Kidney transplantation: placement of a donor kidney (from sibling, parent, cadaver) into the iliac fossa of a recipient and the anastomosis of its ureter to the bladder of the recipient; indicated in end-stage renal disease.
1. Criteria for recipient: irreversible kidney function; under 70 yr of age; patent and functional lower urinary tract; and good surgical risk, free of serious cardiovascular complications. Contraindicated in those with another life-threatening condition.
2. Donor selection:
  1. Sibling or parent - survival rate of kidney is greater; preferred for transplantation.
  2. Cadave - greater rate of rejection following transplantation, although majority of transplantations are with cadaver kidneys.
3. Bilateral nephrectomy: necessary for patients with rapidly progressive glomerulonephritis, malignant hypertension, or chronic kidney infections; prevents complications in transplanted kidney.
4. Analysis/nursing diagnosis:
  1. Altered urinary elimination related to kidney failure.
  2. Fear related to potential transplant rejection.
  3. Risk for infection related to immunosuppression.
  4. Body image disturbance related to immunosuppression.
5. Nursing care plan/implementation:
  1. Preoperative:
    1. Goal: promote physical and emotional adjustment.
      1. Informed consent.
      2. Lab work completed - histocompatibility, CBC, urinalysis, blood type and crossmatch.
      3. Skin preparation.
    2. Goal: encourage expression of feelings: origin of donor, fear of complications, rejection.
    3. Goal: minimize risk of organ rejection: give medications: begin immunosuppression (azathioprine, corticosteroids, cyclosporine); antibiotics if ordered.
    4. Goal: health teaching.
      1. Nature of surgery; placement of kidney.
      2. Postoperative expectations: deep breathing, coughing, turning, early ambulation; reverse isolation.
      3. Medications: immunosuppressive therapy: purpose, effect.
  2. Postoperative:
    1. Goal: promote uncomplicated recovery of recipient.
      1. Vital signs; CVP; I&O - urine output usually immediate with living donor; with cadaver kidney may not work for a week or more and dialysis will be needed within 24-48 hr. Report <100 mL/hr immediately.
      2. Isolation: strict reverse isolation with immunosuppression; wear face mask when out of room.
      3. Position: back to nonoperative side; semi-Fowler’s to promote gas exchange.
      4. Indwelling catheter care: strict asepsis; characteristics of urine - report gross hematuria, heavy sediment; clots; perineal care; bladder spasms may occur after removal of catheter.
      5. Activity: ambulate 24 hr after surgery; avoid prolonged sitting.
      6. Weigh daily.
      7. Medications: immunosuppressives; analgesics as ordered (pain decreases significantly after 24 hr).
      8. Drains: irrigate only on physician order; meticulous catheter care.
      9. Diet: regular after return of bowel sounds; liberal amounts of protein; restrict fluids, sodium, potassium only if oliguric.
    2. Goal: observe for signs of rejection - most dangerous complication. Three classifications:
      1. Hyperacute - occurs within 5-10 min up to 48 hr after transplantation (rare).
      2. Acute - most common 7-14 days; varies depending on living (1 wk6 mo) or cadaver ( 1 wk-2 yr) donor.
      3. Chronic - occurs several months to years
    3. Goal: maintain immunosuppressive therapy.
      1. Azathioprine - an antimetabolite that interferes with cellular division. Side effects:
        
        Gastrointestinal bleeding (give PO form with food).
        
        Bone marrow depression; leukopenia; anemia.
        
        Development of malignant neoplasms.
        
        Infection.
        
        Liver damage.
      2. Prednisone - believed to affect lymphocyte production by inhibiting nucleic acid synthesis: anti-inflammatory action helps prevent tissue damage if rejection occurs. Side effects:
        
        Stress ulcer with bleeding (give with food).
        
        Decreased glucose tolerance (hyperglycemia).
        
        Muscle weakness.
        
        Osteoporosis.
        
        Moon facies.
        
        Acne and striae.
        
        Depression and hallucinations.
      3. Cyclosporine (Neoral, Sandimmune) - polypeptide antibiotic used to prevent rejection of kidney, liver, or heart allografts; PO dose given with room temperature chocolate milk or orange juice in a glass dispenser. Side effects:
        
        Nephrotoxicity (increased BUN, creatinine).
        
        Hypertension.
        
        Tremor.
        
        Hirsutism, gingival hyperplasia.
        
        GI - nausea, vomiting, anorexia, diarrhea, abdominal pain.
        
        Infections - pneumonia, septicemia, abscesses, wound.
      4. Additional drugs may include cyclophosphamide (Cytoxan), antithymocyte (ATG), antilymphocyte globulin, muromonab-CD3 (OKT3), tacrolimus (Prograf), and mycophenolate mofetil (CellCept).
    4. Goal: health teaching.
      1. Signs of rejection.
      2. Drugs: side effects of immunosuppression.
      3. Self-care activities: temperature, blood pressure, I&O, urine specimen collection.
      4. Avoidance of infection.
6. Evaluation/outcome criteria:
  1. No signs of rejection (e.g., no weight gain, oliguria).
  2. No depression.
  3. Patient resumes role responsibilities.
Nephrectomy (radical or partial): removal of kidney through flank, retroperitoneal, abdominal, thoracic, or thoracic-abdominal approach; indicated with malignant tumors, severe trauma, or under certain conditions before renal transplantation.

