Disorders of the Kidneys and Ureters

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Disorders of the Kidneys and Ureters

• Chapter 64

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Overview pg 1124

• The most common urologic disorders are infectious
  and inflammatory conditions.
• Those that affect the kidneys are extremely
  dangerous because damage to the nephrons can
  result in permanent renal dysfunction.

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Pyelonephritis pg 1124

• An acute or chronic bacterial infection of the
  kidney and the lining of the collecting system
  (kidney pelvis).
• Acute phelonephritis presents with moderate to
  severe symptoms that usually last 1 to 2 weeks.
• If the treatment of acute pyelonephritis is not
  successful and the infection recurs, it is termed
  chronic pyelonephritis.

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Patho

• Bacteria ascend to the kidney and kidney pelvis
  by way of the bladder and urethra.
• Normal fecal flora such as E. coli, is the most
  common bacteria that cause acute pyelonephritis.
• E. Coli accounts for about 85 of infections.

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Patho

• In acute pyelonephritis, the inflammation causes
  the kidneys to grossly enlarge.
• Chronic pyelonephritis occurs after recurrent
  episodes of acute pyelonephritis.
• The kidneys develop irreversible degenerative
  changes and become small and atrophic.

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Patho

• If extensive numbers of nephrons are destroyed,
  renal failure develops.
• Renal dysfunction may not occur for 20 or more
  years after the onset of the disease.
• About 10 to 15 of clients with chronic
  pyelonephritis require dialysis.

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Pyelonephritis S/S pg 1124

• Flank pain or tenderness
• Chills, fever, and malaise
• Frequency and burning on urination if there is an
  accompanying cystitis (bladder inf)
• Some with chronic are asymptomatic
• Others have a low-grade fever and vague GI
  complaints.
• Polyuria and nocturia develop when the tubules of
  the nephrons fail to reabsorb water efficiently.

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Medical Management

• Tx includes relieving the fever and pain and
  prescribing antimicrobial drugs such as Septra or
  Cipro for 14 days.
• Antispasmodics and anticholinergics such as
  Ditropan Pro-Banthine relax smooth muscles of
  the ureters and bladder, promote comfort, and
  increase bladder capacity.
• 4 weeks of drug therapy is prescribed

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Nursing Management pg 1125

• Obtain a complete medical, drug, allergy
  history.
• V/S (? temp or BP)
• Any s/s of fluid retention such as peripheral
  edema and SOB.
• Collect a clean-catch urine specimen for
  urinalysis and urine culture.
• Measure I O

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Nursing Management

• Provide a liberal fluid intake of approx. 2,000
  to 3,000 mL to flush the infectious
  microorganisms from the urinary tract.
• LAB TEST BUN, creatinine, serum electrolytes,
  and urine culture

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Family Teaching pg 1126 Box 64-1

• Suggest consuming acid-forming foods such as
  meat, fish, poultry, eggs, grains, corn, lentils,
  cranberries, prune, plums, and their juices to
  prevent calcium and magnesium phosphate stone
  formation.
• Recommend avoiding alcohol and caffeine products
  if bladder spasms are present or until a clinical
  response to therapy is verified.

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Acute Glomerulonephritis pg 1126

• The term nephritis describes a group of
  inflammatory but NONINFECTIOUS disease
  characterized by wide-spread kidney damage.
• Glomerulonephritis is a type of nephritis that
  occurs most frequently in children and young
  adults however, it can affect individuals at any
  age.

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Patho

• Symptoms of acute glomerulonephritis appear about
  1 to 2 weeks after a group A beta-hemolytic
  streptococci upper respiratory infection.
• The relationship between the infection acute
  glomerulonephritis is not clear microorganisms
  are not present in the kidney when symptoms
  appear, but the glomeruli are acutely inflamed.

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Acute Glomerulonephritis S/S

• About 50 are symptom free.
• Occasionally the onset is sudden with pronounced
  symptoms such as fever, nausea, malaise,
  headache, generalized edema, or periorbital
  edema, puffiness around the eyes.
• In some instances, the disorder is discovered
  during a routine physical examination.

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Acute Glomerulonephritis S/S

• More often, the client or family notices that the
  persons face is pale and puffy and that slight
  ankle edema occurs in the evening.
• Many other vague symptoms.read on your own

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Diagnostic Findings

• Gross or microscopic hematuria gives the urine a
  dark, smoky, or frankly bloody appearance.

