NURSING CARE OF THE CLIENT HAVING A KIDNEY …

1 CHAPTER 27 / NURSING Care of clients with KIDNEY Disorders 783. NURSING CARE OF THE CLIENT HAVING A KIDNEY transplant . PREOPERATIVE CARE Monitor for possible complications: Provide routine preoperative care as outlined in Chapter 7. a. Hemorrhage from an arterial or venous anastomosis can Assess knowledge and feelings about the procedure, answer- be either acute or insidious. Indicators include swelling at ing questions and clarifying information as needed. Listen and the operative site, increased abdominal girth, and signs of address concerns about surgery, the source of the donor or- shock, including changes in vital signs and level of con- gan, and possible complications. Addressing concerns and re- sciousness. Hemorrhage is a surgical emergency, requiring ducing preoperative anxiety improve postoperative recovery. prompt recognition and treatment to preserve the graft. Continue dialysis as ordered.

2 Continued renal replacement ther- b. Ureteral anastomosis failure causes urine leakage into the apy is necessary to manage fluid and electrolyte balance and peritoneal cavity. It may be marked by decreased urine prevent uremia prior to surgery. output with abdominal swelling and tenderness. Failure of Administer immunosuppressive drugs as ordered before sur- the ureteral anastomosis requires surgical intervention. gery. Immunosuppression is initiated before transplantation to c. Renal artery thrombosis is characterized by an abrupt on- prevent immediate graft rejection. set of hypertension and reduced GFR. Renal artery throm- bosis can result in transplant failure. POSTOPERATIVE CARE d. Infection due to immunosuppression is an immediate and continuing risk. The inflammatory response is blunted, Provide routine postoperative care as outlined in Chapter 7. and infection may not significantly elevate the tempera- Maintain urinary catheter patency and a closed system.

3 Ture. Monitor for signs such as change in level of con- Catheter patency is vital to keep the bladder decompressed and sciousness, cloudy or malodorous urine, or purulent prevent pressure on suture lines. A closed drainage system mini- drainage from the incision. Prevention and prompt treat- mizes the risk for urinary tract infection. ment of infections is particularly important in the immuno- Measure urine output every 30 to 60 minutes initially. Careful suppressed CLIENT . assessment of urine output helps determine fluid balance and Include the following in predischarge teaching for the CLIENT transplant function. Acute tubular necrosis (ATN) is a common and family: early complication, usually due to tissue ischemia during the pe- a. The use and effects of prescribed medications, including riod between removal of the KIDNEY from the donor and trans- antihypertensive medications, immunosuppressive plantation.

4 Oliguria is an early sign. agents, prophylactic antibiotics, and others as ordered. Monitor vital signs and hemodynamic pressures closely. b. Monitoring vital signs (including temperature) and Diuresis may occur immediately, resulting in hypovolemia, low weight. cardiac output, and impaired perfusion of the transplanted kid- c. Manifestations of organ rejection, such as swelling and ten- ney. derness over the graft site, fever, joint aching, weight gain, Maintain fluid replacement, generally calculated to replace and decreased urinary output. Stress the importance of urine output over the previous 30 or 60 minutes, milliliter for promptly reporting signs and symptoms to the physician. milliliter. Fluid replacement is vital to maintain vascular volume d. Ordered or recommended dietary restrictions such as re- and tissue perfusion. stricted carbohydrate and sodium intake, and increased Administer diuretics as ordered.

5 Loop and/or osmotic diuretics protein intake. such as furosemide or mannitol may be used to promote postop- e. Measures to prevent infection, such as avoiding crowds erative diuresis. and obviously ill individuals. Remove the catheter within 2 to 3 days or as ordered. Encour- The CLIENT and family will manage care after discharge, and age to void every 1 to 2 hours and assess frequently for signs therefore need a good understanding of what to expect, how to of urinary retention following catheter removal. The bladder monitor graft status, and measures to reduce the adverse effects may have atrophied prior to surgery, reducing its capacity. Uri- of medications. nary retention places stress on suture lines and increases the risk Provide psychologic support, address concerns, and provide of infection. information as needed. The CLIENT knows that transplant suc- Monitor serum electrolytes and renal function tests.

6 These tests cess is not guaranteed. In addition, the CLIENT has often been are used to monitor graft function and fluid and electrolyte status. managing a chronic disease independently and is used to hav- Electrolyte imbalances may develop as the transplanted KIDNEY ing a degree of control. Providing information and allowing the begins to function and diuresis occurs. Elevated serum creatinine CLIENT to retain control relieves anxiety and improves recovery. and BUN levels may be early signs of rejection or graft failure. nally, encourage the CLIENT with ESRD to investigate options Subjective: complaints of anorexia, nausea, weight gain, or for early transplantation to avoid long-term dialysis. edema; current treatment (if any), including type and fre- quency of dialysis or previous KIDNEY transplant ; chronic dis- Assessment eases such as diabetes, heart failure, or KIDNEY disease Both subjective and objective data are used to assess the CLIENT Objective: mental status; vital signs including temperature, with chronic renal failure.

7 Heart and lung sounds, and peripheral pulses; urine output (if)