Analysis/nursing diagnosis:
1. Pain related to surgical incision.
2. Risk for infection related to wound contamination.
3. Risk for aspiration related to vomiting.
4. Constipation related to paralytic ileus.
5. Anxiety related to possible loss of function in remaining kidney.
6. Dysfunctional grieving related to perceived loss.
Nursing care plan/implementation:
1. Preoperative: Goal: optimize physical and psychological functioning.
2. Postoperative: Goal: promote comfort and prevent complications.
  1. Observe for signs of:
    1. Paralytic ileus - abdominal distention, absent bowel sounds, vomiting (common complication following renal surgery).
    2. Hemorrhage.
  2. Fluid balance: daily weight - maintain within 2% of preoperative level.
Evaluation/outcome criteria:
1. No complications (e.g., hemorrhage, paralytic ileus, wound infection).
2. Acceptance of loss of kidney.

Renal calculi (urolithiasis): formation of calculi (stones) in renal calyces or pelvis that pass to lower regions of urinary tract - ureters, bladder, or urethra; occurs after age 30, with greatest incidence in men, particularly over age 50.

Pathophysiology: organic crystals form (most consist of calcium salts or magnesium - ammonium phosphate (struvite) —> obstruction, infection; increased backward pressure in kidney —> hydronephrosis —> atrophy, fibrosis of renal tubules.
Risk factors (in over 50% of cases, cause is idiopathic):

Urinary tract infection.
Urinary stasis - obstruction.
Metabolic factors - excessive intake of vitamin D or C, calcium carbonate.

Assessment (depends on size, shape, location of stone):

Subjective data:

Pain: occasional, dull, in loin or back when stones are in calyces or renal pelvis; excruciating in flank area (renal colic), radiating to groin when stones are ureteral.
Nausea associated with pain.

Objective data:

Pallor, sweating, syncope, shock, and vomiting due to pain.
Palpable kidney mass with hydronephrosis.
Fever and pyuria with infection.
Lab data:
1. Urinalysis: abnormal - pH (acidic or alkaline); RBCs (injury); WBCs (infection); increased - specific gravity; casts; crystals; other organic substances, depending on type of stone (i.e., calcium, struvite, uric acid or cystine); positive culture.
2. Blood: increased calcium, phosphorus, total protein, alkaline phosphatase, creatinine, uric acid, BUN.
Diagnostic tests:

I VP: reveals nonopaque stones, degree of obstruction.
X-ray; radiopaque stones seen.
Ultrasound may also be used.

Analysis/nursing diagnosis:

Pain related to passage of stone.
Altered urinary elimination related to potential obstruction.
Urinary retention related to obstruction of urethra.

Nursing care plan/implementation:

Goal: reduce pain and prevent complications.
1. Medication: narcotics, antiemetics, antibiotics.
2. Fluids: 3-4 L/day; IVs if nauseated, vomiting.
3. Activity: ambulate to promote passage of stone, except bed rest during acute attack (colic).
4. Reduce spasms: warm soaks to affected flank.
5. Observe for signs of:
  1. Obstruction - decreased urinary output, increased flank pain.
  2. Passage of stone (90% will pass <5 mm size) - cessation of pain; filter urine with gauze.
6. Monitor: hydration status - I&O, daily weight; vital signs - particularly temperature for sign of infection; urine - color, odor.
Goal: health teaching.
1. Importance of fluids: minimum 3000 mL/day; 2 glasses during night.
2. Diet: modify according to stone type.
  1. Calcium oxalate and calcium phosphate stones - low calcium phosphorus and oxalate (e.g., avoid tea, cocoa, cola, beans, spinach, acidic fruits).
  2. Magnesium-ammonium phosphate - low phosphorus.
  3. Uric acid stones - low purine.
  4. Cystine stones - low protein.
3. Acid-ash diet with calcium oxalate and calcium phosphate stones, magnesium and ammonium phosphate (struvite) stones.
4. Alkaline-ash diet with uric acid and cystine stones.
5. Signs of urinary infection: dysuria, frequency, hematuria; seek immediate treatment.
6. Prepare for removal if indicated; percutaneous or extracorporeal lithotripsy done for stones < 1 cm; ureterolithotomy may also be ordered for larger stones; nephrectomy in extreme cases.

Evaluation/outcome criteria:

Relief from pain.
No signs of urinary obstruction (e.g., increased flank pain, decreased urine output).
No recurrence of lithiasis (adheres to diet and fluid regimen).