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Medical Management pg 1127

• No specific treatment exists for acute
  glomerulonephritis and treatment is guided by the
  symptoms and their underlying abnormality.
• Treatment may consist of bed rest, a
  sodium-restricted diet (if edema or HTN is
  present), and antimicrobial drugs to prevent a
  superimposed infection in the already inflamed
  kidney.

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Medical Management

• The client is not considered cured until the
  urine is free of protein and red blood cells for
  6 months.
• Return to full activity usually is not permitted
  until the urine is free of protein for 1 month.

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Nursing Management

• Maintain bed rest when the blood pressure is
  elevated and edema is present
• Collect daily urine specimens to assist with
  evaluating the clients response to TX.
• Assess the BP q 4 hours or prn
• Encourage adequate fluid intake and measure I
  O.
• Encourage carbohydrate intake to prevent the
  catabolism of body protein stores (may be
  restricted in sodium and protein)

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Chronic Glomerulonephritis pg 1127

• A slowly progressive disease characterized by
  inflammation of the glomeruli that causes
  irreversible damage to the kidney nephrons.
• Some live for years with only occasional
  symptomatic episodes or none at all, or the
  disease may be rapidly fatal unless renal failure
  is treated with dialysis.

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Patho

• The chronic inflammation leads to ever-increasing
  bands of scar tissue that replace nephrons, the
  vital functioning units of the kidney.
• Decreased glomerular filtration can eventually
  lead to renal failure.
• Chronic glomerulonephritis accounts for approx.
  40 of people on dialysis.

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Chronic S/S

• Some experience no symptoms of this disorder
  until renal damage is severe.
• Generalized edema known as ANASARCA is a common
  finding.
• Anasarca is due to the shift of fluid from the
  intravascular space to interstitial and
  intracellular fluid locations.
• The fluid shift is due to depletion of serum
  proteins, albumin in particular, which is lost in
  the urine.

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S/S

• Clients remain markedly edematous for months or
  years.
• The client may feel relatively well, but the
  kidney continues to excrete albumin.
• The fluid burden and subsequent renal failure
  contribute to fatigue, headache, hypertension,
  dyspnea, and visual disturbances.

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Diagnostic Findings

• Azotemia, accumulation of nitrogen waste products
  in the blood, is evidenced by elevated BUN, serum
  creatinine, and uric acid levels.
• The urine contains protein (albumin), sediment,
  cast (deposits of minerals that break loose from
  the walls of the tubules), and red and white
  blood cells.

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Medical Management

• Treatment is nonspecific and symptomatic
• Management goals include (1) controlling HTN with
  medications and sodium restriction (2) correcting
  fluid and electrolyte imbalance, (3) reducing
  edema with diuretic therapy (4) preventing
  congestive heart failure (5) eliminating urinary
  tract infections with antimicrobials.
• May necessitate dialysis or kidney transplantation

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Nursing ManagementFluid Volume Excess

• Weigh daily at the same time on the same scale
  while wearing similar clothing.
• Measure I O
• Monitor BP, HR, lung and heart sounds each shift
• Assess for pitting edema, tight rings or shoes,
  clothes that do not fit comfortably
• Educate on low sodium restriction
• Administer prescribed diuretics

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Nursing ManagementFatigue Activity Intolerance

• Avoid clustering nursing tasks and physical
  activities
• Provide periods of rest and promote uninterrupted
  sleep at night
• Eliminate any activities of daily living that are
  not necessary.
• Assist the client with activities when evidence
  of tachycardia or dyspnea is present.

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Polycystic Disease pg 1129

• A congenital kidney disorder that has a familial
  tendency.
• 2 forms the infantile and adult forms
• 1. The infantile form is rare. It may cause
  fetal death (before delivery), early neonatal
  death, or renal failure during childhood.
• 2. The adult form has its onset between 30 to 50
  years of age and insidiously progresses to renal
  insufficiency.

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Polycystic Disease

• Once renal failure develops, polycystic disease
  is usually fatal within 4 years, unless the
  client receives dialysis treatment or organ
  transplant.

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Patho

• Adult polycystic kidney disease is the result of
  autosomal dominant inheritance.
• This means that the gene for the disease is
  passed from an affected parent to his or her
  children.
• Each child has a 5050 chance of acquiring the
  defective gene

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Patho

• As the name implies, this disorder is
  characterized by the formation of multiple
  bilateral kidney cysts. Fig 64-4 pg 1130.
• The cysts interfere with kidney function and
  eventually lead to renal failure.
• The fluid-filled cysts cause enormous enlargement
  of the kidneys from normal fist size to as much
  as the size of a football.

