
swelling of tissues. Severity of pain is related to the sudden onset rather
than the extent of distention.
2. Changes in Voiding
Common problems associated with voiding include frequency, urgency,
dysuria, hesitancy,
3. Gastrointestinal Symptoms
a. nausea& vomiting.
b. diarrhea.
c. abdominal discomfort, and abdominal distention.
Diagnostic tests
1. Urine Cultures and sensitivity
2. Cellular Studies
Microscopic hematuria is present in about half of patients with an
acute UTI. Pyuria(greater than 4 white blood cells [WBCs] per high-
power field) occurs in all patients with UTI; however, it is not specific
for bacterial infection. Pyuria can also be seen with kidney stones,
interstitial nephritis, and renal tuberculosis.
3.Computed tomography (CT)scan may detect pyelonephritis or
abscesses.

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4.Ultrasonographyis extremely sensitive for detecting obstruction,
abscesses, tumors, and cysts.
5.Transrectal ultrasonography (to assess the prostate and bladder) is
the procedure of choice for men with recurrent or complicated UTIs.
6. A cystourethroscopy may be indicated to visualize the ureters or to
detect strictures, calculi, or tumors.

Preventing Recurrent Urinary Tract Infections
1.Hygiene
a. Shower rather than bath in tube because bacteria in the bath water
mayenter the urethra.
b. After each bowel movement, clean the perineum and urethral meatus
from front to back. This will help reduce concentrations of
pathogens at the urethral opening and, in women, the vaginal
opening.
2. Fluid Intake
a.Drink liberal amounts of fluids daily to flush out bacteria.
b. Avoid coffee, tea, colas, alcohol, and other fluids that are urinary
tract irritants.
3. Voiding Habits
a. Void every 2 to 3 hours during the day and completely empty the
bladder. This prevents over distention of the bladder and
compromised blood supply to the bladder wall.

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b. Both predispose the patient to UTI. Precautions expressly for
women include voiding immediately after sexual intercourse.
4. Therapy
Take medication as prescribed.
Nursing Process for Patient With Urinary Tract Infection
A: Assessment
A history of signs and symptoms related to UTI is
B: Nursing Diagnoses
Acute pain related to infection within the urinary tract
Deficient knowledge about factors predisposing the patient to
infection and recurrence, detection and prevention of recurrence,
and pharmacologic therapy.

C: Planning and Goals
relief of pain and discomfort,
increased knowledge of preventive measures and treatment
modalities, and
absence of complications.


D: Nursing Interventions

1. Analgesic agents and the application of heat to the perineum help
relieve pain and spasm.
2. The patient is encouraged to drink liberal amounts of fluids (water
is the best choice) to promote renal blood flow and to flush the
bacteria from the urinary tract.
3. Urinary tract irritants (eg, coffee, tea, citrus, spices, colas, alcohol)
are avoided.

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4. the patient must be taught to recognize early signs and symptoms,
to test for bacteriuria, and to initiate treatment as prescribed.
5. Appropriate antimicrobial therapy, liberal fluid intake, frequent
voiding, and hygienic measures are commonly prescribed for
managing UTIs.
6. Careful assessment of vital signs and level of consciousness may
alert the nurse to kidney involvement or impending sepsis.

E: Evaluation
1. Experiences relief of pain
a. Reports absence of pain, urgency, dysuria, frequency,
nocturia, or hesitancy on voiding
b. Takes analgesic, antispasmodic, and antibiotic agents as
prescribed
2. Explains UTIs and their treatment
a. Demonstrates knowledge of preventive measures and
prescribed treatments
b. Drinks 8 to 10 glasses of fluids daily
c. Voids every 2 to 3 hours
d. Voids urine that is clear and odorless
3. Experiences no complications
a. Reports no symptoms of infection (fever, dysuria, frequency)
b. Has normal renal function, negative urine and blood cultures
c. Exhibits normal vital signs and temperature; no signs or
symptoms of sepsis (urosepsis)
d. Maintains adequate urine output more than 30 mL per hour

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Kidney stones
Renal stones are small, solid masses that form when salts or mineral
normally found in urine become solid crystals inside the kidney. In
most cases the crystals are too tiny to be noticed.
The condition of having kidney stones is termed nephrolithiasis.
Having stones at any location in the urinary tract is referred to as
urolithiasis, and the term ureterolithiasis is used to refer to stones located
in the ureters.
Urolithiasis and nephrolithiasis refer to stones (calculi) in the
urinary tract and kidney,
The occurrence of urinary stones occurs predominantly in the third to
fifth decades of life and affects men more than women. About half of
patients with a single renal stone have another episode within 5 years.

Kinds of kidney stone
1. Calcium Stone: common types of kidney stones, there are either
spiky or large and smooth, and are made up of calcium oxalate or
calcium phosphate.
2. Uric acid Stone: are smooth, brown and soft. Excess amounts of
uric acid can be caused by eating a lot of meat. Conditions such as
gout and treatment such as chemotherapy can also increase the risk
of getting uric acid stones.
3. Struvite Stone (infection stone): are usually large and have a horn-
like shape. They develop when there is too much ammonia in the

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urine this can happen if you have a urinary tract infection ( UTI ).
Because the bacteria that cause these infection can generate
ammonia. This kind of kidney stone is most often found in women.
4. Cystine Stone: are yellow and crystalline. They develop if you have
high level of cystine in your urine, which happens if there is a
hereditary disorder called cystinuria. Only one in a hundred kidney
stones are caused by this condition. Cystine stones tend to develop
earlier in life than other kidney stones.

