Renal and urinary care

Renal care on the NCLEX is volume, potassium, access protection, and a short list of urinary drugs that stain the toilet or tip an older adult into confusion.

AKI and CKD: phases and diet

When the kidneys suddenly stop clearing water and solutes, urine falls and potassium, urea, and creatinine climb. That oliguric stretch is an overload and hyperkalemia trap. When filtration returns, urine can flood out. The recovery phase looks “better” on the output sheet while the client is quietly losing volume and electrolytes.

• Urine under 30 mL/hr for hours: assess bladder, vitals, volume status; notify.
• CKD phosphorus teaching often targets dairy, cola, nuts, and processed foods. Follow the diet order in front of you.

At the bedside, treat oliguria as a full assessment, not a chart note: bladder scan or catheter check for obstruction, vitals and lung sounds for overload, and labs/ECG if potassium is rising. In the diuretic phase, weigh daily, watch for tachycardia or dry mucous membranes, and expect replacement orders when sodium or potassium drop with the high urine. CKD teaching is chronic and order-driven. Sodium and fluid when overload is the problem, potassium and phosphorus when those labs climb, protein only as the dietitian/provider ordered.

The distractor that looks reassuring is celebrating a sudden high urine output as “kidneys fixed” and skipping volume checks, or treating urine under 30 mL/hr for hours as “wait and see.” Another common miss: teaching a CKD client to “eat more dairy for calcium” when the real problem is phosphate load. For how peaked T waves and critical potassium behave as emergencies, stay in this chapter’s next section; for ion-by-ion detail, see Electrolytes.

Hyperkalemia and overload

Potassium above the critical range with peaked T waves, weakness, or bradydysrhythmias is a membrane emergency. Stabilize the heart first when ECG changes are present, then shift and remove potassium per the ordered pathway. Exact drug order and dialysis timing are protocol-specific.

• Fluid overload cues: weight gain, edema, crackles, rising BP, dyspnea.
• Kidney stone pain: analgesia, fluids as ordered, strain urine, infection watch.

Dialysis access and sessions

Hemodialysis needs a high-flow access; an AV fistula (or graft) is that lifeline. Anything that compresses or punctures the arm can clot or injure the vessel and cost the client their dialysis route. Peritoneal dialysis uses the peritoneum as the filter. Cloudy drain fluid means infection in that closed space until proven otherwise.

1. No BP, IVs, or blood draws on the fistula arm.
2. Palpate thrill / auscultate bruit each assessment.
3. Between treatments expect fluid/diet limits and daily weights as taught.

Check thrill and bruit every assessment and teach the client to feel the buzz at home. Hang a “no BP / no sticks” sign and use the other arm for vitals and labs. Between HD sessions, daily weights and the taught fluid/diet limits are what keep the next run from becoming an emergency pull-off of fluid. For PD, look at the effluent every drain: clear or straw-colored is expected; cloudy plus abdominal pain or fever starts the peritonitis pathway (notify, culture per protocol, do not treat as a “dirty bag” to ignore).

The distractor that looks efficient is taking a BP on the fistula arm “just this once,” or flushing cloudy PD fluid and waiting for the next exchange. First hemodialysis with headache, nausea, or confusion is dialysis disequilibrium until the team says otherwise. Slow or stop per protocol and notify; do not push through for a “full treatment.” Absent thrill/bruit is access emergency territory, not a tomorrow clinic problem.

Renal and bladder medications

Renal meds either bind what the diet brings in, push hemoglobin up, or pull potassium out of the gut. Bladder meds either calm an overactive detrusor, ease outlet obstruction, or stimulate emptying. And each class has a bedside trap the exam loves.

Phosphate binders only work if they meet food. Give calcium acetate with meals, not on an empty stomach between trays. Epoetin is a slow climb; hypertension or a rapid hemoglobin rise is a report, not a success story. Sodium polystyrene sulfonate needs a working gut. Constipation and impaction risk mean you watch bowel function while potassium falls. Phenazopyridine stains urine orange-red and eases dysuria; it is not the antibiotic. Oxybutynin’s anticholinergic load dries the mouth and can tip an older adult into confusion or urinary retention. Tamsulosin drops vascular tone at the outlet. Teach slow position changes. Bethanechol pushes bladder contraction for retention; sweating, diarrhea, or bradycardia-type cholinergic excess means hold and escalate.

The distractor that looks caring is holding phenazopyridine for “hematuria,” taking binders at bedtime away from meals, or treating new confusion on oxybutynin as ordinary aging. Another miss: skipping orthostatic teaching for tamsulosin because “it’s just a prostate pill.”

UTI, pyelonephritis, and glomerulonephritis

Lower UTI (cystitis) brings dysuria, frequency, urgency, and sometimes cloudy urine. Pyelonephritis adds flank pain, fever, nausea, and systemic look because the infection climbed to the kidney. Force fluids as allowed, give antibiotics as ordered, and teach wiping front to back, voiding after intercourse when that fits the stem, and finishing the antibiotic course. Older adults may show confusion without classic dysuria. Do not dismiss new delirium as “aging.”

Acute glomerulonephritis often follows a streptococcal infection by one to two weeks. Immune injury to the glomerulus leaks blood and protein into urine, drops urine output, and raises blood pressure. Periorbital edema, cola-colored urine, and hypertension on a post-strep stem are the fingerprint. Care is rest as ordered, fluid and sodium limits when overload is present, antihypertensives as ordered, and infection watch. The distractor treats cola urine as a simple UTI and misses the renal-inflammation map.

Urinary diversion and transplant highs

An ileal conduit routes urine through a bowel segment to a stoma. Expect mucus in the urine (bowel makes mucus), fit the appliance to protect skin, and measure output. Stoma should look pink and moist, not dusky. Self-catheterization teaching for continent diversions follows the ordered clean technique. Kidney transplant clients live on immunosuppression: infection reporting, rejection cues (fever, graft tenderness, rising creatinine, decreased urine), and no live vaccines when protocol forbids them. Cross-link infection prevention with the autoimmune and immunisation chapters when the stem is vaccine timing rather than graft function.

• Empty the conduit pouch when it is about one-third to one-half full to protect the seal.
• Report a dusky or retracting stoma and skin breakdown under the wafer.
• Transplant: fever and graft pain are escalate findings, not “wait for clinic day.”

Priority map