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Patho

• As the cysts enlarge, they compress the renal
  blood vessels and cause chronic hypertension.
• Bleeding into cysts causes flank pain

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Polycystic Disease S/S

• Hypertension is present in approx 75 of affected
  individuals at the time of diagnosis.
• Other symptoms, such as pain from retroperitoneal
  bleeding, lumbar discomfort, and abdominal
  tenderness, are due to the size and effects of
  the cysts.
• Colic (acute spasmodic pain) is experienced when
  there is ureteral passage of clots or calculi.

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Medical Management

• Has no cure, but some interventions reduce the
  rate of progression.
• HTN --- antihypertensive drugs, diuretic med and
  sodium restriction
• UTIpromptly with antibiotics
• Low RBC countiron supplements, injections of
  erythropoietin (Epogen) or blood transfusions

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Medical Management

• NEPHROTOXIC MEDICATIONS, SUCH AS NONSTEROIDAL
  ANTI-INFLAMMATORY DRUGS AND CEPHALOSPORIN
  ANTIBIOTICS, ARE AVOIDED AT ALL COSTS.
• Dialysis substitutes for kidney function when
  renal failure occurs and while the client awaits
  an organ transplant

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Nursing Management

• Assess V/S especially BP
• Observe the urine for signs of bleeding or
  infection
• Measure I O
• Report any decrease in or absence of urine
  output.

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Obstructive Disorders pg 1130

• KIDNEY AND URETRERAL STONES
• A stone (calculus) is a precipitate of mineral
  salts that ordinarily remain dissolved in urine.
• About 80 of renal calculi in the US are composed
  of calcium oxalate.
• Stones may be smooth, jagged, or staghorn shaped
  fig 64-5 pg 1131

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Kidney Ureteral Stones Pg. 1130

• Calculi can occur anywhere in the urinary tract
  from the kidney pelvis and beyond.
• When a stone forms, the condition is called
  urolithiasis.
• Nephrolithiasis refers to the presence of a
  kidney stone, the size of which may range form
  microscopic to several centimeters in diameter.
• Ureterolithiaisis is a stone within the ureter.
  Ureteral stones are usually small some may be no
  larger than a grain of sand.

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Patho

• Predisposing factors
• Calciuria, excessive calcium in the urine
  (hyperparathyroid dx, calcium-based antacids, and
  excessive intake of vitamin D)
• Dehydration
• Osteoporosis in which bone is demineralized
• Obstructive disorders (enlarged prostate)
• Immobility
• UTI

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Patho

• Calculi traumatize the walls of the urinary tract
  and irritate the cellular lining, causing pain as
  violent contractions of the ureter develop to
  pass the stone along.
• But the ureteral spasms may just as easily hold a
  stone in place.
• If a stone totally or partially obstructs the
  passage of urine beyond its location, pressure
  increases in the area above the stone.

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S/S

• Small stones may pass unnoticed
• However, sudden, sharp, severe flank pain that
  travels to the suprapubic region and external
  genitalia is the classic symptom of urinary
  calculi.
• The pain comes in waves that radiate to the
  inguinal ring, the inner aspect of the thigh, and
  to the testicle or tip of the penis in men , or
  the urinary meatus or labia in women.

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Medical Management 1132

• Small calculi are passed naturally with no
  specific interventions.
• If the stone is 5 mm or less in diameter, moving,
  the pain is tolerable, and no obstruction is
  present, the client is managed medically with
  vigorous hydration, analgesics, antimicrobial
  therapy, and drugs that dissolve calculi or
  eventually alter conditions that promote their
  formation (Table 64-1 pg 1132)

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Medical Management

• For larger stones, extracorporeal shock wave
  lithotripsy (ESWL), a procedure that uses 800 to
  2,400 shock waves aimed from outside the body
  toward dense stones may be used (fig 64-6) pg
  1133
• The stones are shattered into smaller particles
  that are passed from the urinary tract

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Medical Management

• ESWL is administered with the client in a water
  bath or surrounded by a soft cushion while under
  light anesthesia or sedation.
• Stones can also be pulverized with laser
  lithotripsy.--- to do so, a fine wire, through
  which the laser beam passes, is inserted into the
  ureter by means of a cystoscope. Repeated bursts
  of the laser reduces the stone to a fine powder,
  which is then passed in the urine.