Risk factors of kidney stone
1. A family history of kidney stones.
2. Being aged between 20 and 40 years olds.
3. Taking certain medicines such as diuretics (water tablets),
anti-acid and thyroid medications.
4. Having only one kidney, or abnormally shaped kidney.
5. Eating a diet in protein.
6. Being regularly dehydrated.
7. Having very poor mobility (e.g. being confined to bed).
8. Having a disease of the small intestine or a small intestinal.

Predisposing factors for kidney stone
1. Increased exercise with dehydration.
2. Medications that cause hyperuricemia (high uric acid)
.

3. History of gout.
The majority of stones pass spontaneously within 48 hours. However,
some stones may not.

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There are several factors which influence the ability to pass a stone.
These include:
1.The size of the person.
2. Prior stone passage.
3. Prostate enlargement.
4. Pregnancy.
5. Size of the stone.
Signs and Symptoms of kidney Stones
1. Colicky pain: "loin to groin". Often described as the worst pain
ever experienced.
2. Hematuria: blood in the urine, due to minor damage to inside wall
of kidney, ureter and/or urethra.
3. Pyuria: pus in the urine.
4. Dysuria: burning on urination when passing stones (rare). More
typical of infection.
5. Oliguria: reduced urinary volume caused by obstruction of the
bladder or urethra by stone, or extremely rarely, simultaneous
obstruction of both ureters by a stone.
6. Abdominal distention.
7. Nausea/vomiting: embryological link with intestine stimulates the
vomiting center.

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8. Fever and chills.
9. Sudden spasms of excruciating pain.
10. A frequent urge to urinate, or a burning sensation during urination.

Diagnostic tests
Urinalysis shows red blood cells.
Ultrasound shows stones.
X- ray of kidneys, ureters, and bladder (KUB) shows stones.
CT scan shows stones.
MRI shows stones.
Managements
1.Provide pain relief ( narcotics such as morphine, non-narcotics such
as ketorolac, a nonsteroidal anti-inflammatory).
2. Administer antispasmodics as adjuncts for pain control.
3. Increase fluid intake to flush through the urinary tract.
4. Lithotripsyshock waves are used to break the stone into very
small pieces that can pass more easily.
5. Stent placement to allow free flow of urine and passage of small
stones or stone pieces.
6. Calcium channel blockers such as nifedipine and alpha blockers
such as tamsulosin. These drugs may be prescribed to some people
who have stones that do not rapidly pass through the urinary tract.
7. For kidney stones which do not pass on their own, a procedure
called lithotripsy is often used. In this procedure, shock waves are

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used to break up a large stone into smaller pieces that can then pass
through the urinary system.
8. Surgical techniques have also been developed to remove kidney
stones. This may be done through a small incision in the skin
(percutaneous nephrolithotomy) or through an instrument known as an
ureteroscope passed through the urethra and bladder up into the ureter.

Preventing Kidney Stones
1. Avoid protein intake; usually protein is restricted to 60 g/day to
decrease urinary excretion of calcium and uric acid.
2. A sodium intake of 34 g/day is recommended. Table salt and
high-sodium foods should be reduced, because sodium competes
with calcium for reabsorption in the kidneys.
3. Low-calcium diets are not generally recommended, except for true
absorptive hypercalciuria. Evidence shows that limiting calcium,
especially in women, can lead to osteoporosis and does not prevent
renal stones.
4. Avoid intake of oxalate-containing foods (eg, spinach,
strawberries, rhubarb, tea, peanuts, wheat bran).
5. During the day, drink fluids (ideally water) every 12 hours.
6. Drink two glasses of water at bedtime and an additional glass at
each nighttime awakening to prevent urine from becoming too
concentrated during the night.
7. Avoid activities leading to sudden increases in environmental
temperatures that may cause excessive sweating and dehydration.
8. Contact your primary health care provider at the first sign of a
urinary tract infection.

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Medical Management

1. Opioid analgesics are administered to prevent shock and syncope
that may result from the excruciating pain.
2. Non-steroidal anti-inflammatory drugs (NSAIDs) are effective in
treating renal stone pain because they provide specific pain relief.
They also inhibit the synthesis of prostaglandin E, reducing
swelling and facilitating passage of the stone.
3. Hot baths or moist heat to the flank areas may also be useful.
4. fluids are encouraged. This increases the hydrostatic pressure
behind the stone, assisting it in its downward passage.
5. A high fluid intake reduces the concentration of urinary
crystalloids, dilutes the urine, and ensures a high urine output.

Surgical Management

1. If the stone is in the kidney, the surgery performed may be a
nephrolithotomy (incision into the kidney with removal of the
stone) or a nephrectomy, if the kidney is nonfunctional secondary
to infection or hydronephrosis.
2. Stones in the kidney pelvis are removed by a pyelolithotomy.
3. in the ureter by ureterlithotomy.
4. in the bladder by cystotomy.


Nursing process for patients with kidney tones
A: Assessment
Assesse for pain and discomfort as well as associated symptoms,
such as nausea, vomiting, diarrhea, and abdominal distention.

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observing for signs and symptoms of UTI (chills, fever, dysuria,
frequency, and hesitancy) and obstruction (frequent urination of
small amounts, oliguria, or anuria).
The urine is inspected for blood and is strained for stones or
gravel.
history for current episode of renal or ureteral colic.