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Medical Management

• Other stone removal procedures are performed with
  ureteroscopic approaches in which the endoscope
  is inserted from the urethra into the upper
  urinary tract under anesthesia to grasp, crush,
  and remove stones from the kidney pelvis or
  ureter.
• Afterward, a catheter or ureteral stent, a
  slender supportive device, is left in place for 3
  days to splint the ureter or divert the urine
  past any possible tear in the ureteral wall (fig
  64-7) pg 1134

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Medical Management

• If the stone cannot be removed, a ureteral
  catheter is left in place for 24 hours to dilate
  the ureter in the hope that the stone will pass
  through it or that it will be pulled into the
  bladder when the catheter is removed.

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Surgical Management

• A nephrostomy tube, is a catheter that is
  inserted through the skin into the renal pelvis
  to manage any obstruction to urine flow above the
  bladder.
• The tube is kept in place with a suture through
  he skin.
• Unlike the bladder, the kidney pelvis can only
  hold APPROX. 5 TO 8 ML of urine.

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Surgical Management

• If urinary drainage through the tube is impaired
  for even a short time from a blood clot or
  kinking or compression of the tubing,
  hydronephrosis and damage to surgically repaired
  tissue can result.
• The client will complain of pain if the renal
  pelvis becomes distended with urine.

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REVIEW ON YOUR OWN

• Nursing Guidelines 64-1 pg 1135 Managing a
  Nephrostomy Tube

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Ureteral Stricture pg 1136

• A stricture is a narrowing of a lumen in this
  case the ureter is narrowed
• The recurrent inflammation and infection cause
  scar tissue to accumulate within the ureter.
• Other conditions that can interfere with urine
  passing through the ureter are congenital
  anomalies or conditions that mechanically
  compress the ureter such as pregnancy and tumors
  within the abdomen or upper urinary tract.

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S/S

• Flank pain or discomfort and tenderness at the
  costovertebral angle (CVA) due to enlargement of
  the renal pelvis often develop.
• CVA where the last rib joins the vertebra

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Medical Management pg 1137

• The ureter can be stretched by inserting a
  dilator called a filiform or urethral sound, a
  curved metal rod, followed by others that are
  sequentially larger.
• If the obstruction persists, the MD performs a
  ureteroplasty, removal of the narrowed section of
  ureter and reconnection of the patent portions.
• A ureteral stent is placed in the ureter to
  provide support to the walls of the ureter,
  relive the obstruction, and maintain the flow of
  urine through the ureter and into the bladder.

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Nursing Management

• If a ureteral catheter is inserted
  preoperatively, measure the urine output from the
  catheter hourly.
• Immediately report if there is no urine output
  from the ureteral catheter.
• On return from surgery, all urinary drainage
  tubes and catheters are connected to a closed
  drainage system or to the type of drainage
  ordered by the physician.

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Nursing Management

• The main complication associated with ureteral
  surgery is failure of the ureter to transport
  urine from the kidney to the bladder.
• Contact the MD if signs of shock appear, urinary
  output from the ureteral catheter is decreased or
  absent, or if the client complains of significant
  abdominal pain, which may indicate leakage of
  urine into the peritoneal cavity.

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Nursing Management

• Notify the MD if signs of a urinary tract
  infection develop, such as fever and chills or if
  the urine is cloudy or has a foul odor.

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Tumors of the Kidney pg 1137

• A hypernephroma (renal adenocarcinoma) is the
  most common malignant tumor of the kidney in
  adults.
• Squamous cells tumors are second.
• May be associated with carcinogenic effects of
  long-term cigarette smoking, environmental toxin
  (asbestos) or volatile solvents (gasoline)
• Because the kidneys are deeply protected in the
  body, tumors can become quite large before
  causing symptoms.

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S/S

• The classic triad of renal cancer is PAINLESS
  hematuria, flank pain, and the presence of a
  palpable mass.
• Additional symptoms include weight loss, malaise,
  and unexplained fever.
• Later, there is colic-like discomfort during the
  passage of blood clots

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Medical Management

• Nephrectomy, including removal of the surrounding
  perinephric fat, is the treatment for a malignant
  renal tumor.
• Surgery, chemotherapy, and radiation done
• If extensive metastases are found, only
  palliative treatment is given.

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Nursing Management pg 1138

• Review care plan and family teaching on your own
  !!!!