B: Nursing Diagnosis
Acute pain related to inflammation, obstruction, and abrasion of
the urinary tract
Deficient knowledge regarding prevention of recurrence of renal
stones.
C: Planning
1. Include relief of pain and discomfort.
2. Prevention of recurrence of renal stones, and ,
3. Absence of complications
D: Nursing Interventions
1. Monitor intake and output.
2. Monitor pain level and response to pain medications.
3. Strain urine to obtain stone for analysis in lab.
4. Adequate fluid intake at least three liters every 24 hours, or enough
to make urine clear rather than a yellow color.
5. Medications used to reduce chance of recurrence.
6. Dietary modifications needed based on content of stone.

E: Evaluation

1. Reports relief of pain.

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2. States increased knowledge of health-seeking behaviors to prevent
recurrence
Consumes increased fluid intake (at least eight 8-ounce
glasses of fluid per day).
Participates in appropriate activity.
Consumes diet prescribed to reduce dietary factors
predisposing to stone formation
3. Experiences no complications
Benign Prostatic Hyperplasia
Benign prostatic hyperplasia is characterized by progressive enlargement
of the prostate gland (commonly seen in men older than age 50), causing
varying degrees of urethral obstruction and restriction of urinary flow.

Pathophysiology

Bladder outlet obstruction

lumenCompression of the prostatic urethra

Enlarged nodular tissue of the prostatic
Impinges on the urethra

Urethra elongates & compresses

Obstruction of urine flow

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Increase the trabeculation of the bladder wall

Urinary retention

Causes and risk factors
Possible causes of nonbacterial prostatitis include:
1. A past bacterial prostatitis infection.
2. Bacteria that are not typical (atypical), such as mycoplasma or
ureaplasma.
3. Irritation caused by a backup of urine flowing into the prostate .
4. Irritation from chemicals .
5. Nerve problem involving the lower urinary tract.
6. Parasites (trichomonads).
7. Pelvic floor muscle problem.
8. Sexual abuse.
9. Viruses.
10. Increase androgen level.
11. Age above 50 years
Signs and symptoms
When the prostate enlarges, it may constrict the flow of urine. Nerves
within the prostate and bladder may also play a role in causing the
following common symptoms:
1. Urinary frequency.
2. Urinary urgency.
3. Hesitancy - Difficulty initiating the urinary stream; interrupted,
weak stream.

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4. Incomplete bladder emptying - The feeling of persistent residual
urine, regardless of the frequency of urination.
5. Straining - The need strain or push (Valsalva maneuver) to initiate
and maintain urination in order to more fully evacuate the bladder.
6. Decreased force of stream - The subjective loss of force of the
urinary stream over time.
7. Dribbling - The loss of small amounts of urine due to a poor
urinary stream.
8. Blood in the semen
9. Pain that is located:
Above the pubic bone (suprapubic) .
Between the genitals and anus (perineal) .
Low back .
Scrotum .
Tip of penis .
Urethra
10. Pain with ejaculation
Diagnosis
1. Digital rectal examination
During this examination, prostate size and contour can be assessed,
nodules can be evaluated, and areas suggestive of malignancy can be
detected. DRE reveals fullness of prostate, there is an area of increase
firmness within the prostate. The more advance lesion is strong hard and
fixed.
2. Laboratory studies

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Urinalysis ,to assess for the presence of blood, leukocytes, bacteria,
protein, or glucose .
Urine culture ,This may be useful to exclude infectious causes of
irritative voiding .
Prostate-specific antigen - Although BPH does not cause prostate
cancer, men at risk for BPH are also at risk for this disease and
should be screened accordingly (although screening for prostate
cancer remains controversial) . this test is done to help differentiate
BPH from cancer of prostate.
Electrolytes, blood urea nitrogen (BUN), and creatinine - These
evaluations are useful screening tools for chronic renal
insufficiency.
Urography shows high volume of post-void residual urine.
3. Ultrasonography
Ultrasonography (abdominal, renal, transrectal) and intravenous
urography are useful for helping to determine bladder and prostate size
and the degree of hydronephrosis (if any) in patients with urinary
retention or signs of renal insufficiency.
4. Endoscopy of the lower urinary tract
Cystoscopy may be indicated in patients scheduled for invasive treatment
or in whom a foreign body or malignancy is suspected. In addition,
endoscopy may be indicated in patients with a history of sexually
transmitted disease (eg, gonococcal urethritis), prolonged catheterization,
or trauma.
5. Cystourethroscopy s used to assess for outflow obstruction.

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6. Uroflowmetry is a noninvasive procedure that can evaluate bladder
emptying.
7. An intravenous pyelography (IVP) is a test that requires the infection
od dye into the blood stream to outline the urinary tract.





IPSS
The severity of BPH can be determined with the International Prostate
Symptom Score (IPSS) which is based on answers to seven questions
concerning urinary symptoms during the past month.
Incomplete emptying
Frequency
Intermittency
Urgency
Weak stream
Straining, and
Nocturia.
Each question allows the patient to choose one of six answer( 0-5)
indicating increasing severity of the particular symptoms. The total score
ranges from 0- to 30.
Scores below 7 indicate mild symptoms.
Scores from 8- to 19 indicate moderate symptoms.
Scores from 20- and more indicate severe symptoms.

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Management
1. Pharmacologic treatment
The main purpose of medication used in the treatment of BPH is to
decrease the production of dihydrotestosterone.
Finasteride ( proscar), inhibits the activity of 5-alpha-reductase, so
that it cannot turn testosterone to dihydrotestosterone and
consequently can reduce the prostate size.
Alpha-adrenergic receptor blockers, to relax muscles and reduce
straining on urination.
Anticholinergic agents.

2. Surgical treatment
Indications for surgery
Urinary retention.
Hydronephrosis ( with or without impaired renal function).
Recurrent urinary tract infections( secondary to residual urine)
Bladder stone ( secondary to residual urine).
Severe obstructive symptoms ( with or without bladder Instability)
Types of surgery
1.Transurethral resection of the prostate (TURP) . is performed when
major glandular exists in the medical lobe that directly surrounds the
urethra. There must be a relatively small amount of tissue requiring
resection. A resectoscope ( an instrument similar to a cystoscopy but
equipped with a cutting and cauterization loop attached to an electric
current ia past through the urethra.This surgery is not usually done on

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younger men, because it may cause retrograde ejaculation. This can lead
to sterility, impotence, and incontinence.
2. Suprapubic prostatectomy
It is one of open procedures in the suprapubic resection, the prostate
gland is removed from the urethra by way of the bladder. This procedure
is performed when a large mass of tissue must be resected. Some type of
homeostatic agent is placed in the prostatic fossa, and Foley catheter or
cystotomy tube or both drain urine.
Disadvantage
Difficulty in obtaining hemeostasis.
Bladder spasms from suprapubic catheter.
Much postoperative pain.
Hematuria and wound infection.

3. Retro Pubic Prostatectomy
In this procedure , a low abdominal incision similar to that used
for suprapubic prostatectomy is made, but the bladder is not
opened, and the prostatic tissues removed through an incision in
the anterior prostatic capsule.
Disadvantages
Hemorrhage and wound infection.
Postoperative urinary dribbling.

4. Perineal prostatectomy
This procedure done, if both the prostate and the capsule
are removed, removal of the prostate by an open approach

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through an incision between the ischial tuberosity ,scrotum
and rectum.

Disadvantage

Risk of rectal incontinence.
Urinary tract infection
Persistent perineal urinary fistula.

Complications
Complications related to bladder outlet obstruction (BOO) secondary to
BPH include the following:
1. Urinary retention
2. Renal insufficiency
3. Recurrent urinary tract infections
4. Gross hematuria
5. Bladder calculi
6. Renal failure or uremia (rare in current practice).

Nursing diagnosis
Risk for impaired urinary elimination.
Urinary retention.
Risk for urge urinary incontinence.
Altered urinary elimination pattern r/t difficulties voiding
Pain r/t straining with voiding.
High risk for infection r/t surgical manipulation.

Planning and goals
1.Maintain of urinary elimination.
2. Reduce level of pain.

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3.Prevent infection
Nursing interventions
1. The patient Should be instructed to urinate as soon as the first desire
to do so is felt.
2. Its important for the patient to know that regaining urinary control
is gradual process, and that even though he may continue to dribble
after being discharged from the hospital, the dribbling should
gradually diminish up to 1 year.
3. the urine may be cloudy for several weeks but should clear as the
prostate area heals.
4. while the prostate fossa is healing (6-8 weeks), the patient should
Identify ways to reduce pressure on the operative area after
prostatectomy while increase the tendency to bleed:- :
a. Avoid prolonged sitting (in a chair, long automobile rides),
standing, walking.
b. Avoid straining, such as during exercises, bowel movement,
lifting, and sexual intercourse.
5. Monitor intake and output.
6. Monitor vital signs for changes.
7. Monitor postoperative patients bladder irrigation:
8. Monitor the amount of fluid instilled and the amount of fluid
returned and subtract the amount of fluid instilled from the amount
returned to determine the actual urine output.
9. Document color of urinary output postoperatively; the greatest risk
of hemorrhage is the first day after the operation.

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10. Monitor for bladder spasms which may indicate blocked catheter
drainage postoperatively.
11. Familiarize patient with ways of attaining/maintaining bladder
control.
a. Encourage urination every 2 to 3 hours; discourage voiding when
supine.
b. Avoid drinking cola and caffeine beverages; urge a cutoff time in
the evening for drinking fluids to minimize frequent voiding during
the night.
c. Describe perineal exercises to be performed every hour.
d. Develop a schedule with patient that will fit into his routine.
12.The patient is cautioned to drink enough fluid to avoid dehydration,
which increase the tendency to clot to form, and obstruct the flow
of urine.
13. Bleeding or decrease in the size of the urinary stream is to be
reported to the physician.

Renal Failure
Learning Objectives
at the end of this session the student will be able to:
1. Describe the anatomy and physiology of the kidneys.
2. Discuss the pathophysiologic changes seen with acute renal failure.
3. List the causes and risk factors associated with acute renal failure.
4. State the signs and symptoms that present with acute renal failure.

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5. Explain how acute renal failure is diagnosed.
6. Describe the medical management for the patient with acute renal
failure.
7. Discuss the appropriate nursing assessment and interventions when
caring for the patient with acute renal failure.
8. List 3 nursing responsibilities when caring for the patient on
continuous renal replacement therapy.
9. Discuss 3 important nursing diagnoses that will assist with
planning patient care.




Renal Failure
Renal failure results when the kidneys cannot remove the body's
metabolic wastes or perform their regulatory functions.
The substances normally eliminated in the urine accumulate in the
body fluids as a result of impaired renal excretion, leading to a
disruption in endocrine and metabolic functions as well as fluid,
electrolyte, and acidbase disturbances.
Renal failure is a systemic disease and is a final common pathway
of many different kidney and urinary tract diseases. Each year, the
number of deaths from irreversible renal failure increases .

Acute Renal Failure

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Acute renal failure (ARF) is a reversible clinical syndrome where there is
a sudden and almost complete loss of kidney function (decreased GFR)
over a period of hours to days with failure to excrete nitrogenous waste
products and to maintain fluid and electrolyte.