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Renal Failure pg 1139

• The inability of the nephrons within the kidneys
  to maintain fluid, electrolyte, and acid-base
  balance, excrete nitrogen waste products, and
  perform regulatory functions such as maintaining
  calcification of bones and producing
  erythropoietin.

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Renal Failure

• There are two types of renal failure
• 1. Acute renal failure (ARF) is characterized by
  sudden and rapid decrease in renal function. ARF
  is potentially reversible with early, aggressive
  treatment of its contributing etiology.
• 2. Chronic renal failure (CRF) is characterized
  by progressive and irreversible damage to the
  nephrons. It may take months to years for CRF to
  develop.

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Acute Renal Failure

• Acute renal failure progresses through 4 phases
• 1. Initiation phase
• 2. Oliguric phase
• 3. Diuretic phase
• 4. Recovery phase

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Acute Renal Failure

• 1. Initiation Phase begins with the onset of
  the contributing event.
• It is accompanied by a reduction in blood flow to
  the nephrons to the point at which there is acute
  tubular necrosis (ATN)
• ATN refers to the death of cells within the
  collecting tubules of the nephrons where
  reabsorption of water, electrolytes, and
  excretion of protein wastes and excess metabolic
  substances occurs.

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Acute Renal Failure

• 2. Oliguric Phase associated with the
  excretion of less that adequate urinary volumes.
• This phase begins within 48 hours after the
  initial cellular insult and may last for 10 to 14
  days or longer.
• Fluid volume excess develops, which leads to
  edema, HTNlt and cardiopulmonary complications.

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Acute Renal Failure

• Azotemia, marked accumulation of urea and other
  nitrogenous wastes such as creatinine and uric
  acid in the blood, creates a potential for
  neurologic changes such as seizures, coma, and
  death.
• Some clients excrete urinary volumes greater than
  500 mL/day. However, the urine has a very low
  specific gravity because it lacks normal amounts
  of excreted substances such as excess potassium
  and hydrogen ions, to maintain homeostasis.

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Acute Renal Failure

• Consequently, hyperkalemia, metabolic acidosis,
  and uremia, a toxic state caused by the
  accumulation of nitrogen wastes, develop
  regardless of the excreted water volume.

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Acute Renal Failure

• Diuretic Phase diuresis begins as the nephrons
  recover.
• Despite an increase in the water content of
  urine, the excretion of wastes and electrolytes
  continues to be impaired.
• The BUN, creatinine, potassium, and phosphate
  levels remain elevated in the blood.

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Acute Renal Failure

• Recovery Phase it may take one or more years of
  recovery while normal glomerular filtration and
  tubular function are restored.
• Some clients recover completely others develop
  varying degrees of permanent renal dysfunction.

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Chronic Renal Failure

• In CRF, the kidneys are so extensively damaged
  that they do not adequately remove protein
  by-products and electrolytes from the blood and
  do not maintain acid-base balance.
• End-stage renal disease (ESRD) is the term given
  for the point at which a regular course of
  dialysis or kidney transplantation is necessary
  to maintain life.

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Chronic Renal Failure

• Actual electrolyte imbalances include
  hyperkalemia, hyperphosphatemia, hypermagnesemia,
  and hypocalcemia.
• The skin becomes the excretory organ for the
  substances the kidney usually clears from the
  body.
• A precipitate, referred to as uremic frost, may
  form on the skin.

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Chronic Renal Failure

• Assessment S/SIn both ARF CRF, the client
  has an elevated blood pressure and weight gain.
• Urine output is generally decreased.
• Facial features appear puffy due to fluid
  retention
• The skin is pale ulceration and bleeding of the
  GI tract may occur.

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Chronic Renal Failure

• The oral mucous membranes bleed, and blood may be
  found in the feces.
• Vague symptoms of lethargy, HA, anorexia, and dry
  mouth.
• The clients breath and body may have an odor
  characteristic of urine.
• Table 64-4 lists the systemic manifestations of
  CRF. Pg 1141

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Medical Management pg 1141

• Dialysis
• Fluid and dietary restrictions that include
• Low protein
• High calories
• Low sodium
• Low potassium

90
Medical Management

• Kayexalatean ion-exchange resin, is prescribed
  for oral or rectal administration to remove
  excess potassium when hyperkalemia occurs.
• An IV infusion of glucose and insulin also
  facilitates movement of potassium within the
  cell.
• Instead of blood transfusions to correct chronic
  anemia, Epogen is administered to stimulate bone
  marrow production of RBCs

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Surgical Management Pg 1142

• Some are candidates for a kidney transplant
• One healthy kidney can perform the work of two
• Any potential donor with a history of HTN,
  malignant disease, or DM is excluded form
  donation.
• When a transplant is performed, the donor kidney
  is inserted through an abdominal incision and the
  nonfunctioning kidneys are left in place unless
  the client is extremely hypertensive.