Phases of Acute Renal Failure

Onset Phase: this period represents the time from the onset of injury
through the cell death period. This phase can last from hours to days and
is characterized by:
1. Renal flow at 25% of normal
2. Oxygenation to the tissue at 25% of normal
3. Urine output at 30 ml (or less) per hour
4. Urine sodium excretion greater than 40 mEq/L.
In this phase only 50% of the patients are noted to be oliguric. With
prompt treatment, irreversible damage can be achieved during this pre
renal failure onset phase.
Oliguric/Anuric Phase : this phase usually lasts between 8-14 days and
is characterized by further damage to the renal tubular wall and
membranes. Other characteristics in the oliguric-anuric phase include:
1. Great reduction in the glomerular filtration rate (GFR)
2. Increased BUN/Creatinine
3. Electrolyte abnormalities (hyperkalemia, hyperphosphatemia and
hypocalcemia)
4. Metabolic acidosis

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Diuretic Phase : this phase occurs when the source of obstruction has
been removed but the residual scarring and edema of the renal tubules
remains. This phase usually lasts and additional 7-14 days and is
characterized by:
1. Increase in glomerular filtration rate (GFR)
2. Urine output as high as 2-4 L/day
3. Urine that flows through renal tubules
4. Renal cells that cannot concentrate urine
Increased GFR in this phase contributes to the passive loss of electrolytes
which requires the administration of IV crystalloids to maintain
hydration.

Recovery Period Phase : The recovery phase can last from several
months to over a year. During this phase, edema decreases, the renal
tubules begin to function adequately and fluid and electrolyte balance are
restored (if damage was significant, BUN and Creatinine may never
return to normal levels). At this point the GFR has usually returned to
70% to 80% of normal.


Causes of Acute Renal Failure

A: Prerenal Failure
1. Volume depletion resulting from:
a. Hemorrhage
b. Renal losses (diuretics, osmotic diuresis)
c. Gastrointestinal losses (vomiting, diarrhea, nasogastric
suction)
2. Impaired cardiac efficiency resulting from:
a. Myocardial infarction
b. Heart failure
c. Dysrhythmias
d. Cardiogenic shock
3. Vasodilation resulting from:

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a. Sepsis
b. Anaphylaxis
c. Antihypertensive medications or other medications that
cause vasodilation
B: Intrarenal Failure
1. Prolonged renal ischemia resulting from:
a. Pigment nephropathy (associated with the break-down of
blood cells containing pigments that in turn occlude kidney
structures)
b. Myoglobinuria (trauma, crush injuries, burns)
c. Hemoglobinuria (transfusion reaction, hemolytic anemia)
2. Nephrotoxic agents such as:
a. Aminoglycoside antibiotics (gentamicin, tobramycin)
b. Radiopaque contrast agents
c. Heavy metals (lead, mercury)
d. Solvents and chemicals (ethylene glycol, carbon
tetrachloride, arsenic)
e. Nonsteroidal anti-inflammatory drugs (NSAIDs)
f. Angiotensin-converting enzyme inhibitors (ACE inhibitors)
3. Infectious processes such as:
a. Acute pyelonephritis
b. Acute glomerulonephritis

C: Postrenal failure
1. Urinary tract obstruction, including:
a. Calculi (stones)
b. Tumors
c. Benign prostatic hyperplasia
d. Strictures
e. Blood clots

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Clinical Manifestations of ARF
The following signs and symptoms are consistent with acute renal failure:
1. Decreased urine output (urine may be pink or reddish in color)
2. Edema (face, arms, legs, feet eyes)
3. Flank pain/Pelvic pain
4. Poor appetite (nausea, vomiting)
5. Bitter or metallic taste in mouth
6. Dry itchy skin
7. Easy bruising
8. Fatigue
9. Seizures/LOC
10. Shortness of breath
11. Arrhythmias
12. Sudden weight gain








Probable Cause of ARF Based on Physical Findings

Physical Finding Possible Cause
Elevated Temperature Infection
Hypertension Nephrotic syndrome/malignant hypertension

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Hypotension Volume depletion/sepsis
Weight loss or gain Hypovolemia/hypervolemia
Dry mouth Hypovolemia
Jugular vein distention Hypervolemia
Heart (new murmurs) Endocarditis/heart failure
Bladder distention Urethral obstruction
Skin rash
Interstitial nephritis/micro vascular
disease/splinter hemorrhages


Pharmaceutical Interventions
Furosemide (Lasix) : a loop diuretic that can be used to increase
urinary flow with the intent of flushing out cellular debris that may
be causing an obstruction.
Mannitol: an osmotic diuretic that can be used to dilate renal
arteries by increasing the synthesis of prostaglandins (resulting in
restored renal flow).
Dopamine: at low doses (1-5 mcg/kg/min), dopamine dilates renal
arterioles and increases renal blood flow and glomerular filtration.
Because dopamine (even at low doses) can cause tachycardia,
myocardial ischemia and arrhythmias it use should be considered
carefully.
N-acetylcysteine (Mucomyst) : this medication can help reverse
acute renal failure when the cause is thought to be from a

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nephrotoxic source.

Preventing Acute Renal Failure
1. Provide adequate hydration to patients at risk of dehydration:
a. Surgical patients before, during, and after surgery
b. Patients undergoing intensive diagnostic studies requiring
fluid restriction and contrast agents (eg, barium enema,
intravenous pyelograms), especially elderly patients who
may have marginal renal reserve
c. Patients with neoplastic disorders or disorders of metabolism
(eg, gout) and those receiving chemotherapy
2. Prevent and treat shock promptly with blood and fluid replacement.
3. Monitor central venous and arterial pressures and hourly urine
output of critically ill patients to detect the onset of renal failure as
early as possible.
4. Treat hypotension promptly.
5. Continually assess renal function (urine output, laboratory values)
when appropriate.
6. Take precautions to ensure that the appropriate blood is
administered to the correct patient in order to avoid severe
transfusion reactions, which can precipitate renal failure.
7. Prevent and treat infections promptly. Infections can produce
progressive renal damage.
8. Pay special attention to wounds, burns, and other precursors of
sepsis.
9. To prevent infections from ascending in the urinary tract, give
meticulous care to patients with indwelling catheters. Remove
catheters as soon as possible.

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10. To prevent toxic drug effects, closely monitor dosage, duration of
use, and blood levels of all medications metabolized or excreted by
the kidneys.
Chronic Renal Failure
Chronic renal failure is a progressive, irreversible kidney injury.
Kidney function does not recover. When kidney function is too poor to
sustain life, it is called end-stage-renal disease (ESRD).
CRF has a gradual onset of months to years as opposed to ARF.
Approximately 90-95% of nephrons are affected by CRF, damage is
permanent and irreversible, and the disease is fatal without renal
replacement therapy such as dialysis or transplant.
Azotemia and uremia are terms used with chronic renal failure.
Azotemia is collection of nitrogenous waste in the blood.
Uremia is azotemia with clinical symptoms
Stages in CRF
1. Stage 1- GFR > 90 ml/min-normal renal function
2. Stage 2 (Renal Insufficiency).
GFR 60-89 ml/min- mild decrease in GFR.
No buildup of waste but nephrons are still working overtime,
may have an increase in BP which causes an increase in
glomerular pressure on healthy nephrons.
There is no S&S of renal failure in this phase.
3. Stage 3 (Moderate CRF)- GFR 30-59 ml/min-
moderate decrease in GFR.

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buildup of waste- Not enough healthy nephrons to prevent it.
There is an increase in BUN, creatinine, uric acid and
phosphorous.
An increase managing fluid volume and an increase in BP and
edema.
There are fluid and electrolytes changes.
If the pt. can manage their BP and diet, they can slow down the
progression.
4. Stage 4 (Severe CRF).
GFR 15-29 ml/min-there is a severe decrease in GFR.
5. Stage 5 (End-stage renal disease).
GFR is less than 15 ml/min.
S&S and kidney failure are seen.
ESRF will result from severe fluid and electrolytes imbalances.



Pathophysiology
Renal function declines
The products of protein metabolism accumulate in the blood
Uremia develops

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The rate of glumural filtration increase& protein exceed & decline
Develop hypertension
So the patient goes through 3 well- recognized stages of CRF

Reduced renal reserve, Renal insufficiency & ESRD

Causes of Chronic Renal Failure
1. hypertension
2. Diabetes
3. Long history of analgesic abuse- Phenacetin
4. Chronic urinary tract infections
5. Glomerulonephritis.
6. long history of renal stones.
7. Polycystic kidney disease
8. Systemic Lupus erythematous (SLE ).


Clinical Manifestations of Renal Failure:
1. Cardiovascular Signs:
a. Anemia.

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b. Pericarditis/ Pericardial Effusion
c. Hypertension
d. Congestive Heart Failure
e. Hyperkalemia and edema
2. Pulmonary Signs:
a. Pulmonary Edema
b. Dyspnea
c. Pleural Effusion
3. Gastrointestinal Signs:
a. Anorexia
b. Nausea/Vomiting
c. Diarrhea or Constipation
d. Mucosal Ulcerations- GI Bleeding
4. Integumentary Signs:
a. Pruritus
b. Uremic Frost (rare)
c. Easy Bruising
5. Neuromuscular/Behavioral signs:
a. Headache
b. Daytime drowsiness/insomnia

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c. Confusion/ disorientation
d.Asterixis
e. Muscle weakness and cramping
f. Peripheral Neuropathy
h. Body image/ Self-Concept disturbances
6. Endocrine/ metabolic Signs
a. Calcium/Phosphorus Imbalance- Renal osteodystrophy
b. Metabolic Acidosis
7. Psychosocial Signs
a. Denial
b. Depression/ Grief
c. Dependency
8. Reproductive
a. Amenorrhea
b. Testicular atrophy
c. Infertility
d. Decreased libido



Complications

1. Hyperkalemia due to decreased excretion, metabolic acidosis,
catabolism, and excessive intake (diet, medications, fluids).

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2. Pericarditis, pericardial effusion, and pericardial tamponade due to
retention of uremic waste products and inadequate dialysis.
3. Hypertension due to sodium and water retention and malfunction of
the reninangiotensinaldosterone system.
4. Anemia due to decreased erythropoietin production, decreased RBC
life span, bleeding in the GI tract from irritating toxins and ulcer
formation, and blood loss during hemodialysis.
5. Bone disease and metastatic and vascular calcifications due to
retention of phosphorus, low serum calcium levels, abnormal
vitamin D metabolism, and elevated aluminum levels.
Renal Medications
a . Multivitamin, Iron supplements (ferrous fumurate), Folic acid
b.Epogen - to prevent anemia
c. Tums (Calcium carbonate) or Basalgel- phosphate binders, can
cause constipation
d.Shohls solution- bicarbonate replacement, used for chronic
metabolic acidosis
e.Rocalcitrol- Vitamin D supplement
f. Stool softeners
g. Sorbitol- artificial sweetener used as a laxative
h.Kayexalate- resin that binds K in GI tract, causes diarrhea
Renal Nutrition
1. Typical renal diet: restricted protein, potassium, and sodium.
2. Less restricted diet for PD patients, lose protein through PD.