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Surgical Management

• The blood vessels from the donor kidney are
  sutured to the iliac artery and vein and the
  ureter is implanted in the bladder. (fig 64-11 pg
  1142)

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Dialysis Pg. 1143

• A procedure for cleaning and filtering the blood.
• It provides a substitute for kidney function when
  the kidneys are unable to remove the nitrogenous
  waste products and maintain adequate fluid,
  electrolyte, and acid-base balance.

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Dialysis

• During dialysis the clients blood is filtered by
  diffusion and osmosis.
• Substances such as urea, creatinine,and
  dangerously high levels of potassium, and water
  move FROM the blood through the semipermeable
  membrane TO the dialysate, the solution used
  during dialysis that has a composition similar to
  normal human plasma.

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Dialysis

• Dialysis is performed by hemodialysis and
  peritoneal dialysis.
• Either technique can be performed at home or in a
  dialysis center.
• Each type of dialysis has advantages and
  disadvantages. Table 64-5 pg. 1148

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Arteriovenous Fistula

• A surgical anastomosis (connection) of an artery
  and vein lying in close proximity. Fig 64-13 pg
  1149
• The vessels usually joined are the cephalic vein
  and the radial artery or the cephalic vein and
  brachial artery.
• They require from 1 to 4 months to mature before
  being used.

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Arteriovenous Fistula

• At the time of dialysis, two venipunctures are
  performed at either end of the fistula
• The distal venipuncture is used to remove blood
  that is transported to the machine.
• The proximal needle puncture is used to return
  the dialyzed blood.
• When dialysis is completed, the needles are
  removed and pressure dressings are applied for
  several hours.

102
Arteriovenous Fistula

• Blood samples are taken before and after
  dialysis.
• The clients predialysis and postdialysis weights
  are compared. Sometimes as much as 10 lb of
  fluid is removed.
• BUN, creatinine, sodium, potassium, chlorides,
  and HCT are used as indicators of efficiency of
  dialysis.l

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Arteriovenous Graft

• A type of vascular access method that uses a tube
  of synthetic material to connect a vein and
  artery in the upper or lower arm Fig 64-13 pg
  1149.
• The graft pulsates with blood flow
• AV grafts can be used 14 days after their
  insertion.
• Although the graft reseals after each needle
  puncture, the expected life of the graft is 3 to
  5 years with repeated use.

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Nursing Management

• Assess record vital signs before and after
  hemodialysis.
• Weigh the client and obtain blood for labs
• To prepare for vascular access
• Palpate for a THRILL (vibration) over the
  vascular access. Listen for a BRUIT, a loud
  sound caused by turbulent blood flow. IF ABSENT,
  POSTPONE FURTHER USE AND REPORT FINDINGS.

107
Nursing Management

• After dialysis is completed, do not administer
  injections for 2 to 4 hours.
• This allows time for the metabolism and excretion
  of heparin, which is administered during
  dialysis, to reach safe levels.
• Before discharging the client, observe for
  disequilibrium syndrome.

108
Nursing Management

• Disequilibrium Syndrome a neurologic condition
  believed to be caused by cerebral edema.
• The shift in cerebral fluid volume occurs when
  the concentrations of solutes within the blood
  are lowered rapidly during dialysis
• Decreasing solute concentration lowers the plasma
  osmolality.
• WATER THEN FLOODS THE BRAIN TISSUE!!!

109
Nursing Management

• This syndrome is characterized by HA,
  disorientation, restlessness, blurred vision,
  confusion, and seizures.
• The symptoms are self-limiting and disappear
  within several hours after dialysis as fluid and
  solute concentrations equalize.
• The syndrome can be prevented by slowing the
  dialysis process to allow time for gradual
  equilibration of water.

110
Nursing Management

• Client Teaching Avoid carrying heavy items in
  the arm with the fistula or graft
• Do not sleep on the vascular access arm
• Do not permit venipunctures, injections, or blood
  pressures in the arm with the vascular access.
• Assess for a thrill or bruit daily!!