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3. Beware of salt substitutes, frequently contain KCl.
4. Frequently require fluid restrictions - 1 liter/day.
5. More liberal diet for PD patient.

Nursing Diagnoses & Interventions for Clients with ESRD
ND: Fluid volume excess & electrolyte imbalance related to decrease
urine output & dietary & fluid restriction.
Goal: maintain of fluid & electrolyte balance.
Nursing intervention with Rational
Assess serum electrolyte level to provide base line data.
Daily weight the patient before & after doing dialysis to determine
if the weight achieve & decreased to normal, which was recorded
by the doctor.
Assess skin turgorto determine if there is presence of edema.
Assess V/S (BP, pulse, respiratory rat & rhythm ) to monitoring
changes.
Provide foods & fluid with dietary restriction to promote dietary
changes.

ND: Altered nutrition less than body requirement RT dietary restriction
Goal:maintain adequate nutritional status.
1. Assess nutritional status by daily weight the patient &
laboratory values to determine base line data for monitoring
changes.
2. Provide patients food preference within dietary restriction
to increase dietary intake.
3. encourage high calorie, low protein, low potassium & low
sodium snacks between mealsto reduce sources of restricted

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food & provides calories for energy while low protein for
growth & tissue healing.
4. Explain to patient & family rational for restrictions of certain
foods & fluid.
5. Assist patient to cope with discomforts resulting from restriction
to increase patient comfort with dietary restriction.

ND: Activity intolerance related to fatigue & dialysis procedure.
Goal:
Participation in activity within tolerance.
1. Assess factors contributing to fatigue (anemia, fluid
&electrolyte imbalance, depression) to provide indication of
severity of fatigue.
2. Promote independence in self-care activities to promote &
improve self-esteem.
3. Encourage the patient to alternate activity within rest to
promote activity & exercise within limits & adequate rest.
4. Encourage the patient to rest after dialysis treatment
because the dialysis treatment will exhaust the patient.
5. Place the patient in high fowler positionto facilitate
diaphragmatic expansion.




Sensory and perceptual alterations related to uremia

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1. assess mental status. Watch for confusion, irritability, behavioral
changes, decreased attention.
2. Educate patient/family on relationship of uremia to mental status
changes
3. Provide calm, non-stimulating environment
4. Provide short teaching sessions.
5. Safety measures as appropriate.
6. Reorient patient as necessary. Provide supportive environment.

Risk for infection related to uremic effects on immune system
1. Maintain aseptic technique for procedures.
2. Assess for signs of infection (fever, chills, redness, edema, or
drainage of site).
3. Instruct patient to avoid people with infections
Knowledge deficit related to lack of information about diet, meds,
dialysis, self-monitoring
1.Teach patient/family about dietary restrictions and rationale for these. 2.
Dietary consult helpful.
3. Instruct patient/family about meds and administration times.
4. Provide information about dialysis treatment options, procedures, etc
5. Assess patient/familys understanding of above and reinforce as
necessary.




Evaluation

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1. The patient is able to maintain dietary & fluid intake with
restriction.
2. The patient explained in his own word the rational for dietary
restriction & his appetite is increased at meal time.
3. Patient reports an increase in sense of well-being & he is
more able to participate in activity & exercise.

Dialysis
Dialysis is the procedure which is used to restore fluid and
electrolyte balance and acid base balance and to remove wastes
and toxic materials from the body when the kidney is unable to
do .
Indications for dialysis
1. Renal failure that can no longer be controlled by conservative
management (i.e. Dietary modification and administration of
mediations.
2. Glomerular filtration rate (GFR) less than 5 ml/min.
3. Serum creatinine level greater than 10mg/dl, blood urea nitrogen
(BUN) greater than 100mg/dl.
4. Unmanageable hyperkalemia.
5. Drug overdose.
6. Sever acid-base disorders.

Basic Goals of Dialysis Therapy:

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1. To remove the end products of protein metabolism, such as urea
and creatinine, from the blood.
2. To maintain a safe concentration of serum electrolytes.
3. To maintain acid-base balance.
4. To remove excess fluid from the blood.

Types of dialysis
Hemodialysis
Peritoneal dialysis.

Hemodialysis
HD is a process of cleansing the blood of accumulated
wasteproducts and restore fluid and electrolyte balance. It is
used for patients with end stage of renal failure( ESRF), or for
acutely ill patients who require short-term ( day to week)
dialysis.
The processes involved in hemodialysis are diffusion, osmosis, and
ultra-filtration.
1. Diffusion: is the movement of toxins and wastes from an area of
greater concentration in the blood to an area to lower
concentration in the dialysis.
2. Osmosis: is the removal of excess water from an area of higher
solute concentration (blood) to lower solute concentration ( the
dialysis bath).

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3. Ultra filtration: is the removing of water under high pressure to an
area of lower pressure.



Types of dialysis
Hemodialysis (HD)
HDis the most commonly used method of dialysis and a highly
efficient for removing waters and waste products from the body.
It used for patients who are acutely ill and require short- term dialysis
(days to week) and for patients with End Stage renal disease (ESRD)
who require long- term or permanent therapy.
HD patients require treatment three times a week for an average three
to four hours per dialysis.
within dialysis machine, blood and dialysate compartment are
separated by semi permeable membrane .blood is removed from the
arterial end of the vascular access device, pumped through the
machine at a rate of 100 to200 ml/min, and returned to the body
through the venous access.
Heparin may be added to the blood at the arterial end to prevent blood
clotting while in the machine.

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Vascular Access for Hemodialysis
A vascular access should be prepared weeks or months before starting
dialysis.
Type of vascular access
1. Arteriovenous fistula.
2. Arteriovenous graft.
3. Eternal arteriovenous shunt.
4. Femoral vein catheterization.
5. Sub clavian vein catheterization.
Complications of HD

A: short-term complications

1. Hypotension may occur during treatment as fluid removed. Nausea
and vomiting, diaphoresis, tachycardia, and dizziness are common
signs of hypotension.
2. Painful muscle cramping occurs late in dialysis as fluid and
electrolytes rapidly leave the extracellular space.
3. Exsanguination may occur if blood lines separate or dialysis needles
accidently dislodge.
4. Dysrhythmias may result from electrolyte and PH changes or from
removal of antiarrhythmic medications during dialysis.
5. Air embolism is rare but can occur if air enters the patient's vascular
system.
6. Chest pain may occurs because of anemia or in patients with ischemic
heart diseases.

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7. Dialysis disequilibrium result from cerebral fluid shifts. It is more
likely to occur in acute renal failure or when blood urea nitrogen
levels are very high( exceeding 150 mg/L).Manifestation includes:

Head ache.
N &V.
Restlessness.
Decrease level consciousness., or seizure.


Long term complications of HD

1. Anemia: is one of the majorclinical problemof CRF patient

Causes:

Less production of erythropoietin .
Loss of renal parenchyma.
Toxic effect uremia on CBC membrane.
Secondary causes include infection, malnutrition, iron
deficiency and folic acid).

2. Bone disease.

Peritoneal Dialysis (PD)
Definition
Peritoneal dialysis is a way to remove waste products from the blood
when the kidneys can no longer do the function adequately.
During peritoneal dialysis, blood vessels in the abdominal lining
(peritoneum) fill in for the kidneys, with the help of a fluid (dialysate)
that flows into and out of the peritoneal space.

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It is involves the introduction of sterile dialyzing fluid through an
implanted catheter into the abdominal cavity, the dialysate bathes the
peritoneal membrane.
PD works by using peritoneal membrane, which is inside the abdomen
as a semi permeable membrane. By the processes of osmosis,
diffusion, and active transport, excess fluid & solutes travel through
peritoneal membrane and into the dialyzing fluid.
After a selected period about(20- 30) minute, then the fluid is drained
out of the abdomen by gravity.
Peritoneal dialysis differs from hemodialysis as:
a. a more commonly used blood-filtering procedure.
b. use fewer medications and,
c. eat a less restrictive diet than you can with hemodialysis.
Types of Peritoneal Dialysis (PD)
1. Continuous Ambulatory P.D. (CAPD) :
Between 1.5 and 3 liters of fluid is run in four times a day,
exchanging for the fluid from the previous exchange. This takes
about 30-40 minutes.
Gravity moves the fluid through the tube and into and out of the
belly.
Each exchange includes filling the abdomen with dialysate fluid,
letting the fluid dwell in the abdomen, then draining the fluid.
Patient may need three to four exchanges during the day and one
with a longer dwell time while sleeping .

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Patient is free to go about the normal activities while the dialysis
solution dwells in the abdomen between exchanges.
2. Continuous Cycle P.D. (CCPD) :
a machine called an automated cycler performs three to five
exchanges at night while you sleep.
The cycler automatically fills the abdomen with dialysis solution,
allows it to dwell there and then drains it to a sterile drainage bag
that empty in the morning.
The machine will exchange 8-12 liters over 8-10 hours and then
leave 1-2 liters to dwell during the day.
This gives thepatient more flexibility during the day, but he must
remain attached to the machine for 10 to 12 hours at night.
In the morning, patient begins one exchange with a dwell time
that lasts the entire day.


Contraindication of PD
Peritoneal dialysis is not recommended if the patents have:
extensive surgical scars in the abdomen.
a large abdominal hernia.
inflammatory bowel disease or frequent bouts of diverticulitis.
Procedure of PD

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In peritoneal dialysis, a sterile cleansing solution (dialysate) flows
through the catheter into the abdomen.
The solution stays in the abdomen for a prescribed period of time,
known as dwell time.
During this dwell time, waste, chemicals and extra fluid in the
blood pass from tiny blood vessels (capillaries) in the lining of the
abdominal cavity (peritoneum) into the dialysis solution.
The solution contains a sugar that draws wastes and extra fluid
through the capillaries in the peritoneum.
the belly may feel fuller than usual while the dialysis solution is
there, but it's generally not uncomfortable.
When the dwell time is over, the solution, along with waste
products drawn from the blood and any excess fluid, drains into a
sterile collection bag.
The process of filling and then draining the abdomen is called an
exchange.


Peritoneal dialysis complications
Peritonitis. An infection can develop at the site where the tube
(catheter) is inserted to carry the cleansing fluid into and out of
your abdomen.
Weight gain. The fluid used to clean the blood in peritoneal
dialysis contains sugar (dextrose). Patient may take in several
hundred calories each day by absorbing some of this fluid, known

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as dialysate. Weight gain may follow. The extra calories can also
lead to high blood sugar especially in diabetic patients.
Weakening of the abdominal muscles (hernia). Holding fluid in
the abdomen for long periods may strain the belly muscles.
Fluid obstruction.
Dehydration, and shoulder pain.
Nursing managements for peritoneal dialysis patients
1. The client should be urinate before insert the catheter into the
peritoneum, to prevent the bladder puncture.
2. Place the bottles of dialysate in warm water.
3. Keep accurate intake and output records related to the amount of
dialysis fluid entering the peritoneal cavity and the amount in the
drainage.
4. Monitor the client's vital signs every 15 minutes.
5. Monitor the client's weight daily.